Transtheoretical Model – Understanding Addiction
- Title: The Transtheoretical Model
- Authored by Pin Ng PhD
- Edited by Stefan Beresford
- Reviewed by Philippa Gold
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The Transtheoretical Model – Understanding Addiction
Ever heard that, for an addict to recover, they have to really want to get better?
Well, it’s true. Sort of.
Addiction is hard to understand for those who have never suffered. Surely, they can see that substance use and unhealthy behaviors are destroying their life? For someone in the precontemplation page of addiction recovery, they can’t see this. The consequences aren’t clear, they don’t view their behaviors as unhealthy, and they aren’t ready to change.
In this article we’ll discuss the stages a person goes through when stopping an unhealthy behavior, how this can be used to understand addiction recovery, and how it relates to the 12 step recovery models used by recovery programs worldwide.
What is the Transtheoretical Model?
The transtheoretical model has been developed over the past 35 years, with many changes made over the years to improve how health professionals can apply it to help addicts. Initially used to understand experiences of smokers who were able to quit, it helps categorize different stages of change that someone with an unhealthy behavior undergoes on their path to recovery.
The 6-stage model is anything but linear – a person can move between stages rapidly, skip stages altogether, and move backwards as well as forward. While the transtheoretical model was designed as a tool for health professionals, it gives addicts, relatives and loved ones the ability to understand the mindset at each stage of the cycle.
The 6 Stage Model of Behavior Change
The 6 stages of change model was developed as part of the transtheoretical model and is able to place anyone with an unhealthy behavior or addiction at one or more stage.
The stages of change are:
- Termination or Relapse
A person in active addiction is generally in the first three stages, whereas those in recovery are taking action or maintaining their recovery. Relapse is frequent and can take an addict back to the precontemplation page, while termination describes a change in mindset in someone who is no longer at risk of relapse.
Termination is rare in addiction, and most will need to actively work to maintain their recovery. For other unhealthy habits such as overeating the stages of change model still applies, and termination is easier to achieve.
Stage One – Precontemplation
The precontemplation stage encompasses those who have an unhealthy behavior, but don’t see a problem with it. It can include those that are starting to see negative consequences but don’t fully understand why this is having a negative impact on their life.
People in this stage are resistant to change and aren’t ready to take steps to controlling their unhealthy behaviors. An addiction is more than just substance misuse – it is maintained by a range of unhealthy behaviors which can include:
- Obtaining their addictive substance (or behavior, such as gambling) – finding a dealer or supply.
- Maintaining access to that supply – financially and through making contacts with those who use.
- Supporting their addiction financially – sometimes includes partaking in criminal activities to fund their addiction.
- Keeping their addiction a secret from those who might try to intervene. An addict might need to make excuses to others (or themselves) if someone points out the negative consequences of their addiction.
This isn’t assigning blame on the addict. In the precontemplation stage they might not “know better” and will continue to justify their substance use. This is part of the illness of addiction.
Helping someone at this stage of addiction will include taking steps to help the addict acknowledge that they have a problem, increasing their awareness of the consequences, and exploring other activities that might address the underlying reason why they started to use (such as poor emotional regulation – using an “upper” when they are down or vice versa).
Stage Two – Contemplation
Those who are in the contemplation stage can see that there are negative effects to their behaviors. Acting out and using might be causing problems with their health, their finances, or their personal life. As time goes on, they start to build a picture of all the pros of changing their unhealthy behavior, but are also very aware of the cons.
Recovering from addiction is incredibly difficult and requires a lot of effort from the addicted person. They may have committed many misdeeds and kept many secrets from themselves and loved ones to support their addictive behaviors. Guilt and shame related to this can be overwhelming and continuing that way of life might seem easier than facing the past. Those in the contemplation stage are not ready to act, but are intending to change in the next 6 months.
At this stage of change, you may be able to help the addicted person by aiding them to consider the pros and cons of recovery and find any barriers to change.
Stage Three – Preparation
At this stage of change, the addicted person knows that they must change. They have finally understood and believe that there are more benefits than negatives to changing their ways.
Recovery can be incredibly daunting, so this stage might include collecting information about their behaviors, preparing a list of goals they want to achieve, and creating a plan of action that might start with small changes to their lifestyle.
A great first step is to get rid of triggers, for example removing drug paraphernalia. A visit to the doctor at this stage can help the addicted person find resources which can help them in their journey to recovery.
It’s important at this stage that the addicted person gets support. It is often necessary to cut contact with those who might put their recovery at risk of relapse, and the steps needed to change can take a huge mental toll. Non-judgmental support from loved ones is invaluable, as is the peer support from 12 step program such as alcoholics anonymous (AA) and narcotics anonymous (NA).
Stage Four – Action
At this stage the addicted person is ready to make the necessary changes to their life to change their unhealthy behavior. The addicted person can use a change plan from the preparation stage, as well as advice from those in recovery, to guide them towards new healthy behaviors and coping strategies.
