SOC8385 - SECTION 3: THE FIVE-STAGE MODEL OF CHANGE
Motivation in Terms of Stages
A very effective strategy for dealing with people who are ambivalent or resistant about changing problem behavior is to see motivation for change as consisting of stages. 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 (2003) five stages of change model. The five stages are: precontemplation, contemplation, preparation, action, and maintenance. The key is to match the therapeutic interventions to the person’s stage of change.
Five-Stage Model for Change
In the precontemplation stage, people have no intention of changing their behavior in the foreseeable future. Resistance to recognizing or modifying a problem is the principle hallmark of people at this stage. This applies whether change means modifying or stopping the problem behavior. Despite what other people may say, people at this stage, see change as irrelevant, unwanted, not needed, or impossible to achieve.
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, employers, school and legal officials may feel there are problems, people at this stage are unaware or underaware 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 or as a requirement from others. Their first question to the counselor is often: “How can I get these people to stop nagging me about_______?” They may be very resistant to treatment or they may demonstrate what some have called psychological attrition, whereby they evidence 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.
Types of Precontemplators
Precontemplators' resistance to change is best summarized as the four R’s: reluctance, rebellion, resignation, and rationalization (DiClemente & Velasquez, 2002). 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 people, careful listening and providing feedback in a sensitive, empathic manner can be very helpful.
Sometimes reluctant precontemplators will progress rapidly once they have verbalized their reluctance, feel listened to, and begin to sort out their ambivalence, while for other people 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 they 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 that they can begin to shift some of their energy into contemplating change rather than using it to resist.
When the counselor agrees with the rebellious precontemplator that no one can force them to change, and the counselor 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 person is to try and instill hope, explore barriers to change, and help them to see that relapse is common and is not to be viewed 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 where it begins to feel like you are in a debate. Empathy and reflective listening seem to work best with this type of person especially with the use of a decisional balance exercise where the person is encouraged to talk about the “good things” about their problem behavior.
Hopefully, they will then begin to realize that the counselor is 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 people be able to come to their own conclusions about their behavior. Arguing for change will usually not work.
For most people there is a simultaneous sense of both wanting and not wanting to change, of liking and disliking the experience, of taking the risk and not taking the risk. At the beginning, most people generally ignore the negative aspects of their problem behavior and they cling to the part of the experience that produces positive consequences for them. As the negative consequences increase, people may become more aware of their ambivalence and they may begin to express a wish to quit or control their behavior. Until the person begins to realize that the costs of the behavior exceed the benefits, they are unlikely to want to stop. Meaningful change will not occur until this state of ambivalence is examined.
Because precontemplators have not begun this process, they can often be very demoralized about their problem. They do not want to think, talk, or read about their problem because they either do not feel they have a problem or they feel the situation is hopeless.
When working with people at the precontemplation stage, the challenge is to try to move them to a place where they will begin to seriously examine their problem behavior. A common strategy used by many counselors and treatment programs is to try to “break through” the person’s “resistance” through various confrontational tactics.
The research consistently shows that using these confrontational tactics typically do not work with most people. If the intervention focuses only on convincing the person to change their behavior, most people at this stage of motivation will then be equally dogmatic that they do not have a problem and they are committed to continuing their behavior.
If the counselor only focuses on the negative aspects of their behavior, most people will be equally adamant about the positive benefits. Most people are more likely to take action to change when they perceive they have personally chosen to do so, not when they are told to do so.
Benjamin Franklin reportedly has his own method for making complex decisions. He drew a line down the middle of a page, then listed the pros and cons, making an estimation of their relative importance or weights as a means of reaching a conclusion.
A slight variation of the decision balance sheet is to construct four columns with benefits and costs of continuing the problem behavior and benefits and costs of discontinuing the problem behavior. Research and clinical experience has shown that having clients construct such a decisional balance sheet can begin to influence their motivation for change.
