Funded by CPNP, The SMART Guide: Motivational Approaches Within the Stages of Change for Pregnant Women Who Use Alcohol is a Training Manual for Services Providers written by Wendy Reynolds, MSW, and Margaret Leslie, Dip.C.S., C.Psych.Assoc. The SMART Guide is a co-production of Action on Women’s Addictions – Research & Education (AWARE) and Mothercraft (Breaking the Cycle). The content of The SMART Guide is based on work with pregnant women by the Breaking the Cycle program, and in health promotion, training, and policy work at AWARE.

The information contained in The SMART Guide was developed referencing the work of Dr. William Miller’s on motivational counselling strategies, and grounded in the Transtheoretical Model of the Stages of Change (TTM) developed by James Prochaska and Carlo diClemente. The TTM, a popular stage model in health psychology, has proven successful with a wide variety of simple and complex health behaviours, including smoking cessation, weight control, sunscreen use, reduction of dietary fat, exercise acquisition, quitting cocaine, mammography screening, and condom use (Prochaska, et al, 1994).

The SMART Guide was developed for service providers who have direct contact with pregnant women, such as CAPC/CPNP/AHS, in order to:

• Set the stage to intervene in an empathic, non-judgmental way with pregnant women who use alcohol

• Describe the stages of change a woman goes through when she uses alcohol

• Help service providers to identify the stage of change a woman is in

• Outline motivational techniques that apply to each specific stage of change

• Provide approaches or strategies that can be used at each stage of change

• Lessen the anxiety many service providers feel when they interact with pregnant women who use alcohol

The toolkit begins by providing some baseline facts.

1. Many women, even those who are heavy or problem drinkers, quit using alcohol when they find out they are pregnant, and there are many points of engagement with women during their pregnancies, so it is important for service providers not to feel hopeless or helpless.

2. Many women don’t use alcohol because they are irresponsible. Often they may have received incorrect information about the effects of drugs and alcohol from a variety of family and community sources.

3. Many factors, including poverty, lack of food security, domestic violence, and other negative life events, can lead to negative birth outcomes. Pregnant women who use alcohol want to be treated within the context of their whole lives, not just as a pregnant person.

Pregnant women who use alcohol report that the top supports they have received are supportive professionals, supportive family members, supportive family/recovery group members, children as motivators to get help, and health problems as motivators. Given this, the toolkit notes the challenges for service providers are to ensure a holistic approach, provide a safe, comfortable environment, and eliminate barriers to accessing support.

The toolkit provides starting point questions for service providers to ask about their own life experience, access to research- and evidence-based information, attitudes and judgments of others’ behavior, and ability to adopt a harm reduction approach.

The guide goes into detail about how to ask questions in ways that are straightforward, non-judgmental, calm and direct, open a range of possibilities, and form part of general health questions. It looks at how to facilitate an on-going discussion, be prepared with follow-up questions, and refer as needed. The manual remind service providers that it is not their role to make a diagnosis, rather to support and refer. It points out the value of dispelling myths and providing reliable written information in easy-to-read language, such as the Give and Take booklet produced from AWARE https://preventionconversation.files.wordpress.com/2015/03/give-and-take.pdf

Sometimes helping professionals fall into the trap of asking questions about alcohol use only once. The toolkit emphasizes that every interaction with a pregnant woman (regardless of whether or not she initially revealed it) should include questions about alcohol use, framed in a matter-of-fact, non-judgmental way and within the overall context of her health.

Remembering the barriers to getting help, such as guilt, fear of being judged, and fear of losing the infant, service providers are in a position to:

• Provide a lot of positive feedback

• Highlight the woman’s ability to make choices

• Be non-judgmental

• Encourage small changes that reduce high risk behaviours

• Talk about alcohol use and pregnancy or parenting concerns, looking at the whole person

• Be sensitive to trauma issues

• Address family issues and offer support to family members where possible

The guide states, “The approach you take is one of the strongest indicators of whether a woman will change. Your approach is just as important as the woman’s personal characteristics and behaviour.”

The toolkit gives information on motivational approaches, and lists the five basic principles of motivational approaches:

1. Express empathy through reflective listening.

2. Avoid argument.

3. Roll with resistance. Adjust to resistance by changing strategies.

4. Develop discrepancy between the woman’s goals or values and her current behaviour. A powerful motivator to change is her ability to recognize contradictions between her current behaviour and he hopes for the future.

5. Support self-efficacy, focusing on the woman’s strengths, and supporting the hope and optimism needed to make change.

The guide identifies strategies, such as use of open-ended questions, reflective listening, affirmations, and elicitation of self-motivational statements, and looks at the Stages of Change. “In the Stages of Change, change is not seen as a sudden event. People don’t just wake up one morning and change their behaviour. The reality is that change happens in stages or cycles.”

The Stages of Change involve:

• Pre-Contemplation: the stage in which an individual has no intent to change behavior in the near future (e.g. the next 6 months). At this stage, one is often characterized as resistant or unmotivated, tending to avoid information, discussion, or thought with regard to the targeted health behavior (Prochaska et al, 1972).

• Contemplation: In this stage, individuals openly state their intent to change within the next 6 months, but are often perceived as ambivalent to change or as procrastinators. (Prochaska & DiClemente, 1984).

• Preparation: A transitional (rather than a stable) stage in which individuals intend to take steps to change, usually within the next month (DiClemente et al, 1991).

• Action: The stage in which an individual has made over, perceptible lifestyle modifications for fewer than 6 months (Prochaska et al, 1997).

• Maintenance: Individuals working to prevent relapse and consolidate gains secured during the Action phase (Prochaska et al, 1992).

• Termination: At this stage, former problem behaviours are no longer perceived as desirable (e.g. skipping exercise results in frustration rather than pleasure). OR Relapse: This involves return to old behaviours, and can happen many times, and at any stage.

The guide points out that “people, including pregnant women who use alcohol, need different kinds of help, depending on which stage of change they are in”. The toolkit provides a wide range of strategies for use in each of the differing stages, along with examples of strategies in practice.

The Appendices provide worksheets including sample questions to evoke self-motivational statements, a sample timeline follow-back tracking sheet, a change plan worksheet, a confidence and self-efficacy rating sheet, and a functional analysis tool.