Motivation: Stages of Change Model
Let’s face it. Recovery from addiction is not an easy task. In fact, change of any sort is usually somewhat stressful and uncomfortable. Whether or not someone attempts natural recovery or gets help, “something” must change. In other words, “something” must cause them to move away from addiction and toward recovery. That “something” is the motivation to change.
Throughout this topic center on addiction, we have stressed that recovery is fundamentally about the motivation to change. At some point in every addicted person’s life, there comes a moment when they realize they need to change. The difference between those who successfully make the needed changes, and those who do not, comes down to motivation. Since motivation is so critical to recovery, it is important for therapists and therapy participants alike to understand the motivation for change. This includes understanding the degree of motivation; the type of motivation; as well as understanding various ways to increase motivation. Once sufficiently motivated, people can and do change.
Most of us recognize that change is not an event that suddenly occurs. Rather, it is a process that gradually unfolds over time. As this process begins to unfold, a person’s motivation changes. The most popular framework for discussing motivation to change is the Stages of Change Model developed by James Prochaska, Ph.D. and Carlo DiClimente, Ph.D. Their work began during the late 1970s when they became interested in the way people change. They developed, tested, and refined the Stages of Change Model. This model is one of the most widely used and accepted models within the field of addiction treatment.
In Changing for Good (1994), Prochaska and DiClemente describe the six stages of change:
Stage #1: Pre-Contemplation
People at this stage may be aware of the costs of their addiction. However, they do not see them as significant as compared to the benefits. Of course, others may view this situation differently. Characteristics of this stage are a lack of interest in change and have no plan or intention to change. We might describe this person as unaware.
People in the contemplation stage have become aware of problems associated with their behavior. However, they are ambivalent about whether or not it is worthwhile to change. Characteristics of this stage are: exploring the potential to change; desiring change but lacking the confidence and commitment to change behavior; and having the intention to change at some unspecified time in the future. We might describe this person as aware and open to change.
Between stage 2 and 3: A decision is made. People conclude that the negatives of their behavior outweigh the positives. They choose to change their behavior. They make a commitment to change. This decision represents an event, not a process.
Stage #3: Preparation
At this stage, people accept responsibility to change their behavior. They evaluate and select techniques for behavioral change. Characteristics of this stage include: developing a plan to make the needed changes; building confidence and commitment to change; and having the intention to change within one month. We might describe this person as willing to change and anticipating of the benefits of change.
Stage #4: Action
At this stage, people engage in self-directed behavioral change efforts while gaining new insights and developing new skills. Although these change efforts are self-directed, outside help may be sought. This might include rehab or therapy. Characteristics of this stage include: consciously choosing new behavior; learning to overcome the tendencies toward unwanted behavior; and engaging in change actions for less than six months. We might describe this person as enthusiastically embracing change and gaining momentum.
Stage #5: Maintenance
People in the maintenance stage have mastered the ability to sustain new behavior with minimal effort. They have established new behavioral patterns and self-control. Characteristics of this stage include: remaining alert to high-risk situations; maintaining a focus on relapse prevention; and behavioral change that has been sustained six months. We might describe this person as persevering and consolidating their change efforts. They are integrating change into the way they live their life.
Stage #6: Termination
At the termination stage, people have adopted a new self-image consistent with desired behavior and lifestyle. They do not react to temptation in any situation. Characteristics of this stage include confidence; enjoying self-control; and appreciation of a healthier and happier life. The relapse prevention plan has evolved into the pursuit of a meaningful and healthy lifestyle. As such, relapse into the former way of life becomes almost unthinkable.
Note: Relapse to a prior stage can occur anywhere during this process. For example, someone in the action stage may move back to the contemplation or pre-contemplation stage.
Prochaska and DiClemente initially developed this model to describe the process of adopting any healthy behavior. However, it is particularly useful in addictions treatment. Ordinarily, most psychological, behavioral, emotional, or relationship difficulties cause people to experience acute distress. This distress is sufficiently motivating and they are ready to change. They typically enter treatment at Stage 3 Preparation or Stage 4 Action. For example, consider the person with depression. They clearly do not get any enjoyment or benefit from being depressed. By the time they seek treatment, they are usually ready and motivated to make needed changes so that they can feel better. They are not ambivalent about whether or not they want to remain depressed.
In contrast, many people enter addiction treatment against their will. Sometimes this is in response to a court order. Other times it may be their partner has threatened to leave. Or, perhaps they are about to lose their job. In other words, their external environment is motivating them to change. However, they are not completely certain they want to change. They are ambivalent. Unlike our example of a depressed person, the addiction still has some appeal.
This ambivalence is one of the key differences between addictive disorders and other types of mental health concerns. Unlike most other types of mental disorders, people with addictive disorders often enter treatment at Stage 1 Pre-contemplation or Stage 2 Contemplation. Therefore, their treatment does not begin by helping them to make changes as it might for a depressed person. Instead, treatment focuses on strengthening the motivation for change. This requires a specific therapeutic strategy. Motivational Interviewing LINK is one such strategy.
Therapists often serve as “change agents.” For this reason, the Stages of Change Model has been particularly useful for therapists. Prior to the development of this model, many therapists discharged patients seeking addiction treatment because they “lacked motivation.” Therapists considered these patients untreatable due to this apparent lack of motivation. We now know that therapists working with addictive disorders may be required to help someone to strengthen their motivation for change. Furthermore, the Stages of Change Model helps clinicians identify which therapeutic strategies would be best suited for a particular therapy participant, at a particular point in time. For instance, motivational interviewing is most suitable for people in the pre-contemplation and contemplation stage of change. On the other hand, relapse prevention is a strategy that is most suitable for people in either the action or maintenance stage of change. Contingency management, cognitive-behavioral therapy, dialectical behavior therapy, and acceptance and commitment therapy are treatment approaches that are most suitable to an action stage. As therapy participants move through the various stages of change, therapists adjust their therapeutic approach to match the participant’s changing motivation.