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Theories of Addiction: The Stages of Change

No one knows why it is easy for some people to overcome addiction but it’s hard for others. Some psychologists believe that the “Stages of Change” theory offers insight. According to the National Institutes of Health, 10 percent of Americans struggle with drug use disorder at some point during the course of their lives. The organization estimates that, at the moment, more than 23 million people are addicted to drugs. Fortunately, many people are able to overcome their addictions. Utilizing resources such as detox, rehab, and 12-step programs, a lot of addicts are able to put their days of drug abuse behind them. But, as overdose statistics show us, many people aren’t so lucky. The National Institute of Drug Abuse estimates that 72,000 people died of a drug overdose in 2017. Oftentimes, these overdose victims are people who’ve tried to get clean but failed. Like their sober counterparts, a lot of these folks tried rehab and NA. Sadly, not all recovery efforts are successful. If you’re here because you’re worried that you or a family member might be an addict, call us for a free phone assessment. We’ll help you to figure out whether the problem needs to be addressed. Obviously, this raises an interesting question: Why is it easy for some people to overcome addiction and hard for others? This question has persisted in the addiction research community for many years. Unfortunately, there aren’t any clear answers. But, one theory, referred to as the “Transtheoretical Model of Behavior Change”, attempts to explain why this is the case. While it’s far from a perfect theory (no theoretical model is perfect), it gives us some interesting insight into how to think about addiction. It also offers some techniques for helping addicts overcome addiction at their own pace.

Transtheoretical Model? Huh? What Does That Mean?

The “TTM” (which scientists use so that they don’t have to repeat the word “transtheoretical” too often, is a theory that was developed in the 1970s. Basically, it’s a model that some psychologists use to understand negative behaviors. Addiction is just one of the behaviors that this model attempts to explain. The theory was developed by two psychotherapists named James O. Prochaska and Carlo DiClemente. According to the ideas outlined in their writing on the Stages of Change, addiction recovery is a five-stage process. The doctors believe that, if someone tries to quit using drugs without working their way through the all of the Stages in the Model, they are likely to be unsuccessful.

What are the Stages of Change?

DiClemente and Prochaska describe the Transtheoretical Stages like this:

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Stage #1: Precontemplation

The first stage of change in the Transtheoretical Model of Behavior Change is precontemplation. During this stage, addicts tend to overlook that their behavior has negative effects on their life. Their family and friends might express concern, but an addict won’t recognize the problem. As the old saying goes, “You can’t help someone who doesn’t want to help themselves”. So, individuals in this stage are unlikely to benefit from a rehab program. During precontemplation stage, it’s helpful to approach the addict gently. No one should try to force their loved ones to take action. As DiClemente writes, “We cannot make precontemplators change, but we can help motivate them to move to contemplation.”

Stage #2: Contemplation

During the second stage, the addict realizes that they have a problem. They begin to contemplate their habit and the effects that it’s having on their life. Oftentimes, they’ll “get ready” to make a change. However, during the contemplation stage, addicts don’t commit to treatment. They may not even express their concerns out loud. Some addicts stay in this stage for long periods of time. They may move back and forth between precontemplation and contemplation before moving onto the next stage.

Stage #3: Preparation

The next stage of change, preparation, occurs when the addict considers changing their behavior. They realize that they have a problem and they understand that they need to fix something. They may say things like, “I have to do something about my life,” or, “I have a serious problem”. They might reach out to friends and family for help. They may even call clinics and research rehab programs to decide which path to take. But, they still continue to use drugs or drink alcohol. In order for therapists to consider an addict in the preparation stage, the addict must be willing to take tangible steps toward changing their behavior within 30 days.

Stage #4: Action

During this stage, addicts make active changes in their lives. They come to terms with the fact that their habit is destructive to their wellbeing. They also decide to take action in order to end it. This stage may include things like detox, rehab, drug counseling, group support meetings, and participation in other forms of treatment. Unfortunately, this stage carries the highest risk of relapse. Because the addict probably still has traces of their favorite drug still in their system, along with the fact that they are dealing with the emotional effects of addiction, they can easily fall prey to temptation. However, as long as the addict commits to getting sober, they should be able to cycle back to stage four. Some practitioners of Prochaska’s Stages of Change model believe that the best course of action is complete abstinence. However, that view is slightly outdated. It ignores that fact that the “cold turkey” approach doesn’t work for everyone.

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Stage #5: Maintenance

The final stage of change in the Transtheoretical Model doesn’t ever end. In order for an addict to stay sober, they must manage drug cravings and triggers for the rest of their lives. Of course, the cravings dissipate over time. But, the temptation to relapse remains. The body never forgets the way it felt when it was addicted. So, it takes immense self-control to maintain one’s sobriety. During this stage, the addict does not experience the rapid changes that they experience in previous stages. Ideally, they’ll find a rhythm that helps them to stay sober. Occasionally, it is necessary to make adjustments in order to avoid relapse. The longer they stay sober, however, the easier it is to maintain sobriety.

