As an important component of effective treatment planning, physicians may find it helpful to determine which stage of change characterizes the patient. There are six stages of change: precontemplation, contemplation, preparation, action, maintenance, and relapse. Patients can be conceptualized as moving along a continuum marked by these stages, each of which is described below. Readiness to change and stage of change can be evaluated by interview and instruments such as the Stages of Change Readiness and Treatment Eagerness Scale (Miller and Tonigan 1996). Stages of change are clearly linked to a patient’s motivation. It may be possible for a physician to increase motivation (e.g., through motivational enhancement therapy) and thus help a patient move from an early stage of change (e.g., contemplation) to a more active and healthy stage (e.g., action). The discussion of Stages of Changes below is excerpted from Center for Substance Abuse Treatment (CSAT) TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999b ). (See http://www.kap.samhsa.gov/products/manuals/index.htm.)
Transtheoretical Model of Stages of Change
It is important to note that the change process is cyclical, and individuals typically move back and forth between the stages and cycle through the stages at different rates. In one individual, this movement through the stages can vary in relation to different behaviors or objectives. Individuals can move through stages quickly. Sometimes, they move so rapidly that it is difficult to pinpoint where they are because change is a dynamic process. It is not uncommon, however, for individuals to linger in the early stages.
For most substance‐using individuals, progress through the stages of change is circular or spiral in nature, not linear. In this model, recurrence is a normal event because many clients cycle through the different stages several times before achieving stable change. The six stages and the issue of relapse are described below.
During the precontemplation stage, substance‐using individuals are not considering change and do not intend to change behaviors in the foreseeable future. They may be partly or completely unaware that a problem exists, that they have to make changes, and that they may need help in this endeavor. Alternatively, they may be unwilling or too discouraged to change their behavior. Individuals in this stage usually have not experienced adverse consequences or crises because of their substance use and often are not convinced that their pattern of use is problematic or even risky.
As these individuals become aware that a problem exists, they begin to perceive that there may be cause for concern and reasons to change. Typically, they are ambivalent, simultaneously seeing reasons to change and reasons not to change. Individuals in this stage are still using substances, but they are considering the possibility of stopping or cutting back in the near future. At this point, they may seek relevant information, reevaluate their substance use behavior, or seek help to support the possibility of changing behavior. They typically weigh the positive and negative aspects of making a change. It is not uncommon for individuals to remain in this stage for extended periods, often for years, vacillating between wanting and not wanting to change.
When an individual perceives that the envisioned advantages of change and adverse consequences of substance use outweigh any positive features of continuing use at the same level and maintaining the status quo, the decisional balance tips in favor of change. Once instigation to change occurs, an individual enters the preparation stage, during which commitment is strengthened. Preparation entails more specific planning for change, such as making choices about whether treatment is needed and, if so, what kind. Preparation also entails an examination of one’s perceived capabilities—or self‐efficacy—for change. Individuals in the preparation stage are still using substances, but typically they intend to stop using very soon. They may have already attempted to reduce or stop use on their own or may be experimenting now with ways to quit or cut back (DiClemente and Prochaska 1998). They begin to set goals for themselves and make commitments to stop using, even telling close associates or significant others about their plans.
Individuals in the action stage choose a strategy for change and begin to pursue it. At this stage, clients are actively modifying their habits and environment. They are making drastic lifestyle changes and may be faced with particularly challenging situations and the physiological effects of withdrawal. Clients may begin to reevaluate their own self‐image as they move from excessive or hazardous use to nonuse or safe use. For many, the action stage can last from 3 to 6 months following termination or reduction of substance use. For some, it is a honeymoon period before they face more daunting and longstanding challenges.
During the maintenance stage, efforts are made to sustain the gains achieved during the action stage. Maintenance is the stage at which individuals work to sustain sobriety and prevent recurrence (Marlatt and Gordon 1985). Extra precautions may be necessary to keep from reverting to problematic behaviors. Individuals learn how to detect and guard against dangerous situations and other triggers that may cause them to use substances again. In most cases, individuals attempting long‐term behavior change do return to use at least once and revert to an earlier stage (Prochaska et al. 1992). Recurrence of symptoms can be viewed as part of the learning process. Knowledge about the personal cues or dangerous situations that contribute to recurrence is useful information for future change attempts. Maintenance requires prolonged behavioral change—by remaining abstinent or moderating consumption to acceptable, targeted levels—and continued vigilance for a minimum of 6 months to several years, depending on the target behavior (Prochaska and DiClemente 1992).
