The Stages of Change Model

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This empathy, warmth, and genuineness lay the foundation for any productive, therapeutic interaction. Many therapies rely on these aspects of the relationship to help support growth. Motivational interviewing combines these qualities with the stages of change model to help inspire a shift away from problem drug use. The stages of change model describes particular steps that individuals appear to take any time they alter a problem behavior (Prochaska & DiClemente, 1983). Researchers identified these steps by interviewing people who quit smoking on their own. The investigators proposed six stages common to the process: precontemplation, contemplation, determination, action, maintenance, and relapse (Prochaska, Norcross, & DiClemente, 1994).

Precontemplation describes the period before individuals consider altering their behavior. The idea of precontemplation as a stage of change may serve as one of the most novel aspects of this model. Marijuana users in precontemplation have never considered changing their consumption. An adept therapist would not waste time attempting to teach

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these people how to quit using; they would likely lack motivation to learn these skills. Instead, the therapist would begin with assessment. A report on the amount and frequency of marijuana use would serve as a good start. The therapist would also want to ask about any associated consequences, including negative emotions, fatigue, uncomfortable interpersonal interactions, or any other negative consequences the smoker might experience. This assessment can often make the connections between use and consequences more salient. If these connections lead individuals to consider change in any way, they have entered the contemplation stage.

Contemplation includes the weighing of the pros and cons of altering actions or continuing the same behavior. The motivational interviewer would allow the marijuana smokers to candidly report all the positive experiences they attributed to drug use, including any beliefs about enhanced sexual interactions, enjoyment, slowing of time, or connections to the counterculture. Then the interviewer might ask smokers to highlight negative consequences. Initial assessments of pros and cons often reveal strong desires to continue using, as well as equally strong desires to stop. This situation may reflect the ambivalence people feel about altering their consumption of marijuana. Ambivalence serves as a common and important component of contemplation. Other approaches to treatment may see this ambivalence as denial. The stages of change model emphasizes ambivalence as an inherent part of change. During further discussion, the therapist respectfully reflects the marijuana users's concerns back to them, emphasizing the negative consequences that they generated earlier. This process often leads problem users to a decision to change. A firm decision to change qualifies as a step toward determination.

Determination begins with a clearly stated desire to alter actions. This stage serves as the appropriate time for a marijuana user to formulate a plan for limiting consumption. Note that any attempts to devise a strategy for change before the determination stage would essentially waste effort. Motivation must increase before a plan can succeed. The plan often stems from brainstorming between the interviewer and the smoker and may include any options that look promising. For example, the strategy for change may rely on techniques from cognitive-behavioral therapy like altering beliefs and preventing relapse. In addition, the smoker may decide that membership in a twelve-step program sounds appropriate.

Once clients regularly alter old behaviors in favor of new ones, they

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have entered the action stage. They no longer merely consider change; they actually do it. This stage proves particularly informative. The genuine experience of new habits and actions can reveal valuable information unanticipated during contemplation and determination. Clients may find some situations easier than they expected. Other aspects of abstinence or controlled use may prove unexpectedly difficult. The motivational interviewers will now offer reassurance about the process becoming less difficult with practice. They will help clients solve problems related to use. They will listen attentively to detailed descriptions of difficulties and proud retellings of each resisted temptation.

After a steady period of action, clients may report increased confidence in their skills. This sense of efficacy, an optimism in one's own ability to continue the new behaviors, serves as a hallmark of the maintenance stage. Self-efficacy and sustained change are the keys to maintenance. Client and therapist will work together now to prevent relapse. They will identify situations that put the smoker at high risk for relapse and plan ways to avoid problematic use in these circumstances. For example, clients may decide to avoid parties where drugs are present. They may role play refusing drugs if they are offered. They may practice relaxation techniques if tension often preceded their drug use. They may call a hot line or a friend in times of temptation. Note that these techniques for preventing relapse are consistent with twelve-step and cognitive-behavioral approaches. Perhaps this overlap contributes to the comparable results of these different programs.

Occasional backsliding occurs in many efforts to alter behavior. Original studies of people who quit smoking cigarettes reveal that they rarely remain abstinent on their first try (Prochaska et al., 1994). They quit, relapse, and quit again. The stages of change model considers lapses and relapses as another category of change. This approach may help normalize the occasional slip. Considering lapses as a part of the change process may decrease the chances of an abstinence violation effect, transforming a slip into a full-blown relapse. The key to the lapse stage parallels the key to the maintenance stage: preventing relapse. Lapses require immediate action. Lapsing smokers can prevent relapse by rapidly exiting the situation and removing the chance of continued use.

Many who lapse berate themselves, but their time and energy may be better spent identifying the precursors to the drug use. A frank examination may reveal a new high-risk situation, providing the opportunity to formulate a plan for how to handle this predicament in the future.

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For example, a former cannabis smoker may find himself lighting up after a fight with a family member. This situation may not be one that he had identified as high risk before. Now he knows that he needs to plan new ways to deal with conflict. He can turn this lapse into a learning experience to prevent later use. Thus, lapses remain a part of the change process; planning for them may minimize problems. By combining good therapeutic skills in general and targeted interventions for each stage of change, a motivational interviewer can help problem drug users through many steps toward minimizing problem drug use.

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