It is also useful for the counselor because it clarifies the positive and negative expectations the person has for continuing their problem behavior. The counselor can then discuss with the client alternative ways to achieve the desired benefits the problem behavior provides.
Instead of actively confronting the client’s resistance, many treatment professionals feel it is better to go along with the resistance as the counselor tries to help the person move through the stages of change. The key is to try to understand people’s ambivalence and resistance - that is, try to learn more about their reasons for being at this motivation stage.
The goal should be to gradually help people shift their primary focus from the perceived benefits of their behavior to begin to examine some of the negative consequences of the behavior. An effective strategy is to discuss with the person their life values and goals and how their problem behavior may be compromising some of these aspirations. It also important to communicate to people that you sincerely believe they can take meaningful changes in their lives and you will help them in any way you can.
Case Example: Client in the Precontemplation Stage
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, but 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 questions about how much he drinks, 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 4 and 8 beers a night and 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.”
When further questioned about the consequences of his drinking, the client replies that he had been arrested for one DWI’s in the past year, 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 controlling the drinking, and 4) learning new cognitive and behavioral skills for coping with high-risk situations.
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. Feedback about the severity of his drinking problem must be imparted in a respectful manner. It is important that the counselor remain aware of his ambivalence about modifying his drinking and convey understanding of the difficulties involved in making such difficult decisions and not try to talk him into believing he has a drinking problem.
You might try a response like this: “It sounds like, compared to what your friends drink, you don’t think you drink too much. However, 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 4 to 8 beers 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 only goal with this type of client is to try and 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, but 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 and he might contemplate some changes.
Consideration of the value and the need for change represents movement into the contemplation stage. People who say “I want to stop feeling so stuck” or “I am tired of feeling like a drunk” are at the contemplation stage. At the contemplation stage, people become aware that they may have a problem and are beginning to think about doing something about it, but they are struggling with the problem and 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 continuing their behavior with the amount of effort and energy it will take to overcome the problem. At this stage, part of the person wants to change and part does not. Fear of failure can keep people contemplating change for long periods of time.
The contemplation stage involves a process of evaluating risks and benefits, the pros and cons of both current behavior patterns and the potential new behavior patterns. The task for contemplators is to resolve their decisional considerations in favor of change. It is very important for treatment personnel to be comfortable with, and recognize, ambivalence as a vital part of the contemplation stage of change.
When working with contemplators it is important to assess how long people have been considering change and whether they have made significant past attempts. It is important to remember that contemplation does not mean commitment. Researchers have found, in a representative sample across more than fifteen high-risk behaviors, that less than 20% of a problem population is prepared for action at any given time. However, more than 90% of behavior change programs are designed with this 20% in mind (Prochaska, Norcross, & DiClemente, 1997).
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 (Joe, Simpson, & Broome, 1998). The key is to assist contemplators in thinking through the risks and consequences of their behavior and the potential benefits of change and to instill hope that change is possible. 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.
In highlighting the negative aspects of their behavior, the counselor should be careful not to paint such a negative picture that it further discourages people from thinking that change is possible. Overcoming the ambivalence and shifting the decisional balance requires time and patience (Trotter, 1999). The decision to try to change marks the transition out of the contemplation stage and into preparation.
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 see 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 being drunk and disorderly outside a bar soon after his divorce, but he has not had an arrest since that time. 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 way alcohol makes him feel if he does not drink too much.
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 to not drink during the day with the exception of maybe having a drink with lunch if he is having a business related lunch. After work, he sometimes stops at a bar to have 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 to be depressed.
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’s 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 though 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 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 control his use.
The counselor 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 counselor 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).
Addressing this ambivalence can be accomplished by doing a comprehensive alcohol, family, and personal history, referring James for a complete physical examination, and providing him with objective feedback - based upon these assessments - on 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 experiences 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.
In the preparation stage, most people 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. People at this stage of change may make their intentions public announcing that they are going to “stop drinking tomorrow,” but they do not get rid of all of the alcohol in their house.
