Five Stages of Change in Prochaska and Did Clementis Model of Drug Dependence and Its Implications for Practice - Coursework Example

Critically analyse the five ‘Stages of Change’ in Prochaska and did Clementi’s model of drug dependence and its implications for clinical practice.  Your Name University Schools Number and Name of Course Instructors Name Date of Submission (e.g., October 12, 2009) 1.0 Introduction DiClemente and Proschaska (1988, as cited in Bouis et al., 2007) proposed the transtheoretical model, which is based on the premise that there are different phases of readiness for behavioral change. Researchers consider readiness to change as a motivational state influenced by environmental, cognitive, affective, and interpersonal events. The five stages in the transtheoretical model include “pre-contemplation, contemplation, preparation, action, and maintenance.” These stages represent the cyclic and continuous processes by which individuals modify their addictive behaviors. DiClemente and Proschaska (as cited in Lewis, 2005) reiterated that individuals with drug problems progress through a series of stages. The first stages entail minimal awareness of the problem. Meanwhile, the last phases involve the attempt to eliminate the undesirable behavior. Individuals do not progress into these stages in a linear manner (Lorish, 1999). There is a likelihood that clients will vacillate between the stages. Individuals in the action stage may move back to pre-contemplation phase upon encountering setbacks (as cited in Lewis, 2005). Researchers stress that an individual is classified into a single stage at a certain moment; thus, the stages are considered as mutually exclusive. Individuals progress through these stages in an orderly manner without stage-keeping (as cited in Littell & Girvin, 2004; as cited in K. Carey, Maisto, M. Carey, & Purnine, 2001, p. 79). This paper sought to provide an in-depth analysis of the transtheoretical model of behavior change. It outlines the stages of change, processes of change, criticisms, and implications for the clinical practice of the Trans theoretical model. 2.0 Transtheoretical Model of Behavior Change Lenio (n.d., p. 43) reiterated that transtheoretical model concentrates on the decision-making capabilities of individuals instead of biological and social influences of behavior. This model is conceived from integrating approximately 300 theories in psychotherapy along with behavior change theories (Lenio, n.d., p. 43). It recognizes the importance of the developmental approach of change instead of a theoretical approach. Transtheoretical model was developed to assimilate different aspects of counseling without separating practice from the theory (Petrocelli, 2002). The main assumptions of transtheoretical model include stages of change, self-efficacy, processes of change, and decisional balance. The processes of change are considered as the covert and overt activities that individuals perform to modify their problem behavior. Meanwhile, self efficacy assesses the confidence of the client to change and keep the change over time. Lastly, decisional balance measures how the client weighs the advantages and disadvantages of changing (Brodeur, Rondeau, Bruchu, Lindsay, & Phelps, 2008). According to Calderwood (2011), the advantage of transtheoretical model lies in its common-sense and evidence-based approach to individual motivation. Transtheoretical model supports the assumption that individuals undergo five stages of change in an attempt to modify undesirable behavior (Pringle, 1998). Behavior change is regarded as dynamic instead of “all or nothing phenomenon.” Researchers consider this as one of the strengths of the model (Lenio, n.d., p. 74). Transtheoretical model serves as an effective means of eliminating problem behavior and acquiring positive behaviors. The temptation to perform the problem behavior diminishes across the stages (Burkitt & Larkin, 2008). Transtheoretical model posits the need for intervention strategies that address barriers and stage-specific psychosocial interventions. Cho (2006) acknowledges the individuals inherent ability to accomplish the necessary behavior changes without therapy. Individuals perform various solutions to address problem behaviors, undesirable affect, deficiencies in functioning, and problematic thinking. The processes of change pertain to individuals attempt to change with or without the aid of therapy (Cho, 2006). The stages of change reflect the temporal aspect when shifts in intentions, behaviors, and attitudes occur. The processes of change in the transtheoretical model present how these shifts occur. Researchers identified ten processes classified as experiential and behavioral processes that facilitate progress through five stages