Area 1: Demystifying Change
This is the first in a series of four posts that I will use to summarize my current thinking about addiction, particularly how people recover from it.
The question of why some people with addictions recover—while others do not—continues to puzzle me. Understanding how change occurs allows me to do a better job of increasing the numbers of those who do recover. One model that I found to be helpful in this regard is known as the “Transtheoretical Stages of Change Model.”
As the result of completing a landmark research study, funded by the National Cancer Institute, of people who stopped smoking tobacco, Drs. James Prochaska and Carlo DiClementi argued that change can best be thought of as a process rather than as a discrete event. This process evolves through a predictable series of five “stages”: pre-contemplation, contemplation, preparation, action and maintenance. Clinicians, who treat patients struggling with addictions, usually find pre-contemplation and contemplation to be both the most common and most challenging stages.
Important elements of this model are:
- Each stage, in which certain tasks are accomplished, must be processed sequentially. If the tasks are not completed or a stage is skipped entirely, the resulting change is only temporary.
- The stages are not entirely discrete. For example, someone in the action stage may continue to experience some of the ambivalence that dominates the pre-contemplation stage.
- Before achieving a stable state of abstinence, a person usually goes through the cycle of stages several times. The graphic representation of the model is, therefore, in the shape of a spiral rather than a circle, indicating that with each “unsuccessful” cycle, the person potentially learns something that is applied to the next attempt. Recycling does not necessarily mean going back to the beginning. Most people who relapse return to a preparation or contemplation stage rather than pre-contemplation.
- The action stage is the one in which the most visible changes occur, but important changes can occur in every stage of the process.
- The model is described as “transtheoretical” because it appears to be applicable regardless of the theoretical orientation of the therapist. The authors suggest, however, that some theoretical orientations may be more useful in some stages and less so in others. If they are correct, a degree of theoretical eclecticism would be in order.
Being able to identify the patient’s current stage is important in choosing what to say to the patient. For example, hearing the details of different treatment alternatives might be welcomed by someone in the preparation stage but be of little interest to a person in the pre-contemplation stage. The next step after identifying the stage is to understand the experience of a person within that stage.
For instance, pre-contemplator patients have no plans to change often because they do not yet acknowledge that a problem exists. Sometimes, however, they acknowledge the problem but have had so many failed attempts to address it that their inaction is the result of hopelessness. Knowing which situation prevails informs the clinician as to how best to talk to the patient.
When it comes to recovery from addictions, relapses—while not universal—are common and can be the source of discouragement or even hopelessness on the part of patients and therapists. For those individuals, the Stages of Change Model can be a source of realistic hope. I know that this has been the case for me, allowing me to persevere with my patients to a successful recovery in instances when this would not have otherwise been the case. For those interested in more details about the Stages of Change, you might find it helpful to read one of the many articles on the subject.