People at this stage of change may still need to convince themselves that taking action is what they truly want to do. They feel they cannot go on like this, but they are not sure what they can or are able to do. People at 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 behavior.
Being prepared for action does not mean that all ambivalence is resolved. The challenge is to help people at this stage develop a change plan that is acceptable, accessible, and effective. Counselors can do this by gently warning against change plan strategies that seem inappropriate or ineffective and guiding them toward more productive alternatives.
It is critical in the engagement process to construct an individualized rationale for counseling and treatment. The basic approach is to communicate to people that there is something here for them, a place where they will get a chance to tell their story, to be heard, to be taken seriously. 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 people enter treatment without having experienced messages from people around them to get some help. Involving friends, family members, and others in the recovery process can not only help to bring people to treatment, but it can also serve the function of educating these people about problems this person faces, reduce their own interpersonal distress, and help to decrease any of their behaviors which may be enabling the problem behavior.
Case Example: Client in the Preparation Stage
Matthew is a 26 year old single man. You work at the counseling center at the junior college Matthew attends. Matthew called the counseling center to make an appointment. He tells you he was referred to counseling center by a female friend who had been in counseling with you two years earlier. As part of the telephone prescreen, Matthew tells you that he would like to work on a number of things, including his use of amphetamines which he feels has become a problem in his life. He tells you that he has never previously been in counseling or treatment. You make an appointment to see him the following week.
When Matthew shows for his first session he appears to be eager to work on his problems. He is engaged, insightful, and responsive, but he appears tired and drained. He tells you that since graduating from high school he has worked at a number of relatively unfulfilling jobs including working at a fast food restaurant, as a clerk at an electronics store, driving a delivery truck, and at a grocery store warehouse.
A year ago he decided to enroll at a local junior college with the goal of eventually getting his college degree in business. He is currently working the evening shift at the grocery store warehouse so that he can go to class during the day. To earn some extra money, he often drives a delivery truck on weekends for a furniture store.
He reports that about a year ago, in order to juggle work, school, and his other obligations, he began using amphetamines to help him stay awake and remain alert. He also reports that he smokes marijuana one to three times a week primarily to relax when he gets home from work or on the weekends. He reports he often drinks alcohol, maybe one or two beers in the evening and sometimes more on weekends with his buddies at a bar or at a friend’s house.
He is primarily concerned about his increasing use of amphetamines because he feels he has lost some degree of control of their use and he is starting to have more negative symptoms such as using them more frequently; feeling “wired” much of the time; becoming more restless, jittery, and irritable; drinking more to try to calm himself down; sleep problems; and waking up feeling lethargic and depressed.
Matthew’s decision to get some help was difficult for him because, while he knew he had a lot of responsibilities, he thought he could handle them and he was excited to finally be able to go to college and get a career. He is becoming increasingly fearful that he could lose it all if he did not address his drug use and related problems now. He has tried to cut down on his amphetamine use.
He has tried to only use amphetamines when he is truly tired and rundown, but he admits that he does not always do this because he often gets depressed when the drugs wear off. He has tried to cut down on his drinking during the week with some success. He admits that his work at the warehouse has suffered. He has been missing more days of work and he has been late a few times, but he does not feel his job is in jeopardy. He is doing alright in school getting B’s and C’s, but he feels he can do much better. His friends have noticed a difference in him and finally his friend Vanessa suggested that he get some help.
Matthew is clearly ready to make some significant changes in his life. He has gone through the weighing process to conclude more or less he needs to make some changes in his life. He has already made some changes in his behavior including try to reduce his substance use, but he has not always been successful. Despite these changes, he still feels he is not in complete control of his alcohol and drug use. The problem is that he needs to be able to have enough energy to both work and go to school and he does not know how he can do this without some amphetamine use.
Making a decision and following through with the appropriate action are not the same thing. In your work with Matthew, it is important that you validate the important work he has done so far in recognizing that he has a substance use problem and his attempts to try and do something it, including coming to see you. It is important that you develop an individualized treatment plan that will take into account Matthew’s strengths (i.e., his drive to better his life by getting his college degree) and his weaknesses (i.e., his dependence on drugs to support his current lifestyle).