Wait…Doesn’t Prochaska’s Stages of Change Model Have a Sixth Stage?

Prochaska and DiClemente’s original model had only five stages: precontemplation, contemplation, preparation, action, and maintenance. Later on, however, a sixth step was added to the model: termination. Ideally, in the termination stage, addicts will overcome their habit and cease drug use altogether. They no longer feel threatened by their cravings and, thus, are able to abstain without effort. Many professionals argue the validity of the sixth stage. After all, termination implies that the addict’s addiction goes away entirely. Today, of course, we understand enough about addiction and its impact on the brain to know that addiction isn’t curable. So, a lot of folks in the addiction community prefer to think of maintenance as the last stage in the stage of change model. Alcoholics Anonymous is one group that takes this standpoint. The organization, known to use mantras such as “One day at a time”, encourages their members to think of sobriety a process instead of a goal.

How the Transtheoretical Model is Used in Addiction Treatment

When they developed the Stages of Change Model, Prochaska and DiClemente hoped to come up with better forms of addiction treatment. At the time, they aimed to better understand alcoholism. They thought that if they could learn more about the disease, they might be able to provide better treatment. So, in addition to describing each stage, they also outlined how patients should be treated at each stage. In an ideal situation, this systematic approach to treatment would help addicts to overcome their drug habits.

The First Step Toward Recovery: The Motivational Interview

Doctors who use the Stages of Change Model to treat addiction start by conducting an interview with their patient. This interview is known as a “motivational interview” because it’s used to determine how motivated the addict is to get clean. The doctor uses this interview to place the addict into the appropriate stage. Then, they treat them accordingly. Here’s what the treatment strategy looks like in each stage of the model: Precontemplation Stage Treatment: In this stage, patients have not yet realized the severity of their problem. If they’re undergoing a motivational interview, it’s probably because their family or the law has forced them to. Doctors who follow the Stages of Change Model to treat addiction won’t push the addict into treatment. On the other hand, they’ll work to build trust with the addict. They’ll talk to the addict about their life, history, and drug habits. They’ll also encourage the addict to come back for more meetings. Contemplation Stage Treatment: Those addicts in the contemplation stage may harbor thoughts that they are addicted. Typically, these patients have not yet come to terms with this fact. Like those in the previous stage, these addicts are usually forced into a motivational interview. Here, it’s the doctor’s job to help the addict realize the severity of the issue. Usually, they won’t express concern directly. Instead, they’ll converse with the addict on the topic of addiction. The goal is to get the addict to realize on their own that drugs are affecting their life. Ideally, the addict will admit that they are powerless over drugs and hope to change. Preparation Stage Treatment: According to Prochaska’s Stages of Change Model, addicts in the preparation stage are ready to quit but haven’t yet attempted to. These addicts might end up in a doctor’s office after calling a hotline or reaching out for help in some other way. In this stage, the doctor tries to help the addict plan. They assess the addict’s goals and discuss different treatment options. Therapists coach the patient to prepare them for the emotional effects of sobriety. Action Stage Treatment: This stage of addiction recovery occurs when the addict takes tangible steps toward sobriety. Together, the doctor and the patient act out the plan that they devised in the preparation stage. Throughout this stage, the doctor encourages the patient to remain clean. The doctor reminds the addict why they are getting sober and how important it is to avoid relapsing. Addicts don’t move on to the next step until they’ve achieved a stable, sober state. Maintenance Stage Treatment: Once the addict is in a stable place, they move into the maintenance stage. Just because they’ve gotten clean, however, doesn’t mean that they’re done with their therapist. Oftentimes, addicts work with the same psychotherapists long after they’ve gotten sober. Early on in the maintenance stage, the doctor helps them to plan for the future. They discuss the addict’s triggers and urges. They also work together to develop techniques for avoiding triggers and fighting urges. As time goes on, the therapist helps the addict to live the healthiest, most fruitful life possible.

How the Stages of Change Model Approaches Relapse

According to the transtheoretical model, relapse is a sad reality of addiction. While some addicts are able to get clean on their first attempt, others aren’t. As a result, most psychotherapists encourage their patients to see relapse as a learning experience. If the client is committed to recovery, they’re allowed to re-enter the cycle at the beginning and move through the stages once again. While the addict works through the stages, the doctor helps them to identify what went wrong on their first attempt. Both parties work to pinpoint unidentified triggers, answer unanswered questions and devise new solutions for managing cravings. It’s important for addicts to understand that relapses happen. Just because someone relapses doesn’t mean that hope is lost. One of the strengths of this model is that it allows space for addicts to re-enter recovery after a relapse.

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What does the Transtheoretical Model Teach Us About Addiction?

