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CMT8824 - SECTION 9: FIVE STAGE MODEL OF CHANGE

 

There has been significant research on the components or stages of motivation for change. The most well-developed and empirically supported model is DiClemente’s five stages of change model (precontemplation, contemplation, preparation, action, and maintenance). (36) Understanding the stages of change can be of significant help in working with involuntary clients. (9)

Let's look at these stages of change.

DeClemente's Five Stage Model of Change

Stage One - The Precontemplation Stage
Stage Two - The Contemplation Stage
Stage Three - The Preparation Stage
Stage Four - The Action Stage
Stage Five - The Maintenance Stage



Stage One - The Precontemplation Stage


In the “precontemplation” stage, individuals have no intention to change their behavior in the foreseeable future. Resistance to recognizing or modifying a problem is the principle hallmark of individuals at this stage. A useful distinction can be made between an acknowledged problem that is admitted to by an individual and an attributed problem that others say the individual has. While families, friends, and employees may feel there are problems, individuals at this stage are unaware or under-aware of their problems or they are unwilling or discouraged when it comes to changing them. If precontemplators present for treatment, they often do so because of pressure from others, such as when a spouse threatens to leave, an employer threatens to dismiss them, parents threaten to disown them, or courts threaten punishment.

They may demonstrate what some have called “psychological attrition”, whereby they show some degree of behavioral change as long as the pressure is on, but once the pressure is off, they usually return to their old behaviors.

Miller and Rollnick identify four “weights” they feel constitute the balance of indecision for AOD users at the precontemplation stage: 1) the benefits provided by AOD use, 2) the disadvantages of controlled use or nonuse, 3) the negative aspects of continued AOD use, and 4) the positive benefits of controlled use or nonuse. They feel that changes in the AOD problem behavior will not occur until this state of ambivalence is examined and the benefits of controlling their use are weighted more heavily than the costs of not controlling their use. (30)

When working with an individual at the precontemplation stage, the challenge is to try and move them to a place where they will begin to seriously examine their AOD problem and cooperate in treatment. A common strategy used by many individuals and treatment programs is to try to “break through” individual’s “resistance” through various confrontational tactics to get them to admit they have an AOD problem. However, many professionals feel it is better to use a style that some have called “rolling with the resistance” as you try to help the person move through the stages of change.

The key is to try and understand the person’s “resistance,” that is, learning more about the reasons for being at this stage. DiClemente and Velasquez say that precontemplators’ resistance to change is best summarized as the four R’s: 1) reluctance, rebellion, resignation, and rationalization. (11)

Reluctant precontemplators, rather than being actively resistant, are actually more passively reluctant to change. They may be fearful of change or comfortable where they are and do not want to risk the potential discomfort of change. For these clients, careful listening and providing feedback in a sensitive, empathic manner can be very helpful. Sometimes reluctant clients will progress rapidly once they have verbalized their reluctance, feel listened to, and begin to sort out their ambivalence, while for other individuals the seeds of change are planted for some future time.

Rebellious precontemplators often have a great deal of knowledge about their problem behavior, have a heavy investment in the behavior, and do not like being told what to do. Providing a menu of options seems to be the best strategy for working with the rebellious precontemplator, so they can begin to shift some of their energy into contemplating change rather than using it to resist. When the therapist agrees with the rebellious precontemplator that no one can force them to change, and the therapist would not think of doing so, it can have the effect of diffusing the strength of their argument. Once a rebellious precontemplator decides to change, the energy often shifts to a positive energy of determination to succeed.

The resigned precontemplators have given up on the possibility of change and seem overwhelmed by the problem. The best strategy with this type of people is to try and instill hope, explore barriers to change, and help them to see that relapse is common and is not to be view as a failure. The best way to accomplish these goals is to express your confidence in their ability to change and build confidence a bit at a time in small increments with each small change making bigger changes possible.

The rationalizing precontemplators often appear to have all of the answers. Although it may feel like rebellion, their resistance lies much more in their thinking than in their emotions. Challenges to their thinking often create a scenario where it feels like you are in a debate with them. Empathy and reflective listening seem to work best with this type of client, especially with the use of a decisional balance exercise where the client is encouraged to talk about the “good things” about their AOD behavior. They then begin to quickly realize that you are not going to argue with them and they may be more open to considering that there are also some “not so good” things about their behavior. For this process to work, it is critical that clients be able to come to their own conclusions about their behavior. Arguing for change will usually not work.

