How We Grow: The Stages of Change
This month was the 25th anniversary of the death of Nirvana frontman Kurt Cobain. I loved Nirvana as a teenager (sorry Mom) and still enjoy "Heart-Shaped Box" whenever I hear it over the airwaves. I remember his tragic end after a long bout with heroin use.
It had been quite a while since I'd thought about his story. Now, after all these years and working so closely with addictive behaviors and substance use, I felt sad as I read stories like this one about how loved ones tried to help him. They did their best, as we all do, in a difficult situation, and they were listening to the professionals guiding them. Still, they can't help but wonder today: What might they have done differently? How could they have reached him? How could they have helped? Could his story have ended in another way?
Of course, everyone affected by addiction—including those struggling with addictive behaviors and substance use themselves—asks similar questions not in retrospect but every day they live with their using or acting out. Those struggling with substance use or problematic, compulsive sexual behaviors want to understand how they could possibly return to their addictive behavior of choice, sometimes even after a long period of abstinence. "Why do I keep doing this?" they ask. "And how can I change?" Family and friends want to understand helpful ways to support their loved ones. They're often desperate to help the loved one find healing and become hurt, angry, frustrated, and exhausted trying to understand his or her behavior.
A sound understanding of how people change can provide the foundation for answering both of these questions. If we understand the stages of change, we can give ourselves a bit of grace as we struggle with our addictive behavior. And family members can learn how to better support their loved ones and promote their healing.
The Stages of Change: An Introduction
The stages of change, first described by Prochaska, DiClemente, and Norcross (1992), outline the process through which people change their behavior. The model was first formulated in the late 1970s after the researchers conducted studies of smoking cessation.
When considering the stages of change, it's important to keep in mind that progression through the stages is not linear. People move fluidly between the stages, sometimes by the day, hour, or moment. Often, and perhaps most puzzlingly to the suffering individuals and their loved ones, recovering substance users in the maintenance stage often return to earlier stages of change, resulting in continued use or relapse. From the perspective of the stages of change, however, slips and relapses are a normal part of the process of change (though the individual may need to take responsibility for their behavior).
Stage One: Precontemplation
At this stage, the user (i.e., the individual struggling with problematic substance use and/or sexual behaviors) does not consider their substance use or sexual behaviors to be a problem. He may not have experienced any negative consequences, or he may not be ready to understand the impact of the consequences that have already occurred. At this stage, there is no acknowledgement of a problem that needs to change. If this sounds familiar to you, you're probably feeling pestered, annoyed, or frustrated by those around you. Many people might think you're "in denial," but you're not. You just don't see what others around you see. What can the using individual do at this stage?
Listen carefully and non-defensively to friends and family and consider their perspectives
Learn more about drug and alcohol use or sexual behaviors if you'd like to
What can family and friends do at this stage?
Avoid pushing the loved one into taking action (forcing someone to do something will usually backfire)
Ask permission to provide information about drugs, pornography, or problematic sexual behaviors
Do not avoid discussing drugs, alcohol, or sexual behaviors
Practice good self-care, including setting appropriate, non-punitive boundaries
Engage the individual's feelings about their using/acting out in an exploratory, non-judgmental way if possible (the goal here is to establish and maintain trust)
Stage Two: Contemplation
In the contemplation stage, the user is beginning to acknowledge that there is a problem that needs to be addressed. She may be considering initial steps to make a change and sorting through options. She may have tried to modify her using or sexual behaviors on her own but without making substantial changes.
Ambivalence is the hallmark of this stage. Individuals at this stage are often conflicted about their substance use or sexual behaviors. They're considering changes but are not yet ready to do anything.
If this sounds like you, something may have happened, and usually that something isn't good. Maybe you got a DUI or your partner found out about your pornography use. Or, you've been learning more about drug and alcohol use or sexual behaviors and are starting to wonder about how much your habit is costing you. Still, you're of two minds about change; you still enjoy aspects of your using or acting out but are beginning to think it's time for a change. What can the individual do at this stage?
Explore the pros and cons of using/acting out
Consider what your goals for making a change might be and some initial steps toward those goals
Reflect your conflicted feelings about your using or acting out, ideally with a therapist or a non-judgmental loved one
What can family and friends do at this stage?
Avoid pushing the individual into action too soon (again, doing so may backfire)
Help her explore her ambivalence
Continue to practice good self-care and maintain healthy boundaries
Provide any information that the individual is open to receiving about the problematic behavior that may help her make a decision
Stage Three: Preparation
In the preparation stage, the individual is getting ready to change their pattern of drug or alcohol use or sexual behaviors. Maybe he's begun planning the steps he'll take to make change or has made those steps already (e.g., calling a therapist, talking with his doctor, going to a 12-step meeting). He also may be wondering about what other steps he needs to take. Sometimes, actions are not the next move. Just making a decision to change is enough to arrive into the preparation stage.
Still, you're wondering how you're going to enact this decision. Should you reduce your drinking or stop completely? Should you stop masturbating altogether while you pause your porn viewing? It's important at this stage to connect with someone who can help you think through the changes you want to make and some realistic strategies to get there. Otherwise, you can set yourself up for failure. What can the individual do at this stage?
Consider the changes you want to make and your goals for these changes
Create a realistic plan to help you reach these goals: What do you need to do?
Evaluate honestly your plan: Will it work?
Try things out and tweak your plans
Address any obstacles to change and get the help you need solving these problems
What can family and friends do at this stage?
