Processes Of Change Model

Historically, changing an addictive behavior was assumed to be the same as taking action. People with addictions were viewed as changing when they quit drinking, smoking, or abusing other substances. Action-oriented therapies were readily available but only a small percentage of addicted individuals entered therapy, only about 50 percent completed therapy and only 25 to 35 percent were successful in overcoming their addiction following therapy. Action-oriented therapies impacted on a small percentage of addiction problems on a population basis.

In the late 1970s one-thousand ordinary people attempting to stop smoking taught us that change is a process which unfolds over time and involves progress through six stages of change: pre-contemplation, contemplation, preparation, action, maintenance, and termination. Creating therapies that match the needs of people at each stage of change has permitted us to reach, retain, and impact on more people than we ever imagined possible. How can therapy help people progress across the stages?

In precontemplation, people to not intend to take action in the foreseeable future. Individuals in this stage may be unaware or under-aware of their problems. Families, friends, or employers, however, are often well aware that precontemplators have problems. When precontemplators present for psychotherapy, they often do so because of pressure. Often, they feel coerced into counseling by spouses, employers, parents, or courts that threaten to punish them.

These clients are at risk of dropping out of therapy quickly and prematurely. So the first therapeutic strategy is drop-out prevention: ''How can I help you to stay in therapy long enough to have it make a significant difference in your life?'' Fortunately, if therapists match interventions to the client's stage, precontemplators will complete therapy at the same rate as those in preparation.

Stage matching begins by setting realistic goals. If therapists pressure precontemplators into immediate action, they will keep clients away or drive them away from counseling. Historically, thera pists labeled such clients as unmotivated, noncom-pliant, resistant, or not ready for therapy. But, it was therapists who were not ready for them, nor motivated to match clients' needs, and were resistant to changing their paradigms and practices.

The goal is to help precontemplators progress to contemplation. This initial goal produces success early in treatment. Consciousness-raising is used to help clients become aware of how they defend against pressures to quit when they are not ready. ''How do you react when someone tries to pressure you to quit drinking or smoking? ' Common responses include, ''I get angry,'' ''I withdraw,'' ''I tell them to mind their own business,'' ''I change the topic,'' or ''I minimize the problem.''

As precontemplators become aware of their defenses and start to drop them, they can process more of the pros of therapy. ''We're not here just to help you understand your substance use. Therapy can help you be less defensive and happier, raise your esteem, improve your relationships, and help you make more money.'' As the pros of changing increase, we know that clients are progressing into contemplation.

Contemplators intend to take action in the next 6 months. Awareness of the pros of changing increase, but the cons also increase. Once clients intend to stop substance abuse, they confront the costs or cons. ''Am I ready to give up my substance of choice that has been a good friend? Am I prepared to pay the price of time, effort, emotion and the risk of failure?''

A delicate balance between the pros and cons produces a profound ambivalence that causes some people to procrastinate. The love-hate relationship with their ''good friend'' can fool therapists into assuming that these clients are ready for immediate action. In fact, their rule of thumb is, ''When in doubt, don't act!''

The goal for these clients is to progress to preparation. Their perception of the cons of quitting must change. They may need anticipatory grief counseling during which they mourn the loss of a good friend. They need to reevaluate how they think and feel about themselves as an addict and how they imagine themselves free from addiction.

Their cons have to decrease only about half as much as their pros increase, so in stage-matched treatments we place twice as much emphasis on the benefits of changing. Typically, there are more than forty scientific benefits to becoming free from an addiction. One way to enhance motivation is to become aware of how much of one's body, self, social relations, and society benefit from such major changes.

People in preparation are convinced the pros of changing outweigh the cons. They are ready to take immediate action. But, they need to be prepared for how long action will last. Many clients think the worst will be over in a matter of days or weeks. Biologically, the worst is over that quickly as they go through withdrawal. Behaviorally, however, people have to be prepared to work the hardest for about 6 months.

Clients are encouraged to think of such action as the behavioral equivalent of a life-saving surgery: ''Would you inform people that recovery has to be your top priority for 6 months; that you can't be at your best and that you will need their support to get through this toughest of times?''

After 6 months, clients progress into the maintenance stage where they do not have to work nearly as hard but they still have to work to prevent relapse. How long does maintenance last? Some people believe it is a lifetime: Addicts are always in recovery and never recovered. Evidence suggests maintenance lasts 4 to 5 years. With smoking, for example, the national data in the 1990 Surgeon General's Report indicated that after 12 months of not a single puff, the percent of smokers who resume regular smoking is about 40 percent. After 5 years of total abstinence the relapse rate drops to 5 percent. When is cancer cured? Cures are counted after 5 years of no symptoms or remission. Some of the most common cases of cancer, and chronic diseases take five years to be cured.

Therapy will not continue indefinitely. But, clients will need to be prepared to cope with the most common causes of relapse. Across addictions, the most common cause is emotional distress: times of anxiety, anger, depression, boredom, loneliness, and stress. How do average Americans cope with such distress? They drink more, smoke more, eat more, and take more over-the-counter drugs and illicit drugs.

What are healthy alternatives during times of temptation? Three choices are:

(1) talking or social support;

(2) relaxing via yoga, meditation, prayer, or some other form of releasing stress or distress; and

(3) exercise or physical activity as an excellent way to manage moods, stress, and distress.

Clients need to develop a plan for how they will cope in the face of inevitable distress that will hit when therapy has stopped.

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