Individuals are more likely to take action to change when they perceive they have personally chosen to do so, not when they are told they have no other choice. If you only focus on the negative aspects of their use, most AOD users will be equally adamant about the positive benefits. Your goal should be to gradually help the individual shift their primary focus from the perceived benefits of their use to examining the negative consequences of their continued use. An effective strategy is to discuss with the person their life values and goals and how their AOD use may be compromising some of these aspirations. It also important to communicate to your clients that you sincerely believe they can take meaningful changes in their lives and you will help them in any way you can.

Miller and Rollnick have developed what they call “motivational interviewing” which they define as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” (31) They believe that it is the client who should be voicing the arguments for change and if therapists find themselves in the role of arguing for change while their clients are arguing against it, they are in the wrong role. When therapists wrestle with clients, one of them usually leaves the interaction frustrated and dissatisfied. They believe that client resistance behavior is a signal of dissonance in the counseling relationship.

They identify four process categories of client resistance behavior: arguing, interrupting, negating, and ignoring. How the therapist responds to the client’s resistance is what makes the difference. They feel that motivational interviewing should be more like dancing with clients and the leading is subtle and not readily apparent to the client. The therapist tries to respond in particular ways to change talk in order to reinforce it and to resistance talk in order to diminish it.

They feel that discrepancy is fundamental to change. The discrepancy is generally between the client’s present situation and a desired goal. The larger the discrepancy, the greater is the importance of change. The first part of the challenge is to intensify and then resolve ambivalence - by developing discrepancy between the client’s present situation and the desired future. Change is facilitated by communicating with the client in a way that elicits the person’s own reasons for, and advantages of, change by talking about the: 1) disadvantages of the status quo, 2) advantages of change, 3) expressing confidence in the client’s ability to change, and 4) strengthening the commitment to change.

They see the therapeutic process has having two basic phases. In the first phase the emphasis is on building motivation for change and in the second phase the emphasis is on strengthening the commitment to change through setting goals, considering change options, developing a plan, and eliciting commitment.

They identify four guiding principles that underlie motivational interviewing:

1) expressing empathy by respectfully listening to people with a desire to understanding their perspectives;
2) create and amplify, from the person’s perspective, a discrepancy between present behavior and broader goals and values;
3) rolling with resistance by actively involving the person in the process of problem solving; and
4) supporting self-efficacy by enhancing people’s belief in their ability to carry out and succeed with their plan for change.

This approach is collaborative, not prescriptive, in which the therapist evokes the person’s own intrinsic motivation and resources for change. Let's look at some of the treatment issues with clients who are in the precontemplation stage.


Working with Clients in Precontemplation Stage

No manner how clients come to therapy, most of them will have experienced some medical, social, legal, and/or occupational consequences as a result of their AOD use - and the potential for more problems will continue if they continue to use substances in an uncontrolled manner. However, even with these negative consequences, many clients will continue to deny that they have a substance use problem. Most clients will overvalue the positive role of AOD use in their lives, underestimate the seriousness of the consequences of their AOD use, and/or overestimate the negative aspects of abstinence or controlled use. Contemporary models recognize that clients vary along a continuum in the degree to which they recognize their substance use as problematic and in their personal readiness to change. The motivational models suggest that individuals initiate change when the perceived costs of the substance use behavior outweigh the perceived benefits of such use, and when they can anticipate some benefits from behavior change.

Motivation is best viewed as a state that can be influenced by therapeutic behaviors and the client’s life experiences. When clients are unwilling or unable to evaluate in a realistic way the role of drinking in their lives, the therapist’s initial responsibility is to help the client make a more realistic appraisal of the positive and negative consequences of their AOD use - and offer them a realistic way they can learn to have better control of their AOD use and improve the quality of their life. Recognition of the degree of readiness to change, use of specific motivational enhancement techniques, and nonconfrontational therapeutic style are keys to getting clients at the precontemplative stage to look at their current situation. It is typical during the first session with a reluctant client at the precontemplation stage to hear some variation of the following: “I don’t think I have a drinking problem. My wife said she’d leave me if I didn’t come here. So I’m here. But I think it’s more her problem. She is always on my case about something. Every time there is a problem, it is always my fault and it is always a result of my drinking."