As an example, someone that might typically spend their Friday night drinking alcohol and using substances might agree to start a new hobby that keeps them occupied on a Friday evening. Addicts in recovery should reward themselves for positive change and loved ones can reinforce positive steps by offering their praise and support.
There is danger at this stage that the addicted person forms cross addictions –using other addictive substances such as cigarettes or obsessively exercising. Having a sponsor from a 12-step program can help immensely at this stage by offering support and practical advice on how to keep up the good work and avoid cross addiction.
Stage Five – Maintenance
Maintenance is the goal for most addicts in recovery. Complete termination of an addiction is often impossible, and their addictive substance will always pose a risk of relapse. At this stage the addicted person has made specific lifestyle changes and is completely abstinent from their addictive substance.
The hard work never stops, and the addict in recovery will still need to regularly assess their progress and work to prevent relapse – but at this stage the work is less demanding than the action stage.
Maintenance typically lasts from 6 months to 5 years (though for some will become a permanent state), so it’s vital that the person in recovery continues working on their healthy lifestyle changes. It might help the person in recovery to continue attending AA/NA meetings, become a sponsor to those in earlier stages, or volunteer for an addiction support agency.
Stage 6 -Termination or Relapse stage
Complete termination of an addiction is sometimes impossible, and the addicted person will have to continue active efforts to prevent falling back into relapse. For those with unhealthy behaviors that aren’t typically addictive, they may get to a point where they no longer see any benefits to their unhealthy behavior and don’t need to continue maintenance on a weekly basis.
For many though, the risk of relapse is ever-present. The chemical change in their brain means that it only takes one trigger, one drink, one seemingly unimportant decision to take them right back to active addiction.
The good news is that the stages of change are part of a cycle, and someone who has made it this far has many more tools in their toolbox to get themselves back to the maintenance stage.
So how does this apply to the 12-step model of addiction recovery?
Part of the mantra of 12-step program is that there is no “cure” to addiction. The chemical changes are already present, and an addict will never fully “recover” from the addiction. Instead, it encourages 12 steps for the addict to take to help them through the first 5 stages of change and maintain their recovery.
You can apply the 12 steps to different stages of the transtheoretical model:
Precontemplation – Step 1
Step 1 – “We admitted we were powerless over our addiction, that our lives had become unmanageable.”
By the end of the precontemplation stage, you have understood the negative consequences of your addiction and are ready to move on to contemplating making a change to your life.
Contemplation – Step 2-3
Step 2 – “We came to believe that a Power greater than ourselves could restore us to sanity.”
Step 3 – “We made a decision to turn our will and our lives over to the care of God as we understood Him.”
These stages are all about contemplating how any why you should change, and by the end of it you have decided that it’s time to rely on the help and support of others to recover from your addiction.
If you don’t believe in God or a higher power these steps might put you off – however the meaning is different from person to person. A person in active addiction has tried and failed to prevent negative consequences on their life, so this step is all about asking for help. AA Agnostica have compiled a list of steps that don’t include the word god and help explain it to those who don’t believe in the certainty of a higher power.
Preparation – Step 4
Step 4 – “We made a searching and fearless moral inventory of ourselves.”
A difficult stage that is necessary to truly understand the changes that need to be made to your life to end the negative consequences of addiction. This is a key part of the preparation of a recovery plan, as you cannot begin to prepare if you haven’t fully understood all of the things that need to change.
Action – Step 5-9
Step 5 – “We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.”
Step 6 – “We were entirely ready to have God remove all these defects of character.”
Step 7 – “We humbly asked Him to remove our shortcomings.”
Step 8 – “We made a list of all persons we had harmed and became willing to make amends to them all.”
Step 9 – “We made direct amends to such people wherever possible, except when to do so would injure them or others.”
These steps can seem daunting, but for many recovering addicts they hold all the key changes needed to improve their life. The steps are more than just saying and believing the words. Each step includes further groundwork that needs to be completed in order to move on to the next. Steps 8 and 9 are all about acting and making changes to your lifestyle.
Maintenance – Steps 10-12
Step 10 – “We continued to take personal inventory and when we were wrong promptly admitted it.”
Step 11 – “We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.”
Step 12 – “Having had a spiritual awakening as the result of these steps, we tried to carry this message to addicts, and to practice these principles in all our affairs.”
While it seems that the hard work is done, maintenance is often very difficult. The final three steps are all about keeping up the good work and avoiding slipping back into bad habits.
The transtheoretical model is an excellent tool to help health professionals, addicts, and loved ones understand the mindset of someone who suffers from addiction or partakes in unhealthy behaviors.
While the model itself doesn’t provide the information necessary to make the change between stages of change, combined with a 12-step program and addiction recovery services it can help an addicted person understand their journey to recovery.
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