While Matthew appears very eager to address his substance use and related problems, you need to develop a treatment plan (working in conjunction with Matthew) that will allow him to experience early success in the beginning to address these problems. To better understand Matthew and what type of counseling or treatment he needs, you need to do a thorough assessment that addresses the medical, psychological, employment, legal, family, and social factors that have influenced, and are currently influencing, his life.
Particular attention should be paid to the factors that maintain Matthew’s substance abuse and related behaviors. A good strategy would also be to try to enlist any family or friends who can help him in his recovery process. Commitment is needed to negotiate the action plan, particularly in the early phases of counseling or treatment, where the discomfort, disorientation, physiological reactions, and sense of loss are the strongest (Connors, Donovan, DiClemente, 2001).
The action stage is one where people begin to make the overt changes in themselves and their surroundings. Action to stop the old patterns of behavior and begin to engage in new ones is the action stage. However, action is not the first step or the last step in the stages of change. 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 that follow action.
In the action stage, people begin to modify their behaviors and their 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.
It is also important not to assume that once a person has reached the action stage, it is all downhill. The new behavior must be sustained in order to create the new habits. People in the action stage may still have some conflicting feelings about the changes they are beginning to make. Careful listening to and monitoring of what they 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.
There are 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. Techniques cannot be separated from the human encounter. The research shows that the client-counselor relationship is very important in successful outcomes, with the key being the client’s rating of the counselor acceptance, understanding, and competence.
When clients are in the action stage, they have done the prerequisite work to actively prepare for making significant changes in their lives. The research shows that clients are more motivated when they are given choices in the type of treatment. As a result, counselors need to work with the client to develop an active change strategy where observable changes can be realized. At this stage, continuing to focus on heightening ambivalence or reflective strategies would probably be a mistake. Clients at this stage need a treatment plan with specific short-term and long-term goals.
Case Example: Client in the Action Stage
Richard and Jill, both in their late 30s, initially came for couples counseling. It was Jill’s idea to come to counseling and Richard reluctantly agreed to come. They have been married for 8 years and they felt that while their marriage was going reasonably well, Jill felt they needed what she called a “tune up” to address some long standing and more current issues. Richard manages an employment agency that is owned by his father, while Jill works part-time at a manufacturing company in the billing department. They do not have any children.
The couples counseling is going well. The counseling focused primarily on working on their communication skills with each other which allowed them to work on some of the issues that have been hindering their marriage. A significant issue that was impacting their marriage was Richard’s family. Richard, his brother Chris, and his sister Sylvia all work at his father’s employment agency. The agency was started by his father, and since he is now in his 70s, he has started to spend less time at the office and turn more of the responsibilities over to his children.
While Richard is very close to his father and his mother, Grace, there have been increasing conflicts over the business between Richard and his father, and between Richard and his younger brother Chris. Jill often finds herself in the middle of the conflicts between the family members. Richard feels torn between his responsibilities to his family and the family business and his responsibilities to Jill. There is every sign that the counseling is going well with signs of real progress with both Jill and Richard reporting the positive difference the counseling had made in their marriage.
After about 15 counseling sessions, Jill calls your office and asks you to call her back. She tells you that Richard and his father had a huge blow-up over Richard’s using company money to pay some of his outstanding gambling debts. His father found out that Richard had been stealing money from the company for over a year so his father fired him from his position at the company.
In talking with Jill, you find out that Richard has always liked to gamble, primarily on sporting events, but also at gaming tables in Las Vegas and more recently online. Until this latest incident, she had no idea he was gambling so much and losing so much money. You suggest that she talk with Richard and, if he was willing, call you to set up an appointment where you could meet just with Richard to get more information about the situation. Then you would meet with them as a couple to help them decide what they wanted to do. Richard calls your office later that day to set up an appointment.