In response to quantity-frequency questions, the client replied: “Well, I don’t always drink every day. I do most of my drinking at home. While during the week I may stop off at a bar after work and have a few drinks with my friends, I am usually home by 6:00 PM. I usually drink between 6 and 12 beers a night and maybe a little more on the weekends. But all of my friends drink this much, so what’s the problem." In response to questions about any negative consequences associated with his drinking, the client replies: “Except for the constant arguments that I have with my wife about my drinking, I guess I would have to say that I don’t see my drinking as being bad for me. I work hard at my job and drinking has always been a way for me to relax after work or on weekends and it is what I do with my friends.” But when further questioned about the consequences of his drinking, the client replies that he had been arrested for two DWI’s in the past three years, he has missed some work because he was too sick to go to work the day after a night of heavy drinking, and his drinking has become a constant source of arguments with his wife and kids.

Four major factors have been found to contribute to meaningful therapeutic change: 1) accurate assessment of the client’s drinking and its consequences, 2) enhancing self-efficacy by introducing a series of small, successful changes in the client’s behavior, 3) increasing positive reinforcers for abstinence in general, and 4) learning new cognitive and behavioral skills for coping with high-risk situations. However, for a client like this one at the precontemplation stage, the primary goal of the first few sessions is to try to convey to him that you (and other people in his life) feel he has a drinking problem. It is important to note that feedback about the severity of his drinking problem must be imparted in a respectful manner. It is also important that the therapist remain aware of the client's ambivalence about modifying his/her drinking and convey understanding of the difficulties involved in making such difficult decisions.

You might try a response like this: “It sounds like, compared to what your friends drink, you don’t think you drink too much. But I must tell you that, compared to a wide range of clients I have seen, and based on the severity of the negative consequences you have experienced, I see your drinking as a problem for you and your family. Most people don’t drink two six-packs at night after work. Most people come home after work and think about what’s for dinner, or what’s on TV that night, or what they need to repair around the house, or if their kid has a baseball game—not how many cold beers are left in the refrigerator, and how many they can drink before an argument starts between them and their wives and children. The major reasons I see your alcohol use as a problem is that you’ve had two DWI’s in the past 3 years, you have missed work and other responsibilities because of your drinking, and your alcohol use is negatively impacting your relationship with your wife and kids."

The therapist’s initial goal with this type of client is to try to move him to the contemplation stage. At this stage, you are not trying to force him to admit that he has a significant drinking problem. Your goal is to try to begin to shift the positive/negative balance, whereby he begins to think more about some of the negative consequences of his drinking for himself and his family. Then, he might contemplate some changes.



Stage Two - The Contemplation Stage

At the “contemplation” stage, individuals become aware that they may have a problem and are beginning to think about doing something about it, but they have not yet made a commitment to take any serious concrete action. Contemplators can remain that this stage for long periods of time as they seriously struggle with weighing the positive aspects of their AOD behavior with the amount of effort and energy it will take to overcome the problem. Part of the person wants to change and part does not. It is very important for treatment personnel to be comfortable with, and recognize, ambivalence as a vital part of the contemplation stage of change.

Contemplation does not mean commitment. It is important to remember that it can be hard to give up the known - no matter how distressing and painful - and to travel to an unknown place that will require change and risk. (19)

When working with contemplators it is important to assess how long the person has been considering change and whether they have made significant past attempts. The key is to assist the contemplator in thinking through the risks and consequences of their behavior and the potential benefits of change and to instill hope that change is possible.

The research shows that individuals with AOD problems often seek treatment because of medical, psychological, or social problems that caused, or are caused by, their AOD use rather than the use itself. Therefore, treatment personnel addressing these other areas of medical, psychological, and social functioning should also be made aware of the potential for accompanying AOD problems. In addition, AOD treatment personnel should find ways to address or make appropriate referrals for these other psychological, health, and social conditions. Personal feedback based upon a thorough assessment on the nature and extent of their problem can have a strong motivational effect to tip the scales in favor of change. But in highlighting the negative aspects of their behavior, the clinician should be careful not to paint such a negative picture that it further discourages clients from thinking that change is possible. Overcoming the ambivalence and shifting the decisional balance requires time and patience. (40)

Case Example: Client in the Contemplation Stage

James is a 55-year-old divorced, business manager, who comes to therapy with concerns with his current life situation. He came to therapy primarily because his employer felt he was underperforming at work and he suspected that drinking and depression may be factors. James reports that he is the eldest of three children. He has a younger brother and sister. He reports that his father, now deceased, was an untreated alcoholic. While his mother, now deceased, drank, she did not evidence any alcohol related problems during her lifetime. His 50-year-old younger brother has also shown signs of alcohol related problems. There is no family history of psychiatric or other drug problems. He got married two years after he graduated from college, and he and his wife have two children. Both children are now in their early 30s, married, and live in other states. He regularly communicates with his children, but sees them infrequently. He and his wife divorced five years ago. He has not remarried, but he has dated several women since his divorce. His wife has remarried and lives in the general area.

