Talk therapy and the process of change

Each person is on their own journey and has their own pace. It is important to remember that there is no right or wrong in this, and one cannot compare themselves to another person. For some people, it is difficult to understand where they are at or what steps they have been taking; one of the models that can be used to help with this is Prochaska and DiClemente’s “The stages of change model”, which they developed in the 1980s. This model can be applied to many different behaviour changes, and it is highly used in understanding addictions and their treatment. Each of these stages will inform the treatment differently.

This model includes five stages. Let’s start with the Pre-contemplation – Imagine that this person has no awareness of their problem and, therefore, no desire to change. They often defend their use and speak only about the benefits. They are in denial about the consequences of their behaviour. You could hear them say things like, “My partner has a problem with me smoking, but I have it under control”; “I have smoked since I was 12, and I am better at handling it than most guys”. The second stage is Contemplation – In this stage, the person can see both benefits and consequences of their behaviour. They consider the possibility of reducing or quitting. However, they still speak highly about the positives. They often start acknowledging/experiencing adverse consequences – family issues, mental health decline, legal issues, etc. “I had a big weekend, I may take a break for a bit.”; “I have lost some good friends cos they don’t want to be around me when I use, I may slow down.” This often highlights how difficult it can be to change. When a person moves through this stage, they start preparing for a new chapter in their life. The person sees the consequences that outweigh the benefits. Little or non-ambivalence about change is seen here as they made up their mind. They understand the need to change and may start taking small steps towards the desired behaviour. The motivation for change can be internal (e.g. I do this for myself, my health) or external (e.g. I need to do this for my partner, for my kids).

Setting specific and realistic goals is essential. A reward system needs to be activated (“How will you reward yourself for not … one day, one week, one month, etc.?”); this will directly support the rewiring of the reward cycle in the brain and overall support the person in their change. Punishment and being scared of failure effectively lead to a relapse. A support network is critical during this process. For long-term abstinence, the person needs to find strong internal motivation for change, as external motivators can quickly come and go. The following step is the action. In this stage, the person is actively involved in changing (trying different techniques and/or programs). It is often advised to start with small steps and increase to greater steps in order to alter own behaviour significantly. This is where one is at the most significant risk of returning to the addiction. Once a person has been actively putting in place new strategies and working on the underlying causes of their behaviour, they enter the maintenance stage. During this time, one can handle high-risk situations, as they have learned to anticipate and manage temptations; they can also use their coping skills, all of which prevent them from relapsing. If they lapse, they don’t see it as a failure and can learn from it and return to abstinence. “I have been clean for 12 months, I am still seeing my counsellor every week”; “I stopped using four years ago, I have a family and a stable job, and I am happy that I stopped”. A person can encounter a high-risk situation anytime; when poor coping strategies are implemented or long-term stress, it can lead to a lapse or relapse. 

Lapse is a “one-off” that can be one drink, one smoke, short-term use or the return to the old behaviour, whatever it is. When handled properly, it can be an essential part of becoming stronger. People can learn about their high-risk situations and therefore develop their ability to resist next time. In treatment, It is important to identify strengths and weaknesses. Positive thinking (“it’s ok, I can learn from this”) leads either to the action or maintenance stage. However, negative thinking (“ I can’t do anything right, I am a failure”) will more likely lead to relapse. Often one would say, “One drink won’t hurt”; “It’s a b’day party; I want to have some fun, I can manage.”Relapse, on the other hand, is about a person going back to their old behaviours for a longer period of time. The negative self believe is very strong. In hindsight, it can be analysed in treatment and help the person prepare for high-risk situations by developing a relapse prevention plan (“What led to this? Why now and not before?”). Often one would say, “I managed not to smoke for a few weeks, but old habits die hard; I use every day”. 

Not only in addiction treatment, but whenever one wants to change their behaviour, it is important to note that it is common for a person to move between stages and a lapse/relapse. When one reflects on them, they are vital for developing and strengthening the relapse prevention plan.