Recovery from addiction is about behavioural change. James Prochaska and Carlo DiClemente’s model about the stages and processes of behavioural change has made a very significant contribution to the field. (2,409 words)
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The Transtheoretical Model of Intentional Behavioural Change, originally developed by James Prochaska and Carlo DiClemente starting in the late 1970s, emerged out of the perceived need to find an integrative framework that could bring together fragmented approaches to treating problematic behaviours.
The model was derived from an analysis of the diverse theories of how people change, and their related therapies, and highlighted potential common processes that could be identified across the various perspectives. [1,2]
Early research investigations focused on how nicotine-addicted smokers were able to quit smoking. However, these investigations broadened into an exploration of how people change various addictive behaviours, both through self-change and through treatment.
As research further expanded, it became evident that the process of change is a generic one—there is a common pathway involved whenever an individual moves through intentional change, be it an addictive behaviour or a general health behaviour.
The Transtheoretical Model consists of four broad dimensions of change and their interactions—stages, processes, markers, and content of change.
1. Stages of Change
Prochaska and DiClemente proposed that intentional change comprises a series of five stages, with each stage representing specific tasks that must be completed and goals that need to be achieved if the individual is to move from one stage to the next. These stages of change are:
Precontemplation is the stage in which people have no intention of changing their behaviour. They may be at this stage because they are uninformed, or under-informed, about the consequences of their problem behaviour. Alternatively, they may have tried to change a number of times unsuccessfully and now feel demoralised.
People at this stage may be in denial. They tend to avoid reading, thinking, or talking about their problem. Their family, friends or work colleagues may see they have a problem, and may complain or pressurise the person, but they can’t see the problem.
Tasks of this stage involve an increased concern about the pattern of behaviour, an increased awareness of the need for change, and an envisioning of the possibility of change. The goal is a serious consideration of changing this behaviour.
Contemplation is the stage where people acknowledge that they have a problem and begin to think seriously about solving it. They may have difficulties in trying to understand the problem, seeing its causes, and may be unsure about solutions.
The Contemplation stage involves a process of evaluating risks and benefits, the pros and cons of both the current behaviour pattern and the potential new behaviour pattern. The person may experience a profound ambivalence that can keep people stuck in this stage for long periods of time. There must be an increase in the pros for change and decrease in the cons for the person to move to the next stage.
Preparation is the stage where people develop a plan of action and create the commitment needed to implement the plan. The person must focus their attention and energy on breaking the old behavioural pattern and creating a new one. Planning is the activity that organises the environment and develops the strategies for making change. Commitment involves finding the time and energy to implement the plan.
The tasks for the Preparation stage are to summon the courage and competencies to accomplish the change.
Action is the stage where people implement their plan of action—they make specific overt modifications in their behaviour and lifestyles. Changes during the Action stage are the most visible, and therefore receive the most recognition. However, the new behaviour must be sustained over a long period time in order to create a new habit. The old behaviour retains its attraction and returning to it is often easier than sustaining a new pattern.
The tasks in this stage are to take effective action in the face of barriers and challenges to making the change.
Maintenance is the stage where the new behaviour pattern becomes automatic, requiring little thought or effort to sustain it. The new behaviour becomes integrated into the lifestyle of the person. However, there is still an ever-present danger of reverting back to the old pattern—lapses or relapses may occur. A variety of strategies are implemented during the maintenance phase to help prevent lapses and relapse.
Termination is the ultimate goal for all people changing a problematic behaviour. This is the stage where the former addiction or other problem does not present any threat. The behaviour will never return and the person has complete confidence that they can cope without relapse. There is no continued effort in maintaining termination.
It is rare that a person moves through the stages of change in a consistent and linear manner. Some people stay in Contemplation for a long period of time, then move forward to Preparation and then backward to Contemplation and Precontemplation. Some move to Preparation and make a plan, but fail to initiate the plan effectively. Others act but fail to sustain the behavioural change and return to an earlier stage in the process of change.
People can cycle back and forward before finally reaching the Termination stage.
2. Processes of Change
The Processes of Change are the cognitive/experiential and behavioural activities that facilitate change. The extent to which each of these processes is used depends on what state of change the person who has a problematic behaviour has reached.
These processes occur in people who change their problem behaviour without professional assistance (self-changers), and in people who work with counsellors or other forms of practitioner. The processes of change for a substance use problem are:
Consciousness Raising involves increasing the awareness of a person about the causes and consequences of a substance use problem, as well as the factors that facilitate recovery, and the forms of help that are available. By increasing the amount of information available, we increase the likelihood of sensible decisions being made. Interventions that increase awareness include education, talks or written stories by people in recovery, media campaigns, and feedback from family and friends.
Emotional Arousal is a significant, often sudden, emotional experience related to the problem at hand. It parallels consciousness-raising but works at a deeper psychological level. For example, a person with a drinking problem may be deeply affected by learning of a drinking buddy’s serious motor accident under the influence. Personal stories, psychodrama, role playing, and grieving can move people emotionally.
Self Re-evaluation requires a thoughtful and emotional reappraisal of a person’s substance use problem, and an assessment of the person they would be if they overcame it. Self re-evaluation allows the person to see how and when their substance use problem conflicts with their personal values. As a result, they can come to really believe that life would be better without their problem.
Environmental Re-evaluation combines both affective and cognitive assessments of how the presence or absence of a personal behavioural problem affects one’s social environment. This includes considering the effect of one’s smoking on others, i.e. the impact of passive smoking. A heroin addict may become concerned about the impact of their addiction behaviour on their family. Environmental re-evaluation also includes the awareness that one can serve as a positive or negative role model for others.
