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Prochaska and DiClemente’s ubiquitous ‘stages of change’ model (the framework for their wider ‘transtheoretical’ model) seems to offer a scientific system to guide clinicians and therapists on how to work with patients, avoiding wasteful change attempts with those not yet ready to change, a rationale for instead nudging them forwards to a more receptive stage, and a way to recognise when someone is ready to commit to and make the changes needed to overcome substance use problems. Implicitly or explicitly, in services across the UK this system is used to categorise patients and clarify how to promote progression to sustained recovery. Its simplicity is beguiling, but can it really be used to generate change by matching patients to interventions, or does it simply describe one type of change process?
Analysed in this Effectiveness Bank review, the model portrays motivational transition as a fixed, segmented sequence leading from ‘No acknowledged problem,’ through to, ‘No problem now.’ In between are stages where change is pondered, prepared for, implemented and stabilised. Among its attractions is the feeling that one has gained insight in to something important, technical and scientifically valid, yet which accords with common sense: that (for example) it is no use trying to close the deal on a change plan if the client has yet to see the need for change, that what it takes to embed change is not the same as what it takes to generate it, and that overcoming dependent substance use is no quick fix, but sequentially requires awareness, thought, preparation, implementation and stabilisation, each stage of which must be completed to provide a foundation on which the next stage can build with a chance of success.
The model amounts to a broad guide to what (not) to do with patients at different stages of change. It is at this crunch point, when it actively engages with change through treatment or brief interventions, that research support is largely absent. That is true not just of drug and alcohol problems but of therapy for psychological problems in general. In contrast to other factors, the American Psychological Association could only say matching interventions to stage of change was “probably effective” – and from the relevant review, even “probably” seems optimistic.
Smoking was where the transtheoretical model originated and where the evidence seems strongest, bolstered by studies of ‘stage-tailored’ computer-generated interventions which provided smokers recruited from the general population with individualised feedback about what they are doing and what they could do to progress toward their smoking cessation goals. When in 2010 these studies were analysed for the Cochrane collaboration, the verdict 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, that across all relevant studies, it could not be shown that matching to stages led to more non-smokers. More generally, “Direct comparisons between the same intervention in a standard format or modified by stage of change, with each intervention delivered at a similar intensity, demonstrate neither a beneficial nor a detrimental effect of the staged approach.” An earlier assessment conducted for the UK’s National Health Service came to a similar conclusion: “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.”
The most stringent text of stage-matching is to provide exactly the same interventions, but at random to either match or not match these to stage of change. The Cochrane review judged disparities in the findings of such studies “difficult to square with the theoretical model” – that set this critical test, the model fails to consistently account for the findings. Most promising of the studies was one of a model developed from the Cycle of Change. It found that generally smokers whose computer-generated feedback and advice matched their stage were more likely to progress to the next stage, but offered no direct confirmation that they were more likely to successfully stop smoking.
Cycle of Change and derivative models offer a framework for understanding intentional, planned change, but this is only one way people alter their substance use. Precipitous, unplanned change (in a positive direction, typically from excess to abstinence) seems to defy the requirement to pass through stages. There can also seem no sign of the model’s change mechanisms – the expected process of the user re-evaluating the pros and cons of continuing as they are, until so decisively do the cons outweigh the pros, that with sufficient confidence in their ability to change (‘self-efficacy’) along with other burgeoning ‘processes of change’, the decision is made, plans laid, then carried out and sustained. When this process is intentional, the model offers a detailed and possibly valid description. But what of when a smoker 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, rather than them intentionally deciding to change? Intentional change is not the only or it seems the most robust way people initiate change. For smoking in particular, it may be a minority route, and one half as likely to ‘stick’ as planned attempts.
Unplanned and famously successful drinking cessation events have been documented by recovery analyst and advocate William White. They include the account of Bill Wilson, who went on to co-found Alcoholics Anonymous. Hospitalised for the fourth time for alcohol detoxification, “he cried, ‘If there is a God, let Him show Himself!’, 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.”
Perhaps in less florid manifestations, that also seems a common kind of experience among dependent drinkers in treatment in Britain. When asked what they thought had helped them overcome their dependence on drink, patients in the UK Alcohol Treatment Trial (UKATT) commonly described revelatory moments which precipitated wholesale transitions in how they saw drinking and drink and in their determination to change. As with smoking, in these situations half-finished bottles can simply be poured down the sink or thrown away in disgust.
That doesn’t mean unplanned abandonment of substance use is without causes; at the time, the desperate Wilson was ripe for such an experience. But whatever led up to this, at the moment of change immediate causes can take the form of triggers which precipitate change rather than a weighing up of the pros and cons. Another UK survey – which again found unplanned stop-smoking attempts twice as likely to succeed as planned – discovered unplanned attempts were commonly triggered by health advice/concerns, expense, and pressure from family/friends, though 1 in 6 respondents could cite no particular reason. In California, a survey of problem drinkers found that weighing the pros and cons of drinking as a reason for cutting down was much less likely to lead to lasting remission than ‘conversion’ experiences like hitting rock bottom, a traumatic event, or experiencing a religious or spiritual awakening.
Despite its limitations, there may still be reasons why the Cycle of Change model remains valuable, though perhaps not in its intended role of helping match interventions to stage of change. In the last paragraph of the Effectiveness Bank review, the author, a cogent critic, nevertheless finds many ways in which the model might be a positive influence – a kind of benevolent fiction which gives hope to and motivates both worker and client. Likewise a duo including a leading UK researcher on psychosocial approaches to drinking problems declared themselves not yet ready to abandon the Cycle of Change, though argued that it itself needs to change. They saw the model’s strengths as portraying change as a process rather than a one-off event, the insight that the process is essentially motivational, featuring conflict, ambivalence, vacillation, and regret, and found evidence that the model might progress change through stage-matching, at least in relation to smoking. Find all our relevant Effectiveness Bank analyses by clicking this tailor-made search.
Last revised 03 September 2015. First uploaded 28 October 2014
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