James reports that he has always been a somewhat heavy drinker, but he feels that he has been able to keep his drinking more or less under control. During his marriage, his wife frequently expressed concern about his drinking and he does acknowledge it may have been a factor in their divorce. He reports that he had one arrest for driving under the influence soon after his divorce, but he has not had an arrest since that time. However, he does report that since his arrest, he has driven while under the influence of alcohol. He does report being depressed at times about his current life situation and he does admit that his increased drinking may be related to these feelings, but the primary reasons he says he drinks is that it helps him to relax, it is a part of his social life with his primarily male friends, and he simply likes the taste of alcohol.

James reports that his drinking shows little variation from week to week, though the quantity and frequency of his drinking has increased since his divorce. Most of this drinking is done at home, though he does frequently drink when he is going out with friends and business associates (playing golf, going to sporting events, etc.). His typical pattern during the week is not to drink during the day, with the exception of perhaps a drink with lunch if he is having a business related lunch. After work, he sometimes stops at a bar to have a drink with friends and associates, but most of his drinking is done at home. He reports that at home he typically consumes three to six drinks (usually wine or mixed drinks) in the evening. He reports that during the weekend he usually starts drinking in the afternoon, often while watching a sporting event on television, or when he is out with friends, and the quantity of his drinking increases.

He does report some health problems that are probably related to his drinking. His doctor has told him to eat better, lose some weight, and get more exercise. He has not been completely honest with his doctor about how much he drinks. When questioned, he reports missing some work, or under-performing at work, because of alcohol, and alcohol-related health problems. His children have expressed concern about his appearing depressed and his drinking. When questioned, James reports that he may have experienced a blackout, or maybe he just passed-out, after a weekend of heavy drinking, and he has experienced some withdrawal symptoms, usually in the form of mild shakes. He reports that he has tried to reduce his drinking in recent years, especially during the week, but he ultimately goes back to his previous patterns. Primarily as a result of these concerns by his employer, family, and doctor, he has come to therapy, but he expresses the opinion that he is not sure he needs treatment or therapy.

James’ presentation reflects several characteristics commonly seen among people in the contemplation stage in their drinking behavior. First, he is simply thinking about making a change, although he is ambivalent about the need to make significant changes in his drinking and associated behavior.

He is reluctant to admit he has a problem with his drinking and he is not sure he wants to give up a lifestyle he has generally enjoyed for most of his adult life. His ambivalence is supported by his belief that he has been able to put some controls on his drinking when he felt it was necessary, usually as a result of direct or indirect external pressure by others.

Second, he is experiencing some distress (family, doctor, employer concerns), though the fact that - from his perspective - he has experienced few major negatives consequences from his drinking has lessened the impact of these factors. For example, he rationalizes his DWI arrest as caused more by his emotional reaction to his divorce than his drinking.

James is in the midst of contemplating the pros and cons of his behavior, and the result of his process will determine if he moves forward to the preparation stage and onto the action stage. James will not be truly committed to changing his drinking behavior until his state of ambivalence is examined and the benefits of controlling his use are weighted more heavily than the costs of not controlling his use.

The therapist working with James at this contemplation stage needs to help him better identify the negative consequences of his drinking - both for himself and others around him - while acknowledging what he feels are the positive benefits of his drinking.

If the therapist focuses only on the negative aspects of his drinking, James will be more likely to stress the positive benefits of his drinking (i.e., it helps him relax, it is part of his social life). Remember, it is difficult for most people to give up something they know and have become used to - no matter how dysfunctional - for something that is unknown to them.

Addressing this ambivalence can be accomplished by performing a comprehensive alcohol, family, and personal history, referring James for a complete physical examination, and providing him with objective feedback based upon these assessments of how his drinking may be compromising his work, family, health, personal, and social functioning.

It is important to stress with James that you sincerely believe he can make meaningful changes in his life (including his drinking behavior) and even though he is currently experiencing some external pressures to get his drinking under control, ultimately it is his decision to make and you are there to help him in this process if he wants to be helped.


