Can knowledge of this stages of change model help us more effectively help us work with active addicts and alcoholics? Yes!
Throughout this series, I have discussed harm reduction as a way to support people engaging in harmful behaviors who may not be ready to stop. Let's discuss a change model that may be helpful to understand how addicts (and anyone else, for that matter) work through change and potentially find recovery.
Clinical psychologists James Prochaska and Carlo DiClemente developed a behavior change model in 1983 that has been useful in tailoring supportive services to people struggling with harmful behaviors. They describe behavior change as a cyclical process, as illustrated above:
The nice thing about this model is that we all can relate to it. Suppose you think about a time you attempted to make some change (quitting smoking, eating better, starting a new gym habit, etc.). In that case, you can see yourself cycling through these changes and exiting and re-entering the cycle multiple times. Although this model applies to any desired behavior change, I will use substance abuse and addiction in the examples below.
Harm reduction methods are appropriate for people in the pre-contemplation and contemplation stages of change described below.
Pre-contemplation: People at this stage are not thinking about change at all. They may have some consequences from their substance use, but they either do not want to quit or do not believe quitting is possible. We can help people at this stage of change by building trust and rapport, which fosters engagement and opens up opportunities for movement into the next stage. Appropriate interventions for this stage are harm reduction or simply engagement in other services, such as healthcare or case management which may provide opportunities later.
Contemplation: People at this stage are becoming dissatisfied with the status quo and are wondering if things could be different. They are beginning to realize the disconnect between what they want and what they do. We can support people at this stage by eliciting pros and cons and exploring their strengths. Low self-efficacy is often an obstacle to change, so helping people increase their effectiveness through small successes or focusing on their strengths can help move them into the next stage.
Appropriate interventions at this stage are harm reduction, individual counseling, and brief interventions, which healthcare providers, social workers, and other points of contact in a person's life can do. A specific style of brief intervention called motivational interviewing helps people move from this stage to the next, and it can be a powerful tool to support change.
Preparation: People in this stage have decided they want to change and are formulating a plan. We can support people in this stage by providing resources and exploring which options are most consistent with their goals. Appropriate interventions for this stage are individual counseling, social work, case management, and support in researching treatment options.
Action: People in this stage are actively making change. This stage is generally defined as the first six months after stopping the harmful behavior (i.e., getting clean and sober). Appropriate interventions for this stage of change are inpatient or outpatient treatment, peer support groups such as AA (Alcoholics Anonymous), NA (Narcotics Anonymous), Smart Recovery, and others.
Maintenance: Once a person has maintained the change for six months and has developed tools and routines to support the change, they are in maintenance. Appropriate interventions at this stage are continued support, acknowledgment of the person's success, and respect for the person's needs to maintain sobriety.
Relapse: It is important to note that most behavior change is cyclical. Some people have the constitution to set their minds to something and unwaveringly succeed, but most don't have such grit. Change can take several tries. When relapse occurs, a person can re-enter the change cycle at any point. Some people re-enter pre-contemplation again, while others throw themselves back into action. Prochaska and DiClemente described an "upward spiral" where people learn from their relapses and improve over time (with relapses becoming less severe and less frequent). (Prochaska, DiClemente et al. 1992)
Before harm reduction and motivational interviewing interventions were developed and implemented, we had little to offer people regarding treatment or support until they were in preparation or action stages of change. Traditionally, we thought of people in earlier stages as "resistant." This model accepts all readiness levels to change as a normal part of the process. It also gives us tools to work with people not ready to change.
As a healthcare provider, I still earnestly want someone to be ready for treatment (action) when they are not. If you have a loved one struggling with addiction, you can relate to this. Identifying which stage of change your loved one is in and adjusting your approach to match it can be more effective and less frustrating than trying to get your loved one to take action they are not ready to take.
A good resource for locating local harm reduction services and getting more information about different harm reduction interventions is www.harmreduction.org.
Local resources for alcohol and drug treatment are available for people in the change cycle. Visit https://www.samhsa.gov/find-help/national-helpline. For people living outside the United States, please search for alcohol and drug treatment help in your resident country.
References:
Prochaska, J. O., et al. (1992). "In search of how people change. Applications to addictive behaviors." Am Psychol 47(9): 1102-1114.
This story was originally published on September 30, 2021.
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