When Richard comes in for his appointment, he tells you that he has always gambled ever since he was in college. He is an avid golfer and he and his buddies at the country club are constantly betting on their golf matches, sporting events, or taking regular trips to Las Vegas to gamble. Over the years he says he felt he was in control of his gambling and he has more or less broken even.
In the last few years his gambling started escalating when he began to gamble online. He thought he had developed a system where he could beat the odds betting on sporting events. One thing led to another and he built up large gambling debts to the point where he had to steal money from his father’s company to pay them off. As is true with most gamblers, when the gambling debts increased, he always convinced himself that he was one bet away from covering his losses. He also likes the excitement of watching a football or basketball game knowing that a lot of money was riding on the outcome. He also acknowledges that he has been drinking more as his gambling problems intensified.
Richard readily admits he has a serious gambling problem and he wants to get whatever help he needs to address his problem. Richard feels that his father firing him was just the wake-up call he needed to finally get some serious help and get his life back together. He says he has tried to stop or cut back on his gambling before, but with little lasting success.
He has read some books on compulsive gambling and among the things he has learned is that gambling can be an addiction just like drug addiction and to stop and gain control over the addiction he needs to get some professional help. He wants to get his job back and restore his relationship with his father and his family. He wants to restore his marriage to Jill because she has always been there for him and he feels that he seriously let her down. He tells you that since he was fired from his job he has not gambled once, though he has been seriously tempted. He has decided to stay away from his golfing buddies for now because they are too much of a temptation. He even disconnected his computer at home so he will not be tempted to gamble online. He says he will do whatever it takes to tackle this problem once and for all.
Richard is at the action stage. Counseling needs to build on Richard’s resolve to finally meaningfully address his gambling problem. There are a number of things that are important at this stage of change. First, no matter what type of treatment is utilized, the client-counselor relationship is very important in any successful treatment.
It is important that Richard perceive the counselor or the treatment program as competent, understanding, and supportive. You have a good relationship with Richard and Jill, but you have had little clinical training or experience in gambling addiction and you need to make a decision to continue seeing Jill and Richard as a couple, see Richard and Jill separately, or refer Richard to a counselor or treatment program that specializes in gambling problems.
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. Richard tells you that he would like to work with you on his gambling addiction. You discuss with him the various counseling and treatment options including working with you, seeing another counselor that specializes in gambling addictions, or enrolling in an outpatient or inpatient gambling addiction treatment program.
After exploring all of the options, including giving Richard a list of referrals he can explore on his own, Richard decides that the best option for him would be to enroll in a 60 day inpatient treatment program that specializes in his problem. Richard felt this was the best option since the treatment would be more intensive, he could not con the counselors since most of the counselors are recovered gambling addicts, and he would be away from the temptations in his life to gamble.
Third, it is important to help Richard develop a support system for recovery in his social world including his family and friends. Jill decides that she would like to continue seeing you while Richard is in the program to better prepare herself when he comes home. She also decides to attend a support group for family members sponsored by the treatment center. She hopes she can talk Richard’s family into attending some sessions with you or at the treatment center either before or after Richard returns.
Finally, attention should be paid to relapse prevention by helping Richard and his family 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.
Change never ends with action. Maintenance is the final stage in the process of change. In the maintenance stage, people try to stabilize their new behaviors and work to prevent relapses. In this stage, people work to consolidate the gains they have made during the action stage and prevent relapse. Programs that promise easy and quick change usually fail to acknowledge that maintaining change can be a long, ongoing process. One only has to look at the diet industry to see programs that do not take into consideration the need to maintain the gains a person has made.
Counselors should prepare themselves and their clients for the termination of counseling or treatment. The counseling relationship can be a powerful presence in people’s lives, and they may feel anxious about the counseling or treatment process coming to an end. Going over the gains that the person has made, affirming the relationship between the counselor and the person, offering follow-up sessions if needed, going over any anxieties about the end of treatment or counseling, and giving referral sources if needed can all help to stabilize the gains that have been made during counseling or treatment.