Stage Three - The Preparation Stage

In the “preparation” stage, most individuals have progressed through the weighing process to conclude more or less in favor of change. They come to the point of saying that something has to change. They feel they cannot go on like this, but they are not sure what they can or are able to do. Individuals in this stage often report making some reductions in their problem behaviors, but the changes are not sustained and they do not feel they have gained sufficient control over their AOD use. Being prepared for action does not mean that all ambivalence is resolved. The challenge is to help clients develop a change plan that is acceptable, accessible, and effective. Clinicians can do this by gently warning against change plan strategies that seem inappropriate or ineffective and guiding them toward more productive alternatives.

One means of enhancing desire for entering and remaining in treatment is to identify any existing motivating forces in people’s lives and use these forces to get them more motivated for treatment. Few AOD abusers enter treatment without having experienced social network messages to seek help. The degree of social network support and how one's social network responds to a person's AOD abuse can have a significant influence on help-seeking patterns. Involving friends and family members in the recovery process can not only help to bring the individual to treatment, but it can also serve the function of educating these people about AOD problems, reduce their own interpersonal distress, and help to decrease any of their behaviors which may be enabling the abuse. Improving family relationships and functioning and helping the client to find non-AOD abusing friends should be addressed during treatment. When the individual lacks such social supports, self-help groups such as AA or NA can be very critical in the total recovery process. (6)(27)


Stage Four - The Action Stage

Many people, including treatment professionals, erroneously equate action with willingness to change and, as a consequence, overlook the requisite work that individuals must do to maintain the changes following action. In the “action” stage, individuals begin to modify their behaviors, experiences, or environment in order to begin to overcome their problems. Modification of the targeted behaviors to an acceptable level and significant overt efforts to change are the hallmarks of the action stage. However, it is important not to assume that once a person has reached the action stage, it is all downhill from here on. Clients in the action stage may still have some conflicting feeling about the changes they are beginning to make. Careful listening and monitoring what clients are doing is important in this stage including affirming what they are doing that is working and helping them to overcome any barriers they may be experiencing.

The research shows that, in general, there is a strong relationship between the amount of treatment and improvement. However, the research shows that no one school or technique is necessarily better than another, rather it is common factors across treatment that are accounting for a substantial amount of improvement found in individuals. The National Institute on Drug Abuse has identified 13 principles of effective drug addiction treatment. The principles center around the concept that programs need to be flexible with no single treatment being appropriate for all individuals, with treatment decisions guided by a thorough multiple-area assessment for each case. NIDA's 13 principles are presented in the Addendum at the end of this course.

It is possible to identify three common developmental factors in most types of therapy and treatment: support, learning, and action. The assumption is that the support functions precede changes in beliefs and attitudes, which precede attempts at action. These three factors interact with three patient factors: affective experiencing, cognitive mastery, and behavioral regulation that can be activated in diverse ways by particular treatment techniques. However, techniques cannot be separated from the human encounter. The research shows that the client-therapist relationship is very important in successful outcome, with the key being the client’s rating of therapist acceptance, understanding, and competence.

Rooney identifies a number of factors that should be examined before, and during, the initial contact with an involuntary client. Among other things, he recommends identifying:

1) from clients’ perspective, why they have been sent to treatment or choose the treatment option, and what they would like to work on;
2) if there are any non-negotiable legal requirements and the impact these requirement may have on the client and the therapist;
3) if there are any non-negotiable (the therapist’s) agency or institutional policies or requirements;
4) what rights the client has, including the right to accept the legal consequences of refusing, or not cooperating with, treatment;
5) available negotiable options (including the type of treatment the client will receive); and
6) any biases the therapist might have which may interfere with successful treatment (including biases against working with involuntary or mandated clients). (37)

To do this will require that the therapist balance a number of often conflicting roles, including enforcers of the mandated court and agency requirements; negotiators who represent the agency in working with the client; mediators in the interactions between the client and other agencies, organizations, and individuals; advocates who work on behalf of their client; and coaches who enhance their clients’ functioning. Balancing these roles effectively can be very difficult. Focusing on the client’s successful decisions, helping them with any barriers to their success, and bolstering their self-efficacy will all help to contribute to a more successful outcome.

Case Example: Client in the Action Stage

Richard is a 35-year-old single man who was initially seen at an intake evaluation session at an addiction treatment center. He is at the treatment center because he was arrested for marijuana possession and the judge agreed to suspend the possession charges if he successfully completed a drug treatment program. He reports he has been using multiple substances in various combinations since junior high school. He reports that he is currently using alcohol and marijuana generally daily and cocaine two or three times per week. He also reports he occasionally uses other drugs, usually stimulants, but that such use is infrequent (maybe once or twice a month).

