Summary by Mirela Feurdean, MD, FACP
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Based on “Principles of Addiction Medicine” Chapter by James O. Prochaska, PhD
Change is a process that unfolds over time through a series of stages. People’s motivation to change (and their response to a certain therapeutic intervention) depends on where they are within this stepwise process.
THE STAGES OF CHANGE
According to Dr. Prochaska’s model of change, these stages are precontemplation, contemplation, preparation, action, maintenance, and termination. There appears to be no inherent motivation for people to progress from one stage to the next; instead three major forces may trigger transition: developmental events (e.g., aging), environmental events (e.g., illness), and planned intervention (e.g., early professional intervention at first sign of serious illness).
1. Precontemplation. At this stage, the individuals do not intend to take action in the foreseeable future (usually measured as the next 6 months), typically because they are either uninformed or underinformed about the consequences of a given behavior, or are demoralized after several failed attempts to change. They tend to avoid reading, talking, or thinking about their high-risk behaviors and typically underestimate the benefits of change and overestimate its costs but are unaware that they are making such mistakes.
2. Contemplation. At this stage, individuals intend to take action within the ensuing 6 months. They are more aware of the benefits of changing but also increasingly aware of the costs of changing. This can produce profound ambivalence that can keep someone stuck at the contemplation stage for long periods of time (i.e., “chronic contemplation,” “behavioral procrastination”). Such individuals are not ready for traditional action-oriented programs.
3. Preparation. At this stage, the individuals plan to take action in the immediate future (usually measured as the ensuing month). They typically have made significant progress over the preceding year and generally have a plan of action. At this stage, patients should be recruited for action-oriented treatment programs.
4. Action. At this stage, individuals have already made specific, observable changes in their behavior within the preceding 6 months. However, in the transtheoretical model (TTM), only behavior modifications that are sufficient to reduce the risk of disease count as action (e.g., total abstinence for smokers).
5. Maintenance. At this stage, individuals are working actively to prevent relapse. Maintenance may last from several months to years. Easing up on efforts too early increases the risk for relapse; as such, patients should be encouraged to think of overcoming an addiction as running a marathon rather than a sprint. Patients need to be prepared to cope with emotional distress without falling back on addictive substances. Suggested alternatives to relapse include talking with others about one’s distress, exercise, meditation, yoga, and spiritual or religious pursuits.
6. Termination. At this stage, individuals experience zero temptation and 100% self-efficacy. In a study of former smokers and alcoholics, fewer than 20% of each group had reached the stage of no temptation and total self-efficacy. Although the ideal is to be cured or totally recovered, it is important to recognize that for many patients, a more realistic expectation is a lifetime of the maintenance stage.
USING THE STAGES OF CHANGE MODEL TO MOTIVATE PATIENTS
To enhance patient’s motivation to enter therapy for addiction and maximize the therapeutic effect, the patient’s stage of change should be matched to the appropriate phase of intervention. The five phases are (1) recruitment, (2) retention, (3) progress, (4) process, and (5) outcomes.
Recruitment
Published data show clearly that traditional (passive–reactive) recruitment programs reach too few people with addictive disorders. Given that addictive disorders are among the costliest of contemporary conditions, we must approach them at a population level by proactive (outreach) recruitment followed by stage-matched interventions, preferably embedded within primary care settings (patient-centered medical home model). This approach has been shown to increase recruitment rates, although retention rates and complete abstinence are still poor.
Retention
Nearly 50% of patients drop out of treatment, with few consistent predictors of premature termination. Among strategies proven to enhance retention are pretreatment motivational interviewing and treatment strategies matched to patient’s stage of readiness to change.
Progress
The amount of successful action taken during and after treatment is directly related to the stage at which the person entered treatment (“stage effect”). One strategy for applying the stage effect clinically involves setting realistic goals for brief encounters with patients at each stage of change. In addition to helping more patients, witnessing the progress through stages may dramatically increase the morale of the health professionals involved in caring for the patient.
Process
To help motivate patients to progress from one stage to the next, it is important to understand and apply the principles and processes of change that can produce such progress.
- Principle 1: The benefits from changing must increase if patients are to progress beyond precontemplation. (Technique: ask the patient to describe all the benefits of a behavioral change such as quitting smoking or starting to exercise. Challenge the patient to double or triple the list for the next meeting. If the patient’s list of benefits grows, he or she will be more motivated to begin to seriously contemplate such a change.)
- Principle 2: The “cons” of changing must decrease if patients are to progress from contemplation to action.
- Principle 3: The relative weight assigned to benefits of change must be greater than the costs of change before a patient will be prepared to take action.
- Principle 4: To progress from precontemplation to effective action, the rewards for changing must increase by one standard deviation (“The strong principle of progress”).
- Principle 5: To progress from contemplation to effective action, the perceived costs of changing must decrease by one-half SD (“The weak principle of progress”). Because the perceived benefits for changing must increase twice as much as the perceived costs decrease, twice as much emphasis must be placed on the benefits than the costs of changing.
- Principle 6: It is important to match particular processes of change with specific stages of change. Processes are compatible with each other and can be combined in a stage-matched paradigm (Table 55-1).
a. Consciousness raising involves increased awareness of causes, consequences, and responses to a particular problem, with a focus to increase the perceived rewards for changing. (Use observations, interpretations, personal feedback, education, and less confrontations.)
b. Dramatic relief involves emotional arousal about one’s current behavior. (Use psychodrama, role playing, grieving, and personal testimonies.)
c. Environmental reevaluation involves affective and cognitive assessments of how addiction affects one’s social environment and how changing would affect that environment. (Use empathy training, values clarification, and family or network interventions.).
d. Self-reevaluation combines both cognitive and affective assessments of an image of one’s self that is free from addiction. (Use imagery, healthier role models, and values clarification.).
e. Self-liberation involves both the belief that one can change and the commitment and recommitment to act on that belief. (Use public rather than private commitments; give two or three best choices for applying each process.)
f. Counterconditioning requires the learning of healthier behaviors that can substitute for addictive behaviors. (Use desensitization, assertion, and cognitive counters to irrational self-statements that can elicit distress.)
g. Contingency management involves the systematic use of reinforcements and punishments for taking steps in a particular direction. It is better to emphasize reinforcements for progressing rather than punishments for regressing. Teach patients to rely more on self-reinforcements than social reinforcements. (Use contingency contracts, overt and covert reinforcements, and group recognition.)
h. Stimulus control involves modifying the environment to increase cues that prompt healthy responses and decrease cues that lead to relapse (e.g., avoidance, removing addictive substances and paraphernalia, self-help groups).
i. Helping relationships combine caring, openness, trust, and acceptance, as well as support for changing (e.g., rapport building, therapeutic alliance, counselor calls, buddy systems, sponsors, and self-help groups). If the patient becomes dependent on such support, it will have to be carefully faded, lest termination become a trigger for relapse.
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