While the theory certainly has its critics, many doctors believe that the transtheoretical model is the most effective approach to addiction treatment. These doctors find the model effective because of the way it treats recovery as a slow process instead of a quick one. One proponent of the theory is Dr. Alex Lickerman, who writes about the Stages of Change in his article, “5 Steps to Changing Any Behavior”. “The true power of this model really becomes apparent when we recognize these stages are sequential and conditional,” he writes. In other words, this model works because it approaches recovery as a step-by-step process. Unless the doctor sees evidence that the patient is ready to progress onto the next stage, they won’t rush the addict into treatment. Using cigarette smokers as an example, Dr. Lickerman writes, “A smoker whose never seriously considered giving up tobacco would be in the stage of Precontemplation—if I expected them to jump from that stage…directly to Action, they’d almost certainly to change and frustrate us both.” According to Dr. Lickerman, the best thing about the Stages of Change Model is that it helps the addict to recover in small increments. That way, they aren’t overwhelmed by the prospect of recovery. “Focus on reaching the next stage rather than the end goal,” he advises, “[Sobriety] may seem too far away and therefore discourage you from even starting on the path towards it.”

Making Changes in Stages

Most addicts aren’t able to quit on their first try. The National Institute on Drug Abuse estimates that 40% to 60% of addicts relapse after they get clean the first time. Some might argue that these relapses occur because the addict fails to receive professional treatment. But, even those who go through alcohol detox or drug rehab fall prey to the temptation to relapse. Proponents of the Transtheoretical Model have different ideas about why relapses occur. Most of them believe that relapse comes down to a matter of readiness. If a therapist can thoroughly prepare their patients for the physical and emotional side effects of each Stage of Change, the addict has a better chance of staying sober in the long run. An article published in Harvard Women’s Health Watch unpacks this concept. “The idea is that each stage is a preparation for the following one, so you mustn’t hurry through or skip stages,” the authors write. “Also, different approaches and strategies (called ‘processes of change’ in the TTM model are needed at different stages.” Echoing Dr. Lickerman’s thoughts, the authors discuss how a smoker might move through the Stages of Change. “A smoke who’s at the precontemplation stage—that is, not even thinking about quitting—probably isn’t ready to make a list of alternatives to smoking.” Therefore, the TTM model allows therapists to assess the addict’s habits at the moment. If the doctor can identify where on the spectrum their patient lies, it’s more likely that they’ll be able to help the addict move forward toward sobriety.

Sounds Like an Outdated Idea? TTM was Radical For Its Time

To some, the Stages of Change model might sound like old news at this point. Addiction recovery as a process? Step-by-step treatment? These ideas are used in Narcotics Anonymous, SMART Recovery, and a host of other addiction treatment programs. But, when Prochaska and DiClemente developed the Model in the 70’s, it was a relatively radical idea. After all, at that time, most people believed that drug addiction and alcoholism were matters of willpower. Doctors, scientists, and the general public thought that an addict could simply quit using drugs if they really wanted to. Of course, this sentiment still exists today. Some non-addicts still believe that addicts can simply quit. But, most scientists understand that addiction is a brain disease. The idea that addicts need to slowly retrain their brains in order to get clean was a radical theory. But, it’s been quite influential in the addiction treatment field. The theory is so influential, in fact, that DiClemente and Prochaska are listed on the American Psychological Association’s list of Most Cited Psychology Researchers.

A Few Glaring Flaws in the Stages of Change Model

As it was pointed out above, Prochaska and DiClemente’s theory is not perfect. It was developed in another era before scientists understood much of what they know about the brain today. As a result, some see the Transtheoretical Model as an outdated tool. Here are a few problems that some scientists have with the Model: Rigid Timelines: The original Model assigns timelines to each Stage of Change. For example, the developers believed that the Preparation Stage should take no longer than six months. This is one of the biggest points of contention with critics. It doesn’t account for the fact that everyone is different and may take longer to move to the next stage. Blurred boundaries: Some argue that the Stages aren’t as clearly defined as Prochaska and DiClemente believe. Robert West argues this point in a research paper. “It has to draw arbitrary dividing lines in order to differentiate between the stages,” West writes. In order for TTM to work, therefore, therapists must have specific benchmarks that signify the beginning and end of each stage. Ignores Addict’s Needs: Some people argue that the Model ignores addicts who lack the desire to change. Because it lumps all pre-contemplative behavior into the first Stage, the Model could encourage addicts to keep using. In the worst case scenario, an addict might overdose simply because their doctor doesn’t want to suggest rehab too early. Ultimately, many doctors believe that this model is an ineffective way to view and treat addiction. But, Prochaska and DiClemente are open to the review of their work. Since their original writings were published in 1977, the two doctors have revisited, repurposed, revised, and expanded upon the ideas put forth in their work.

Stages of Change or Not…It’s Important to Get Help

It’s tough to say whether the Transtheoretical Model is still relevant or not. In the end, it’s up to the doctors who use it and their patients. One thing is for certain though—addicts who have a problem should seek some sort of help. Whether they visit a therapist, check into drug detox, or attend a 12-step meeting, addicts should reach out to someone. The effects of a prolonged drug addiction are disastrous. Without proper treatment, addicts are at risk of all kinds of consequences including overdose. If you’re interested in learning more about the various models for addiction treatment, contact us. We are happy to assess your habit and suggest some treatment options that might work best for you. [kkstarratings]