Richard is the youngest of three children. His parents are in their late 50s. No one else is his family has an AOD use problem. His family has expressed concern over his long-term substance use and they feel his use has caused him long-term difficulties in maintaining meaningful jobs, being involved in meaningful relationships with women, and generally growing up and getting on with his life. Richard graduated from high school, but he dropped out of junior college after one semester. He reports that for about the last ten years he has been either unemployed or underemployed. He feels he is capable of more challenging positions that would pay a better salary and be more stimulating. He has had periods of time that he lived on his own in an apartment or with friends, but he is currently living at home with his parents.

Richard did not seek help for his AOD use problems earlier because up to this point, his use has not caused him any health problems (at least as far as he was aware), significant accidents, or arrests (before his current arrest). However, he does acknowledge that his AOD use has caused him to be depressed and frustrated about his current life situation. His substance use is supported by a group of friends and acquaintances that generally share his use patterns. They would regularly get together at someone’s house or apartment to use or they would meet at local bars to drink. He reports that he does not drink or use other substances very much at his parent’s home because they disapprove of his use, but he does frequently come home drunk or under the influence of other substances.

Richard feels that his arrest was a wake-up call for him to stop all of his AOD use. He noted that on numerous previous occasions he had made the decision to stop using one or more of the substances he was using at the time, but he had not decided to stop all AOD use. For example, on a number of occasions he had decided to stop using cocaine, but he did not feel he needed to stop his use of marijuana or alcohol. Most of these decisions came as a result of external pressure from family, friends, or employers. As a consequence, these past decisions to stop or limit his use were generally short-lived.

Richard stated that this time it was different and he had already made several steps towards controlling his use including not using any AOD for the past 7 days, he has begun attending Alcoholics Anonymous meetings, he is trying to spend less time with his AOD using friends, and he has asked his family to help him in the recovery process. By all appearances Richard is motivated and committed to make significant changes in his life.

The therapist needs to build on Richard’s resolve to meaningfully address his AOD problems. First, no matter what types of treatment is utilized, the client-therapist relationship is very important in any successful treatment. It is important that Richard perceive the therapist as competent, understanding, and supportive. Second, it is important to match Richard’s specific needs with an appropriate treatment strategy and goals. This works best when Richard has some choice in the type of treatment or how the treatment is delivered. Third, it is important to help Richard develop a support system for recovery in his social world including his family and finding non-AOD using friends. Finally, attention should be paid to relapse prevention by helping Richard to identify high-risk situations that might trigger a relapse and helping him to develop alternative coping skills. Attention to these factors will help Richard move to the next stage of his recovery, maintenance.

The therapist needs to build on Richard’s resolve to meaningfully address his AOD problems. First, no matter what types of treatment is utilized, the client-therapist relationship is very important in any successful treatment. It is important that Richard perceive the therapist as competent, understanding, and supportive.

Second, it is important to match Richard’s specific needs with an appropriate treatment strategy and goals.

This works best when Richard has some choice in the type of treatment or how the treatment is delivered. Third, it is important to help Richard develop a support system for recovery in his social world, including his family and finding non-AOD using friends.

Finally, attention should be paid to relapse prevention by helping Richard to identify high-risk situations that might trigger a relapse and helping him to develop alternative coping skills. Attention to these factors will help Richard move to the next stage of his recovery, maintenance.


Stage Five - The Maintenance Stage


“Maintenance” is the final stage in the process of change. In the maintenance stage, individuals try to stabilize their new behaviors and work to prevent relapse. For most AOD abusers, this stage extends from about six months to maybe a lifetime. In this stage, the person works to consolidate the gains they have made during the action stage and prevent relapse. Prevention of relapse is a significant issue at this stage. Many people tend to view any use of AOD during or following treatment as indicative of treatment or client failure. However, it is best to view relapse during and/or after treatment as probably the norm rather than the exception. Relapse is better viewed as a transitional process, as a series of events that may or may not be followed by a return to pretreatment levels of AOD use. It is important to help clients in this stage practice an active and intelligent maintenance of the changes they have made. (8)

