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Moving From One Stage Of Addiction Recovery To The Next

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Moving from one stage of addiction recovery to the next (Harvard Mental Health Letter, July 2008)

Different tasks and interventions are required at different stages.

The transtheoretical model of behavior change — often referred to simply as the “stages of change” model — has become one of the most widely used methods to promote recovery from addictions and to help make other health behavior changes. Although not universally endorsed, the transtheoretical model holds that at any given time, a person is at a particular stage in relation to behavior change: precontemplation, contemplation, preparation, action, or maintenance.

The transtheoretical model was developed by University of Rhode Island researchers James O. Prochaska and Carlo C. DiClemente. At a Boston medical meeting early in 2008, DiClemente (who is now at the University of Maryland) provided advice about how to overcome a major challenge in putting the model to work in clinical practice: helping patients move from one stage to the next.

Too often, clinicians and patients alike think of the five stages as so many boxes — a concept that may help clarify where someone is on the road to recovery, but does not help them progress any further. To help patients move from one stage to the next, DiClemente recommends that clinicians identify particular tasks that serve as engines of change.

Precontemplation

At this stage, a patient is not thinking about changing an addictive behavior in the near future, usually defined as the next six months.

Tasks. To encourage patients to consider making a change, it’s important to motivate them emotionally as well as intellectually. It’s not enough just to educate patients about the harms of a current behavior, such as how smoking may lead to lung cancer. It’s also important to help them envision alternatives to current behaviors.

Consider tasks (for example, a workbook) or tools (a motivation tape) that will help patients start thinking in a different way.

Contemplation

A patient is ready to consider a change in the next one to six months.

Tasks. At this point, tasks are largely cognitive in nature. The goal is to help a patient evaluate options and make preliminary decisions. One exercise is to have the patient create a decisional balance worksheet, by writing down the pros and cons of both maintaining the status quo and making a change. Moving to the next stage is possible only when the relative advantages of making a change seem more compelling to the patient than the disadvantages. A therapist can assist in helping the patient identify additional risks of a harmful behavior and additional benefits of a new behavior, to tip the balance in favor of change.

Preparation

The patient commits to making a behavior change in the next month.

Tasks. The focus is still on cognitive processes. A therapist may encourage a patient to create a behavior change plan with realistic goals and timelines. It’s important for the patient to specify exactly when the behavior change will start, because this increases the chances of actually making the change. Therapists and patients may also want to identify likely barriers to change, and brainstorm in advance ways to overcome them.

Action

The patient actually implements the plan and establishes a new behavior pattern over three to six months.

Tasks. At this point, focus shifts from cognitive to behavioral processes. Typically, as patients implement their original plan for change, they slip back into the old behaviors. Although slips can be discouraging, they usually mean that the original plan was flawed — and that it’s time to revise it. A therapist can work with the patient to re-evaluate the situation and engage in creative problem solving. Then it’s up to the patient to try again.

Maintenance

The new behavior becomes the norm, sustained for at least six months.

Tasks. Behavioral strategies remain central, but require support and reinforcement. Patients may find it helpful to join support groups or investigate online resources to find encouragement. Ongoing problem-solving sessions with a therapist may be necessary as challenges arise — such as the annual office party for someone trying to remain sober.

Lapses and learning

Behavior change rarely takes place in a linear fashion. It’s common for patients to relapse into the old behavior. According to the transtheoretical model, when a relapse occurs, patients cycle back toward an earlier stage — usually precontemplation. Then progression from one stage to another begins again.

Just as addictions and other harmful behaviors develop over many months or years, so, too, do changes usually require sustained effort and multiple attempts. It’s helpful for clinicians and patients to regard relapse and recycling through the stages of change not as a failure — but as a reiterative learning process.

DiClemente CC, et al. “Readiness and Stages of Change in Addiction Treatment,” American Journal of Addiction (March–April 2004): Vol. 13, No. 2, pp. 103–19.

Migneault JP, et al. “Application of the Transtheoretical Model to Substance Abuse: Historical Development and Future Directions,” Drug and Alcohol Review (Sept. 2005): Vol. 24, No. 5, pp. 437–48.

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