Social Liberation involves new opportunities or alternatives that the external environment provides for a person to begin or continue their efforts to change. Examples of social liberation are easy access to clean syringes and needles, structured day care treatment programmes, and recovery communities.
Commitment (or Self-Liberation) is both the belief that one can change, and the commitment and recommitment to act on that belief. The first step of commitment is private, telling oneself that I am choosing to change. The second step is announcing to others that a firm decision to change has been made. Public commitments are more powerful that private ones.
Environmental (or Stimulus) Control involves restructuring one’s environment so that cues/stimuli that trigger or encourage substance use are removed, and cues/stimuli that encourage alternative behaviours are created. Environmental control techniques can be as simple as removing alcohol from the home, or keeping away from people with whom they have previously used drugs. Photographs of the person engaging in an alternative beneficial activity—e.g. working out in the gym or mixing with non-using friends—can be placed displayed at home.
Conditioning (or Counterconditioning) involves the learning of new healthier behaviours to replace the problem behaviours. These healthier behaviours replace substance use, as well the factors that lead to substance use (e.g. substance-related cues). Examples of counterconditioning include going for a jog when the urge to get high occurs, using relaxation to counter stress, or doing something with a friend rather than drinking alone at home. People need to find the countering activities that best suit them.
Rewards (or Reinforcement Management) of an extrinsic or intrinsic nature reinforce behavioural change and commitment to change. Alternative reinforcements begin to replace the addiction. Self-praise or praise from family and friends, buying a present with money one would otherwise used on drugs, group recognition, and gaining a job are examples of rewards that can facilitate and help maintain change.
Helping Relationships take a variety of forms, including help from family members or friends, peer support groups, and professionals (either specialist or generalist workers). It is important that these helping relationships combine empathy, trust, openness and acceptance, as well as support for the healthy behaviour change.
It is important not to make the mistake of confusing these processes of change with techniques of change. Each of the outlined processes above involves a broad strategy that may employ any number of techniques. For example, counterconditioning can involve jogging to deal with cravings, relaxation to counter stress, or positive self-statements when mood is low.
The extent to which each of these processes is used depends on what state of change the person with a problematic behaviour has reached. In fact, effective change depends on doing the right things (using the right processes) at the right time. Consider these inappropriate ways of trying to change.
Some changers rely on processes that are best suited for the early stages—consciousness-raising and self re-evaluation—whilst they are moving into the Action stage. They try to modify behaviours by becoming more aware of them. However, insight alone does not bring about lasting behavioural change.
Other people begin with processes most effective in the Action stage—reward, countering and environmental control—without having gained awareness and readiness from the early stages. However, overt action without insight is likely to lead to only temporary change at best.
3. Markers of Change
Markers of Change are signposts that help identify where a person is in two key change-related areas. The first of these areas is decision making about the change, which is called the Decisional Balance. For any contemplated change, the current (e.g. heroin use) and the new behaviour (abstinence from heroin) has its own set of pros and cons.
The individual’s personal reasons for and against the current behaviour and for and against the new behaviour result in an overall decisional balance, which will help determine whether the person moves from the Contemplation to Preparation stage, and eventually take Action or not.
The second of the Markers of Change concerns the strength of a person’s perceived ability to manage the behavioural change, measured by the self-efficacy/temptation status.
Self-Efficacy is a term used to describe a person’s confidence about performing a specific behaviour. Efficacy evaluations can represent a person’s confidence to abstain from a problematic behaviour, as well as to engage in a desired behaviour. Efficacy evaluations are typically measured across a range of situations or cues connected with engagement in the problem behaviour.
Temptation represents the strength of the desire or inclination to engage in the problem behaviour in a particular situation. Temptation is often negatively correlated with a person’s self-efficacy or confidence to abstain, but this is not always the case. Some people have strong temptations to drink in certain situations, but are confident that they can resist the temptation.
4. Context of Change
The fourth dimension concerns the Context of Change, areas of functioning that promote or hinder movement through the stages of change. Since any behaviour occurs in the context of a person’s entire life, changing a problematic behaviour has important implications for multiple areas of that life. A holistic approach is therefore required to help people overcome problematic behaviours.
The Contribution of Life Context in the process of change consists of five broad areas of functioning that represent the internal workings of the individual and important interactions with environmental influences. These broad areas of functioning are: current life situation; beliefs and attitudes; interpersonal relationships; social systems, and enduring personal characteristics.
Most often, the behaviour change target (e.g. stopping drinking alcohol) is in the foreground of focus, with the contextual areas in the background of the person’s attention. However, if, for example, family problems escalate, it can become pertinent to bring this matter to the foreground to try and address the problems.
Current Life Situation, which includes the emotional and mental status of the person as well as their current living situation, can impact on movement through the stages of change. People with more resources and fewer problems in their current life situation have a better prognosis for moving through the stages.
Beliefs and Attitudes can interact with the change process in a variety of ways. For example, the person who regularly believes they ‘know best’ may respond poorly to helpful feedback.
Interpersonal Relationships, in particular with significant others, can also promote or hinder movement through the stages in a variety of ways. Support of a loved one can be very beneficial, whilst a marriage break-up can cause stress, craving and relapse.
A variety of Social Systems in which the person exists—family, work, social network, peer-support group—may offer support for or interfere with the change process. A peer support group can provide empathy, understanding, and role models. A workplace can cause conflict and stress.
Finally, Enduring Personal Characteristics, such as being impulsive and obsessive, can hinder or promote decision making, planning, implementing the plan, and taking action.
References:
[1] Carlo DiClemente, Addiction and Change: How Addictions Develop and Addicted People Recover, The Guilford Press, 2003.
[2] James O. Prochaska, John C. Norcross and Carlo DiClemente, Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward, Harper Collins, 1994.
> Understanding Intentional Behavioural Change (pdf document)