Marlatt has identified three primarily high-risk situations that are associated with relapse with most AOD users: 1) negative or unpleasant emotional states, 2) recent or ongoing interpersonal conflict, and 3) direct or indirect social pressure. In many of the relapse situations, the first relapse occurs in a high-risk situation that individuals unexpectedly encounter. However, in other situations, the relapse appears to be the last link in a chain of events preceding the first relapse. Especially problematic are situations where the individual comes to feel that their desire to use AOD is justified based upon their evaluation of their circumstances. (24)

Marlatt and Gordon have identified what they call the “Abstinence Violation Effect” (AVE). They postulate that the intensity of potential for relapse will vary as a function of degree of prior effort expended to maintain abstinence, the duration of the abstinence period, and the subjective importance of the prohibited behavior to the individual. (26)

Therefore, programs need to help individuals develop expectations and skills that they can use to successfully cope with these high-risk situations. (26)

There are number of way to accomplish this goal. First, individuals must be taught how to recognize high-risk situations that may trigger a relapse. Next, there should be an assessment of the adequacy of individuals’ current coping abilities. In this way individuals can learn to develop alternative coping skill approaches for their high-risk situations. This skill-training can involve assertiveness training, stress and anger management, learning relaxation techniques, and problem-solving and social skills training. Finally, individuals should be taught that they may experience “a slip” and the expectation that this is best thought of as a unique occurrence, a mistake that does not necessarily mean they have failed in their recovery. (23)

In conclusion, for most individuals moving through these stages of change is not linear. Rather, it tends to be cyclical. Most individuals will make several attempts (including on their own and as a result of formal treatment) to modify or cease their AOD use. These relapse experiences can contribute information that can facilitate or hinder subsequent progression through the stages of change.


Case Study Introduction: Maintenance Stage

Sustaining sobriety following therapy can be difficult. In the maintenance stage, the person works to consolidate the gains attained during the action stage and prevent relapse. Relapse is probably the rule, rather than the exception, for most people trying to deal with AOD problems. For most people, change is not completely established even after 6 months or so of effective action. This is particularly true if the environment is filled with cues that can trigger the problem behavior. Relapses can occur for many different reasons. Individuals may experience a strong, unexpected urge or temptation to return to the problem behavior and fail to cope with it successfully. Sometimes relaxing their guard or testing themselves begins the slide back to the former behavior pattern. A “slip” should not be considered an utter failure, but, rather, a step back. After a relapse, people often regress to an earlier stage and then begin progressing through the stages again. Frequently, people who do relapse have a better chance of success during the next cycle.

Hopefully, based upon these experiences, they have learned new ways to deal with old behaviors, and they now have a history of partial success to build on. During these relapses, clients should be encouraged to turn to their therapist for help without feeling a sense of shame that they have failed. A relapse can either be that they have returned to the problem behavior or they are scared by their heightened desire to go back to the behavior. They come to the clinician with weakened self-efficacy and a fear that the old behavior may be stronger than they are. They seek reassurance and some way to make sense of, and deal with, the relapse. It is important for the therapist to help these clients see the crisis as an opportunity to learn rather than a failure, to problem-solve the failed plan in order to create a more effective one.

Jennifer, aged 37, and Jim, aged 49, had been married for 10 years. Jennifer and Jim have two sons, Ryan, aged 6, and Bob, aged 4. Jennifer has a bachelor’s degree and used to work in a sale support position at a manufacturing company. It was when she was working for this company that she met Jim. When Ryan was born, she left her job to be a full-time homemaker. Jim has a bachelor’s degree in business and works in sales for the manufacturing company. His job requires that he travel frequently (typically two times a month for 2 to 4 days each trip). Jennifer, by her own admission, has had a drinking problem for over 8 years. She has tried many times to stop drinking on her own including reading some book on alcoholism, talking with some friends, and attending a few AA meetings. Her longest period of sobriety has been about one month, but she quickly relapses back to her old daily drinking pattern. Jim said he was aware of Jennifer’s drinking problem, but it was not until the past year that he fully realized how much and how often she drank, and how it was affecting their family.

He has witnessed Jennifer’s struggles to stop drinking, and the positive effect on her and the household when she was sober, but he is frustrated and angry at her continued inability to control her drinking. Both of them describe their relationship as having “its ups and downs,” but they love each other and their children and they will do “whatever it takes” to work on Jennifer’s drinking problem and stay together. Jim threatened to leave Jennifer if she did not get some help for her problems. At first, she refused, saying she could stop drinking on her own, but finally she admitted that she needed to get some professional help. Jennifer reports that her father and brother had a drinking problem. Jennifer said she drank heavily in college, but when she graduated and started working, she cut back her drinking and drank socially for years. She did not drink during her pregnancy with Ryan, but after he was born she began to have a glass of wine many evenings after the baby was asleep, but before Jim came home. Jim also drinks, and she and Jim would frequently have a few drinks when he got home and if they went out on a weekend night. Her drinking slowly began to increase to where she was having two or three glasses of wine before Jim came home and another glass or two with Jim when he came home.

