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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 a s 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.
he 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
THE CYCLE OF CHANGE
Whether the model would be
deemed a success in the field of
substance use depends on how
we judge ‘success’ – on the
model’s ability to help us under -
stand the process of recovery, or
its ability to help clients progress
along the road to recovery.
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.
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 confid -
ence 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,
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