The stages of change concept was one of the primary approaches to understanding recovery and change in working with individuals suffering from addiction, and more broadly with the concept of change in the human experience. The concept involves a sequence of stages through which people typically progress as they think about, initiate, and maintain new behaviours, both within and outside of the therapeutic environment. There are five primary stages in this model. However, I will also discuss and add my personal favourite and additional sixth, inescapable and inevitable stage. There are as follows: Pre‐contemplation; Contemplation; Preparation; Action; Maintenance, (and additionally, Relapse according to new scholars).
The Pre‐contemplation Stage – involves individuals who do not think they have problems, and have no intent to change, yet!, as they see their problem behaviour as having more pros than cons or simply not being a problem at all and merely a make-up of their existence or merely forming part of their ‘personality’. If something works, why mess with the formula, right!? – well.. wrong.. there is a problem, the person themselves are simply not ready to admit this to others or more importantly, themselves, yet… In fact, he or she may be more surprised than opposed when told that he or she has a problem. Individuals in this stage rarely seek treatment unless forced or obligated to do so.
In therapy with individuals in this stage, it is recommended to slowly start to encourage, to establish rapport, and building trust which is accomplished through eliciting the client’s perceptions of the problem, providing non‐confrontational feedback, and expressing concern while maintaining an open minded and non-judgemental approach. This can be tricky at times, especially when a person’s view on their own behaviour screams denial and destruction for any ordinary person, yet the person causing the damage to themselves (and others) does not see the pain and trouble it causes. It is therefore crucial that one does not project one’s own said belief systems onto this person (transference/countertransference), but to rather stay calm, reserved and to try to listen with a very empathetic ear and stance… and to watch your body language at all costs. In fact, non-verbal communication does after all count for 70 to 93 percent of all communication.
The use of art as a therapeutic process can play an important role in this stage. It can serve as a means of self‐exploration, bypassing the automatic defensive reactions to threats that may be associated with having an addiction. This may create much more possibility for self‐exploration. Active engagement with art materials introduces a means of expression and understanding other than repetitive cognitive verbal patterns that “lock” in limited verbal exploration. The use of materials creates opportunities for novel experience and expressiveness. In other words, instead of thus only communicating or trying to give feedback or response to such a scenario in the moment which could be loaded with personal subjective feedback (transference), art therapy can thus be used as a means to describe, explain or simply as a device or tool to express such a controversy as such.
Contemplation
We have now finally reached the following stage which involves the individual’s struggles with ambiguity, doubt, haziness or simply put, uncertainty about the “problem”. They are not in denial anymore, per se; but they are not certain how to go about this ‘dilemma’ either. Individuals at this time are experiencing ambivalence, which comes about with growing awareness of risks and problems associated with substance use. The sense of ambivalence can thus be awfully challenging for the individual as they both consider and reject change which creates a “tug-of-war” mentally In other words, the person struggling with the dilemma, has now become more aware of their situation that needs to change but is also aware that admitting it to themselves (and others) means that they have to change, which is a bitter pill to swallow, proverbially speaking with no pun intended. Thus, finding themselves between a rock and a hard place. However, it is also, in fact, common for people to find treatment or make a change during this stage.
The therapeutic process at this stage involves normalising the ambivalence and helping to “tip the decisional balance scales” by eliciting pros and cons of use while also emphasising client choice and responsibility. A very useful way to get better results is to apply the CRAFT model approach. In other words, reinforce good behaviour, and you don’t reinforce bad behaviour. Nobody wants to be told how bad they are, ever. Instead, focus on the good stuff and work the problem (even change the narrative to “challenge” or “setback”– not problem) backwards. Therefore, the therapist or person or other end can also prompt self‐motivational statements from the client and reflect them back to them. i.e. Wow, it sounds like you have run into quite a setback here, and you are such a great person (or ‘writer’ or ‘sportsman’) with so much potential! Let’s try to curb this challenge to get more good results for you!”…
The client is thinking about changing and seeking information about the problem. Therefore they are evaluating, but probably not prepared to change yet. We are just simply slowly but surely starting to change or sway the narrative towards change and not ‘driving’ directly into it yet.
Again, Art therapy is useful at this stage, relying on the image as a means of understanding and reflecting on the cost/benefits of use. Art can be used as a type of graphic organiser, externalising the internal dialogue, and as a way of bringing the ambivalence to the foreground.