This drinking pattern persisted until Jennifer’s second pregnancy when she drank only an occasional glass of wine. But after Bob was born, she quickly resumed her previous drinking patterns. About the time Bob was born, Jim received a promotion which required that he work longer hours, travel more, and frequently entertain clients. Jennifer frequently accompanied Jim when he entertained clients and drinking was frequently part of the evening. While not as severe as Jennifer’s problem, Jim also has some problems with his drinking. Though his drinking is not daily, he has experienced episodes of loss of control and his quantity and frequency of drinking has increased because of his new job requirements. His drinking has an influence on Jennifer’s drinking patterns. It was decided that Jennifer and Jim were good candidates for couples therapy. Both Jennifer and Jim were highly motivated to change both of their drinking patterns, but the therapy focused primarily on Jennifer’s drinking and Jim’s contributions to her drinking problems. The course of therapy consisted of 20, sixty minute sessions.

Therapy focused on a number of areas including: teaching self-monitoring techniques (including daily monitoring of the frequency and intensity of the urge to drink, the number of drinks consumed, and marital satisfaction); identification of triggers and high-risk situations for drinking and a self-management plan for dealing with these situations; drink refusal training; attendance at AA and Al-Anon meetings; enhancement of their marriage relationship including communication skills training; and non-drinking involved lifestyle changes. Jennifer was now in the maintenance stage of her recovery. She and Jim have remained actively engaged in therapy, and despite a few slips, Jennifer has gradually cut down on her drinking to the point where she has been sober for about three months. Jennifer and Jim are beginning to feel comfortable settling into a new, sober lifestyle.

At this stage in the therapy, the therapist directly addressed the possibility of relapse and developed both preventive and responsive strategies to effectively deal with these problem situations by developing a list of signs of a potential relapse and a set of possible responses. The therapist stressed that when these signs or triggers appeared, it was time for action versus inaction or a feeling of fatalistic resignation. Working with the therapist, Jennifer and Jim developed a “relapse contract” that specified how both of them would handle these situations. It was also decided that Jennifer and Jim would continue therapy once every month, and then every 2 or subsequent months as necessary. They also decided that, in lieu of their weekly therapy sessions, they would have weekly marital meetings on their own, where they would discuss what was going on in their marriage and in their family.


As we can see from our case studies, the choice of a clinician's specific tasks and approaches are dependent upon which stage the client is in when he/she is seen in treatment.

Treatment professionals need to be aware that while they may have designed an excellent action-oriented treatment program, most AOD users are not in the action stage. The techniques and approaches for the action stage may be unsuccessful in helping clients through the earlier stages of change, and many clients may be lost along the way.

Ultimately, for substance abuse treatment programs to be effective, the program must, first of all, assess the history of the client’s recovery attempts, and assess where the client is in the stages of change.

The client's readiness for change will define what approaches are required at each step along the way, not what the clinician is comfortable in doing, or what approaches are built into the plan and structure of a treatment program. Effective treatment always involves doing the right things (process) at the right time (stages). This requires that clinicians and treatment programs have a variety of approaches and tools, and the flexibility to use them at the right time, based upon the client's needs.

Below, we will present a very brief summary of what is needed in treatment for each stage of change.

• Precontemplators need help in raising their awareness.
• Contemplators need help in resolving their ambivalence about their AOD use.
• At the preparation stage, individuals may need help in selecting the type of treatment that would work best for them.
• In the action stage, individuals may need help in carrying out treatment goals.
• Finally, in the maintenance stage, individuals need help in dealing with and avoiding relapses.

Review Questions Section IX

What is motivational interviewing and why is it important?

What are the different kinds of precontemplators, and what is the best way to work with each?

What is the Abstinence Violation Effect (AVE) and why is it important?

What are Marlatt’s three high-risk situations that are associated with relapse with most AOD users?

What are the four process categories of client resistance behavior that have been identified by Miller and Rollnick?

What are DiClemente’s five stages, and what approaches work best within each of the stages?


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