Help the loved one evaluate how their plan is working: "How did that go?" "What did you like about that?" "What's next?"
Support any positive change
Be patient and hang in there—the changes you want to see won't happen overnight
Continue to practice good self-care and maintain healthy boundaries
Visualize with the individual what life might be like with change—it may help you feel more connected to him, and he may be excited to enact his decision
Stage Four: Action
It's time for, well, action. In the action stage, the individual implements changes to their drinking, using, or sexual behavior patterns.
Sometimes this means stopping altogether (as is often true for sexual behaviors that, if they continue, significantly endanger marital and intimate relationships). With regard to substance use, many take steps in this stage to achieve abstinence. In harm reduction, the decisions and changes made in this stage can be more complex as the individual decides about what to change and how much. Sometimes it's more helpful, for instance, to take a smaller step of reducing alcohol intake rather than stopping altogether; often there are dangers posed by withdrawal symptoms, and stopping altogether may not feel possible or be practical. What can the individual do at this stage?
Take the steps that are right for her, making sure they are the right size (Little and Denning, 2017)
Be mindful of how smaller changes may be a part of bigger behavioral changes
Plan for risky situations
Assess how the plan for change is working and tweak it accordingly
Make a relapse prevention plan
What can family and friends do at this stage?
Continue to help the loved one assess how her plan is working
Support plans for risky situations and offer to help, if appropriate
Celebrate small changes (they add up!)
Support the individual's self-efficacy, that is, her ability to implement her plan (Denning and Little, 2012)
Stage Five: Maintenance
Oftentimes, the individual may have attempted to make changes before but they haven't stuck. The maintenance phase is all about keeping the changes going.
Maintenance starts after he has made changes to his using, drinking, or sexual behaviors and considers how to keep the healthy behaviors around. The maintenance stage can be, unexpectedly for many, one of the longer stages of change for a number of reasons.
After the changes are made, there may be underlying emotional or psychological "work" to do (on trauma, for example) in order to sustain the changes. Sometimes it means creating a new life: finding new friends, new hobbies, going to church again, or working on intimate relationships. It might also mean anything from going on a medication that supports your health to changing your environment or living situation to finding another job. Some of this may have started in earlier stages, but you get the idea. What can the individual do at this stage?
Go to therapy to work on psychological or emotional issues that contributed to the problematic behavior
Be cautious about overconfidence
Create a support system that, well, supports the change
Start practicing new hobbies and self-care strategies if you haven't already
Stick to your relapse prevention plan
What can family and friends do at this stage?
Participate positively and authentically in the loved one's life, supporting positive changes
Work with the individual to repair any damage caused by the problematic behavior in the past
Continue to help the loved one assess how the changes are going
Stage Six: Relapse
Relapse isn't necessarily a stage; it can happen at any time throughout the process of change.
Traditionally, it's a return to the problematic sexual behavior or substance use. Usually, it happens when the individual goes back on some kind of commitment to change he has made to himself and to others. It might be a momentary lapse (sometimes called a "slip") or a more prolonged return to the behavior. Most of the time, relapse happens because there's significant imbalance in one's lifestyle and a failure to plan for risky situations.
Unresolved psychological and emotional factors can also contribute greatly to relapse. The great danger with relapse is what's called the abstinence violation effect, and it goes something like this: You go to a summer wedding but didn't realize that there would be an open bar. You've planned for similar situations, and even though you haven't planned for this, you reason with yourself that you can handle a drink. But you have more than you intended, and you start beating yourself up.
Then, the "fuck-its": "Fuck it," you say to yourself, "I've had this many, I might as well keep drinking." This can lead to risky drinking, not to mention aching despair and regret about making any changes to your drinking in the long haul. Whatever your relapse looks like, I mention it here because it's probably going to happen.
It's a normal part of the process of change. Still, don't think of this as an excuse: You can either think about it as the catastrophic end of your journey of change or a learning opportunity. Go back to the drawing board, reconnect with your therapist, and reevaluate. It doesn't have to trip you up. What can the individual do at this stage?
Don't. Give. Up: Keep on keepin' on
Reevaluate your relapse prevention plan and revisit plans for risky situations
Ask for help from your support system
Avoid blaming yourself or beating yourself up
What can family and friends do at this stage?
Understand that a return to the problematic behavior may occur and is a normal part of the process of change
Continue to practice good self-care and maintain healthy boundaries
Blame the plan, not the person (Little and Denning, 2017)
Works Cited:Denning, P. and Little, J. (2012). Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions. Second edition. New York: Guilford.Little, J. and Denning, P. (2017). Over the Influence: The Harm Reduction Guide to Controlling Your Drug and Alcohol Use. Second edition. New York: Guilford.Turner, C. (2017). Can I Keep Drinking? How You Can Decide When Enough Is Enough. New York, Nashville, & Melbourne: Morgan James.
If you're reading this, perhaps you're searching for how to make the changes to your alcohol use, your substance use, or sexual behaviors. Sometimes changes are simple, but I've found that often substance use and sexual behavior problems are complex and not easy to make on your own.If you feel you need help, I'd be honored to support you. Please let me know if there's anything I can do for you, even if it's just a few minutes on the phone.
About the Author
Jeremy Mast is a licensed marriage and family therapist, a Certified Sex Addiction Therapist, and the founder and director of the Center for Integrative Change. He is passionate about helping those struggling with substance use and problematic sexual behaviors and their loved ones find lasting healing. In his spare time, he enjoys reading, rock climbing, health and fitness, and trying out new recipes while cooking at home.