Preparation
Once the individual moves to the “preparation stage,” the process of change has already begun. They are ready to change in attitude; and behaviour have likely begun to increase self‐regulation, and in addition are prepared to make commitments and develop strategies.
Action
The individual must demonstrate a firm commitment to change, and motivation must be engaged and supported during the action stage. The artist in the individual must be activated, supported and reinforced by the significant others. Alternative means of viewing oneself and one’s experience are critical to beginning and following through on new and creative action plans. The use of the imagination is critical in this process. The individual must be supported in seeing beyond their ordinary patterned responsiveness; and start to actualize the extraordinary. Modulating and transforming the problem behaviour is the first component of this stage, followed by learning skills to prevent relapse. (however, this can also be argued against and explored and unpacked more later in this article/blog).
This stage also requires exercising the creative imaginative self. Art therapy can be used to provide concrete form to the internal experience as well as to the vision of moving forward. Directives include creating diagrams of action plans, images of triggers, images of celebrating progress, and developing art making as an outlet and a means of support.
Maintenance
This is a critical stage in the process of change; one has to develop practices that allow alternative rewarding experiences while maintaining pathways that avoid reactive patterns in relation to triggers. The emphasis is on sustaining changes that have been accomplished, which requires an emphasis and effort on avoiding “slips.” Fear and anxiety over relapse may be experienced and can be addressed through intentional expression of emotions in the art form, which can result in reflection and the opportunity to develop maintenance strategies. Intense triggering of desire to use substances may be experienced.
Art therapy can be used in this stage both as a means of maintaining engagement with the artist in the process and as a means of focusing on critical content areas. The use of images for insight and motivation is very valuable in this stage. It is also important to maintain the practice of engagement and dialogue with the images and to maintain the practice of art making for outlet and support.
Relapse (Termination) Stage
This is quite a new, and for some controversial stage that has recently been added. You hear the cliché, ‘relapse is part of the process’, stipulated, but never rationalised well enough to understand why it is part of the process; which inherently creates this stigma and notion of the ‘obvious’; In other words, one must assume that, “addicts” have this brain disease and are thus inherently regarded as a human with a deficiency that will inevitably relapse all the time. However, what if I tell you that the notion of the disease model are one of many ideologies that are NOT the only model or approach and that people can in fact completely terminate old behaviours or patterns OR that relapse can be perceived as a form of ‘writer’s block’; boredom, stuck or procedure that is inevitable form or construct that has to take place in order for us to change from one rigid form to another more flexible or malleable shape in our existence. Therefore, to see relapse as a part of the process where we are stuck in the way that we aren’t growing and transforming
References
- Behavioral change models (no date) The Transtheoretical Model (Stages of Change). Available at: https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/behavioralchangetheories6.html (Accessed: 26 July 2023).
- Carolan, R. (2015). Addiction and Art Therapy. The Wiley Handbook of Art Therapy, 460–468. doi:10.1002/9781118306543.ch44
- Community reinforcement and family training (craft) (no date) American Psychological Association. Available at: https://www.apa.org/pi/about/publications/caregivers/practice-settings/intervention/community-reinforcement (Accessed: 26 July 2023).
- Kirby, K.C., Marlowe, D.B., Festinger, D.S., Garvey, K.A., & LaMonaca, V. (1999). Community reinforcement training for family and significant others of drug abusers: A unilateral intervention to increase treatment entry of drug users. Drug and Alcohol Dependence, 56(1), 85-96.
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- Prochaska, J., & Norcross, J. (2001). Stages of change. Psychotherapy: Theory, Research, Practice, Training, 38(4), 443.
- Prochaska, J., Velicer, W., Rossi, J., Goldstein, M., Marcus, B., Rakowski, W., et al. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13, 39–39.
- Meyers, R.J. & Wolfe, B.L. (2004). Get Your Loved One Sober: Alternatives to nagging, pleading and threatening. Hazelden Publishing & Educational Services: Center City MN.
- Miller, W.R., Meyers, R.J., & Tonigan, J. (1999). Engaging the unmotivated in treatment for alcohol problems: A comparison of three strategies for intervention through family members. Journal of Consulting & Clinical Psychology, 67(5), 688-697.