Most individuals do not immediately sustain the new changes they are attempting to make, and a return to substance use after a period of abstinence is the rule rather than the exception (Brownell et al. 1986; Prochaska and DiClemente 1992). These experiences contribute information that can facilitate or hinder subsequent progression through the stages of change. Recurrence, often referred to as relapse, is the event that triggers the individual’s return to earlier stages of change and recycling through the process. Individuals may learn that certain goals are unrealistic, certain strategies are ineffective, or certain environments are not conducive to successful change. Most substance users will require several revolutions through the stages of change to achieve successful recovery (DiClemente and Scott 1997). After a return to substance use, clients usually revert to an earlier change stage—not always to maintenance or action, but more often to some level of contemplation. They may even become precontemplators again, temporarily unwilling or unable to try to change soon. Resuming substance use and returning to a previous stage of change should not be considered a failure and need not become a disastrous or prolonged recurrence. A recurrence of symptoms does not necessarily mean that a client has abandoned a commitment to change.
Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES 8D)
INSTRUCTIONS: Please read the following statements carefully. Each one describes a way that you might (or might not) feel about your drug use. For each statement, circle one number from 1 to 5 to indicate how much you agree or disagree with it right now. Please circle one and only one number for every statement.
SOCRATES Scoring Form (19‐Item Version 8.0)
Transfer the client’s answers from questionnaire (see note below):
SOCRATES Profile Sheet (19‐Item Version 8A)
INSTRUCTIONS: From the SOCRATES Scoring Form (19‐Item Version) transfer the total scale scores into the empty boxes at the bottom of the Profile Sheet. Then for each scale, CIRCLE the same value above it to determine the decile range.
Guidelines for Interpretation of SOCRATES‐8 Scores
Using the SOCRATES Profile Sheet, circle the client’s raw score within each of the three scale columns. This provides information as to whether the client’s scores are low, average, or high relative to individuals already seeking treatment for alcohol problems. The following are provided as general guidelines for interpretation of scores, but it is wise in an individual case also to examine individual item responses for additional information.
HIGH scorers directly acknowledge that they are having problems related to their drinking, tending to express a desire for change and to perceive that harm will continue if they do not change.
LOW scorers deny that alcohol is causing them serious problems, reject diagnostic labels such as “problem drinker” and “alcoholic,” and do not express a desire for change.
HIGH scorers say that they sometimes wonder if they are in control of their drinking, are drinking too much, are hurting other individuals, and/or are alcoholic. Thus a high score reflects ambivalence or uncertainty. A high score here reflects some openness to reflection, as might be particularly expected in the contemplation stage of change.
LOW scorers say that they do not wonder whether they drink too much, are in control, are hurting others, or are alcoholic. Note that an individual may score low on ambivalence either because they “know” their drinking is causing problems (high Recognition), or because they “know” that they do not have drinking problems (low Recognition). Thus a low Ambivalence score should be interpreted in relation to the Recognition score.
HIGH scorers report that they are already doing things to make a positive change in their drinking, and may have experienced some success in this regard. Change is underway, and they may want help to persist or to prevent backsliding. A high score on this scale has been found to be predictive of successful change.
LOW scorers report that they are not currently doing things to change their drinking and have not made such changes recently.
Resources for More Information
University of Rhode Island Change Assessment (URICA) (McConnaughy et al. 1983). http://www.uri.edu/research/cprc/Measures/urica.htm
Readiness to Change Questionnaire (Rollnick et al. 1992). http://www.niaaa.nih.gov/publications/rtcq.htm http://www.dva.gov.au/health/provider/care_plans/change.htm
Substance Abuse and Mental Health Services Administration (US), Rockville (MD)
Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2004. (Treatment Improvement Protocol (TIP) Series, No. 40.) Appendix G Stages of Change.