What Are The Stages of Change and How Do They Apply to Recovery?

What Are The Stages of Change?

In this entry we are going to take a dive into the stages of change; or at least one perspective surrounding this topic. Similar to how treatment for any disease is unique and individual, the stages a person goes through to achieve recovery will also look different.

Background and TTM

The stages of change is part of a broader model called the transtheoretical model (TTM) developed by Drs. James Prochaska and Carlo DiClemente in 1977. “The transtheoretical model of behavior change is an integrative theory of therapy that assesses an individual's readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual.” (1)

In the most basic of terms, TTM takes various psychological theories and combines them to help determine if a person is ready to change their behaviors to that of more healthy ones, while providing guidance and resources into how to go about change. Like most therapeutic approaches, TTM is not suggestive and will not tell a client what they should, or should not, do.

TTM helps clients gain understanding of the pros and cons of changing; increase self confidence that they not only can change, but can maintain that change; and develop strategies that guide a person to not only changing but sustaining change.

TTM outlines the ten processes of change developed as part of their model. Whether a client uses one, some, or all of these strategies and/or incorporates other positive interventions and coping strategies the goal remains the same - change.

The 10 Processes

Before we look at the stages of change, let's list the ten processes of change in their most basic terms. (1)

1. Get the facts
2. Pay attention to feelings
3. Create a new self-image
4. Notice your effect on others
5. Notice public support
6. Make a commitment
7. Get support
8. Use substitutes
9. Use rewards
10. Manage your environments

It would take another blog post entirely to detail each of these processes. Use the resource at the bottom of this post to read more about them.

The Six Stages of Change

Now that we have a basic understanding of the larger transtheoretical model, let's get into the stages of change. You may have seen the stages of change before represented in a circle or an upward line. The names of the stages are sometimes referred to differently, but whatever word you may use, what is happening in that stage remains the same.

Stage one is Precontemplation, the person is simply not ready for change. Precontemplation can last a long time especially if the person is unable to see the harm their choices are making on themselves and others. They often struggle to see the pros in changing and grasp onto the cons of their behaviors without really seeing them as cons. To help a person in this stage, pushing them toward changing is counterproductive.

Providing them with education, exploring pros and cons of their behaviors as well as the pros and cons for changing those behaviors, and helping them gain confidence in their ability to change and make decisions will be more helpful in leading them toward taking the next step.

That next step is Contemplation, stage two. At this stage they are getting ready to change yet remain ambivalent. While they are more aware of the pros of changing, they are still not outweighing the cons. At this stage, it’s most beneficial to continue to explore the benefits of changing, helping them learn from others who have changed and/or behave in healthy ways, and gently encourage them to reduce their problematic behaviors.

Once a person has embraced the need to change and embraces the benefits of doing so, they start Preparing for change in stage three. They’ll start talking about change with others, discuss what change they want to make and how they will make that change. And while they are more positive in their thinking, they still fear failure. Helping them know set-backs will likely occur, does not mean they have failed. Educating them that even if they “fail” they can start over and if they prepare for that, they will bounce back quicker.

(In truth it can take an average of eight years, and four to five treatment episodes, for a person to start treatment and get one year of sobriety. This shouldn’t be a person’s excuse of not succeeding but them seeing they are not alone when they experience set-backs and relapses.)

Eventually a person will be in the fourth stage of change, Action. In this stage a person has made observable changes in their behaviors. They continue to work to strengthen their commitment to change, and this stage is likely a stage a person will revisit often throughout their life. In this stage people are actively using healthy behaviors and reward themselves (or at least be proud of themselves) that they have reached this point.

After a person has made discernable action toward change they will then be in the fifth stage of Maintenance. It’s important in this stage, which is the stage we all hope to reach and stay in indefinitely, to be aware of triggers and stressors that would cause a relapse into negative behaviors. When a person is in maintenance they will want to be aware of warning signs that a relapse is intimement. If warning signs become apparent to them, or someone points them out, it’s important they seek support - whether it’s talking to a friend, seeking therapy, or really ramping up their coping skills - to avoid a relapse.

Relapse is considered the final stage of change. Some may think including relapse is negative, but relapse is common during any behavior change. It’s rare for a person to be 100% successful and never leave the maintenance stage the first time they change a behavior; we’re not saying it’s impossible and for those who have done this it’s an amazing feat we could all learn from. Knowing that relapse is common can actually help a person accept a relapse when it does happen.

Every relapse is an opportunity to learn from the past and change (yes, there’s that word again) how you did things the last time so you can be even more successful the next. As mentioned earlier, the more prepared a person is for success, and defeat, the more easily they can rebound.

The stages of change, while often depicted as linear, is not; reason being why I use the circle depiction whenever I can. The picture of a circle is more accurate as the stages of change are fluid in the way a person moves through them. While in general a person progresses through each stage in order, when a relapse occurs it does not mean that it always restarts at precontemplation.

And even if it does, a person could be in precontemplation and jump to action having prepared and knowing what they need to do the second (or third, or sixth) time around. They start taking action and move toward maintenance by enacting what they already prepared and at the same time learn new skills and enact new practices.

In Practice

The stages of change is something I talk about often. The stages of change fit naturally into recovery from substance use, misuse, and addiction. It also works for really anything you want to change from smoking cessation to stress management and overcoming depression to medication adherence. (1)

I use the stages of change in my clinical practice and if any therapists out there are looking for group ideas - stages of change can be equally psychoeducational and psychotherapeutic. One of my favorite groups to facilitate is a Stages of Change Group. The group members are provided the definition of each stage and they are encouraged to provide examples of behaviors in each stage drawing from personal experience.

Group members are then encouraged to share what stage they think they are in and provide examples. It’s interesting to see where clients place themselves compared to a therapist’s clinical assessment of them. It’s not uncommon for someone to say they are in the action stage because they are enrolled in therapy (valid point) and still struggling with some use and uncertain if they want to stop using completely (reflective of the contemplation stage).

This can lead to an interesting reflection of how a person views their recovery versus what others may see. It’s important that a client’s point of view isn’t completely dismissed, especially if there is some truth to it; educating them that while yes, they are in the action stage there is still some things they are thinking or doing that may be holding them back to progressing even further and see if they can reflect back on what those are.

Even if you don’t use it in practice, you can use it in theory to assess how a person is progressing in their recovery and can bolster the assessment section of your notes.

In combination with other therapeutic techniques when I have a client grappling with change while engaging in risky behaviors I first want to assess where they are currently in wanting to change as well as their readiness, willingness, and ability to change. Once I have an understanding of that it’s really working with the client on acknowledging their behaviors and having them make the decisional balance - what’s bad and good about these behaviors and what would be negative about positive about making change.

It’s also important to help them work through fear of failure and self-confidence as it comes up. Help them prepare for the highlights of change and the lows of setbacks. It’s also making sure they stack their metaphorical toolbox with skills, resources, support systems, and coping skills they’ll need to change and maintain change.

The stages of change is just one of many approaches to help those in recovery. If you approach each person as an individual you’ll discover what approach works best for them.

1. Transtheoretical model. (n.d.).Wikipedia. Retrieved June 6, 2023, from https://en.wikipedia.org/wiki/Transtheoretical_model#cite_note-Prochaska2005-1

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