Have we been right to embrace the ‘cycle of change’,
asks Natalie Davies.
When Bill Wilson, who went on to co-found Alcoholics Anonymous, was hospitalised for the fourth time for alcohol detoxification, he cried, ‘If there is a God, let Him show Himself!’. As AA’s story goes, ‘the room became ablaze with light and Wilson was overwhelmed by a Presence and a vision of being at the summit of a mountain where a spirit wind blew through him, leaving the thought, “You are a free man”. Wilson never took another drink.’
Though Wilson’s story is spectacular – so much so that we might be inclined to think it a ‘fable’ rather than a blueprint for what might actually happen – it’s not unusual to hear about ‘revelatory moments’ or moments in which someone suddenly or spontaneously discards a substance that up to that point they had depended on. An example is the smoker who suddenly becomes disgusted with their smoking, spits out the cigarette half way through, dumps the remnants of the packet in a bin, and never turns back, as if something had overtaken them.
But another important narrative, and perhaps one more pertinent to the conversations between practitioner and client, is of the ‘longer road to recovery’ – of a process of change rather than a one-off event; of an experience mixed with conflict, ambivalence, vacillation, regret, and often relapse. And it’s this process that Prochaska and DiClemente’s ubiquitous ‘five stages of change’ model endeavours to describe.
The five stages of change
The ‘five stages’ plot the journey from Point A (‘no acknowledged problem’) to Point B (‘no problem now’) – each marker along the way representing a shift in motivation, intention, and capacity to change. Dealing frankly with the possibility of relapse, the popular depiction of the five stages as a ‘cycle of change’ (see the illustration opposite) shows the continued work that people can do or redo until the day they successfully achieve what is known as a ‘lasting exit’ to recovery.
The cycle shows the progression or evolution through the stages of pre-contemplation, contemplation, preparation, action, and maintenance, and how this can come full circle due to (re)lapse. It doesn’t exclude anyone from the process – even ‘not thinking about the harmful behaviour’ or ‘not being sufficiently aware of the health implications’ is a stage in itself.
As well as broadly describing change, the five stages provide a means of separating people into groups. From a practical perspective, if, as its originators have suggested, each stage entails ‘specific unique tasks that need to be accomplished in order to move successfully to the next stage’, the model has the potential to explain and even help generate behavioural change. It acts as a guide to what to do (or not do) with clients at different stages of change – for example, avoiding wasteful change attempts with those not yet ready to change, and recognising when someone is ready to commit to treatment; or if not, how to nudge them towards a more receptive stage.
The model was originally based on a comparison of smokers who were considered ‘self-changers’, versus those in professional smoking-cessation treatment. Although later applied to, and tested on, a range of other health-related behaviours including harmful drinking and drug use, smoking still accounts for the bulk of studies.
Whether the model would be deemed a success in the field of substance use (even if for now we are primarily relying on studies of smokers) depends on how we judge ‘success’ – on the model’s ability to help us understand the process of recovery, or its ability to help clients progress along the road to recovery. If the latter, the key test is the performance of so-called ‘stage-matching’ strategies which deliver different interventions suited to the assessed stage of the client.
An assessment for the UK’s National Health Service concluded that ‘Overall, whilst there is some evidence favouring the use of stage-based interventions for smoking cessation compared to no intervention, there is little evidence that stage-based interventions are more effective than non-stage-based interventions.’
Similarly, the verdict reached for the Cochrane Collaboration was that ‘Expert systems, tailored self-help materials and individual counselling, appear to be as effective in a stage-based intervention as they are in a non-stage-based form’. In other words, across relevant studies, it could not be shown that matching to stages led to more non-smokers.
The most stringent test of ‘stage-matching’ would be to provide exactly the same interventions, but at random, to either match or not match these to stage of change. Of the studies reviewed for the Cochrane Collaboration, the most promising found that generally smokers whose computer-generated feedback and advice matched their stage were more likely to progress to the next stage, but were not necessarily more likely to successfully stop smoking.
The crunch point
Unfortunately, it seems that at the ‘crunch point’ – when the model actively engages with change through treatment or brief interventions – research support is largely absent. The best the American Psychological Association could say on the matter was that matching interventions to stage of change was ‘probably effective’ – and looking at the relevant review, even ‘probably’ is optimistic. Could this indicate that there is something flawed about the stages themselves? That the way they are characterised lacks validity?
The underlying idea that motivation and intention to change increase over time and with each stage is a valid one – studies have found strong positive associations between both these variables and the five stages of change. So, we’re clearly in the right ballpark. But these strong positive associations could also indicate that we are dealing with a continuum of change, rather than a stepped pattern of change – meaning that the five stages may not be ‘true stages’ at all, but ‘pseudo stages’ picked at arbitrary points along a continuum.
If this were the case, and definitive evidence emerged to debunk the idea of stages, would this be enough to dismiss the whole model? Or as a tool for discussing recovery, is it useful in itself to be able to refer to stages as symbols of progression, whether or not they constitute discrete experiential or emotional states?
The cycle of change itself was only one part of a broader model of behavioural change proposed by its originators. Other ‘relatively neglected’ parts of the model have addressed the mechanisms that explain how people navigate change, including the ten common processes of change (eg consciousness-raising, self-re-evaluation, and helping relationships), weighing up the pros and cons of changing, and confidence in one’s ability to change and avoid temptation. But it’s the cycle of change’s ability to translate a complicated, daunting experience into something tangible for people both inside and outside the substance profession, that has arguably made this the most eye-catching aspect of Prochaska and DiClemente’s work.
Until something comes along to displace the cycle of change from our substance use language, perhaps it should continue to be embraced for what it does rather than rejected for what it does not – first and foremost, helping to understand and visualise the process, milestones, and emotional labour involved in recovery.
Jargon is commonplace in the sciences, but relatable language is not. And as a means to starting a conversation, the cycle of change isn’t bad. As a way of keying interventions to the client’s condition, on balance it has yet to be proven beneficial.
Natalie Davies is assistant editor at Drug and Alcohol Findings