Sustaining behavior 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 counselor 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 counselor 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.
It is important to help people in this stage practice an active and intelligent maintenance of the changes they have made. Marlatt (1998) has identified three primarily high- risk situations that are associated with relapse with most substance abusers: 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 lapse occurs in a high-risk situation that individuals unexpectedly encounter. In other situations, the lapse appears to be the last link in a chain of events preceding the first lapse. Especially problematic are situations where the person comes to feel that their desire to use substance is justified based upon their evaluation of their circumstances, for example, they are experiencing stress or anxiety in a situation and they feel they need some relief.
Marlatt and Gordon (1985) 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. Therefore, programs need to help people develop expectations and skills that they can use to successfully cope with these high-risk situations.
There are number of ways to reduce or eliminate relapses. The person must be taught how to recognize high-risk situations that may trigger a relapse. There should be an assessment of the adequacy of person’s current coping abilities. In this way, the person can learn to develop alternative coping skill approaches for their high-risk situations. This skill-training can involve assertiveness training, stress and anger management training, learning relaxation techniques, and problem-solving and social skills training.
One way to approach the discussion of the potential for relapse with a person is to talk about recovery as a journey which involves continuous discovery, dealing with novel situations, improvising when things to not go well, and learning new and useful ways to cope with problems along the way.
It can be useful to tell people that recovery from substance abuse usually proceeds along unremarkably until the person encounters a high-risk situation. This could be anything that threatens the person such as an awkward, stressful social situation or an internal affective state such as anger, anxiety, or depression. The person is then told that handling these high risk situations in an adaptive way is the key to ongoing recovery and how he/she perceives, interprets, and understands a high-risk situation can directly affect the outcome.
Discussion of automatic thoughts and cognitive distortions such as overgeneralization (one slip therefore cannot stop), selective abstraction (focusing on one’s failures), excessive responsibility (personally do not have what it takes to stop using), assumption of temporal causality (if true in the past will always be true in the future), self-reference (I am the sole cause of your problems), catastrophizing (anticipate the worst), and dichotomous thinking (black and white thinking focusing on the negative) can help in this process (Marlatt & Gordon, 1985).
Case Example: Couple in the Maintenance Stage
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 works in a sales 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 says 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 problem. At first she refused saying she could stop drinking on her own, but finally she admitted that she need to get some professional help.
Jennifer reports that her father and brother had drinking problems. 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 wine many evening after he 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. After Bob was born, she quickly resumed her previous drinking patterns. About the time Bob was born, Jim received a promotion that required him to work longer hours, travel more, and frequently entertain clients. Jennifer often accompanied Jim when he entertained clients and drinking was frequently part of the evening.
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 problem. At first she refused, saying she could stop drinking on her own, but finally she admitted that she needed to get some professional help.
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.
The counselor decides 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 is 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 counselor directly addresses the possibility of relapse and develops 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 counselor stresses that when these signs or triggers appeared, it was time for action versus inaction or a feeling of fatalistic resignation. Working with the counselor, Jennifer and Jim developed a “relapse contract” that specified how both of them would handle these situations. It was also decided that Jennifer and Bob would continue counseling once every month and then every 2 or subsequent months as necessary. They also decided 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.
Therefore, it is important to assess the history of the client’s recovery attempts and where they currently are in the stages of change. 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 and for such programs to be effective, they must, first of all, assess the stage of the client’s readiness for change and tailor their interventions accordingly.
Effective treatment involves doing the right things (process) at the right time (stages). 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.
In conclusion, for most people, moving through these stages of change is not linear, rather it tends to be cyclical. Most people will make several attempts (including on their own and as a result of formal treatment) to modify or cease their AOD use. Researchers who followed contemplators for two years found that only 5% of them made it through the cycles of change without at least one setback (Prochaska, Norcross, DiClemente, 1997). These relapse or setback experiences can contribute information that can facilitate or hinder subsequent progression through the stages of change.