of change (as cited in Lenio, n.d., p. 74). Experiential processes concentrate on thinking or emotional reaction to a particular problem behavior, and its subsequent influence to others and the environment. Meanwhile, behavioral processes involve modification of the environment to facilitate behavior change (Babcock, Canady, Senior, & Eckhardt, 2005). Researchers noted that the first-five processes are employed in the early phases of change, while the last-five are utilized in the later stages (as cited Lenio, n.d., p. 74). The ten processes of change are considered as independent variables that individuals must apply to progress to subsequent stages (Wilson & Schlam, 2004, p. 362). The stages of change among individuals can be evaluated through four or a five-item algorithm. Subjects are presented with a “yes” or “no” questions. The responses from these questions determine if the individual can be classified into one of the stages in the transtheoretical model. The questions presented pertain to current behavior, past attempts to change, and future intentions (as cited in Lenio, n.d., p. 74). 2.1 Stages of Change 2.1.1 Pre-contemplation Stage Those who are in the pre-contemplation phase are likely to engage in self-denial. They tend to agree with the statement “I don’t have any problem that requires change” (Diclemente, Bellino, & Neavins, 1999). Individuals in this stage possess no intention to change their behavior. They may be uninformed about the possible consequences of their behavior (Lewis, 2005). These individuals may experience failure upon previous attempts to change. Proschaska et al. (1992, as cited in Lenio, n.d., p. 74) noted that individuals in the pre-contemplation stage are characterized by the resistance to acknowledge or change the problem behavior. They need to experience cognitive dissonance to overcome this stage. The failure to acknowledge the need to change is manifested in six months (Lenio, n.d., p. 74). 2.1.2 Contemplation Stage Individuals who are in the contemplation stage entertain the idea of changing their undesirable behavior within the succeeding 6 months (as cited in Lenio, n.d., p. 74). However, they do not undertake necessary actions that may lead to change. Individuals at this stage experience ambivalent feelings towards change (Lewis, 2005). They weigh the advantages and disadvantages of modifying their problem behavior. Individuals tend to remain in the contemplation stage for longer period of time. Behavioral procrastination or chronic contemplation pertains to the inability of individuals to overcome this stage. During this stage, the individual engages in the risky behavior even if he/she is aware of the undesirable consequences of this particular behavior (as cited in Lenio, n.d., p. 74). Individuals begin to consider that change is beneficial (Lewis, 2005). Prochaska et al. (1992, as cited in Lenio, n.d., p. 74) reiterated that individuals in this stage are seriously considering addressing and resolving the problem behavior. The individuals progress to the next stage if the motivation to change is stronger than remaining stable. 2.1.3 Preparation Stage Meanwhile, individuals in the preparation phase were likely to acknowledge that they have drug problems. They tend to agree with the statement “I am working on my drug problem” (Disclemente, Bellino, & Neavins, 1999). Individuals in the preparation stage make a commitment to modify their undesirable behavior in the near future (Lewis, 2005). They recognize the benefits of changing their undesirable behavior (Vik, Culbertson, & Sellers, 2000). Thus, individuals commit to a cognitive decision to change. However, they get stuck to this cognitive level instead of the means of undertaking change (Lewis, 2005). Individuals in this preparation stage previously attempted to modify the problem behavior. However, they still engage in the risky behavior. This may be driven by a fear or doubt on their ability to change. The individuals are presented with a plan of action in reducing or eliminating the problem behavior. This provides individuals with alternative potential solutions (as cited in Lenio, n.d., p. 75). 2.1.4 Action Stage Those who are in the action stage perform steps to address their problems (Lewis, 2005). These individuals concentrate their efforts in modifying their experiences, behaviors, and attitudes in the period of six months. This stage necessitates a significant amount of energy and time. Individuals receive recognition from others for their efforts during this stage. However, researchers reiterated that the attempt to change is different from change itself. The individual’s actual change is assessed through a criteria established by professionals and scientists. Prochaska, DiClemente, and Norcross (1992, as cited in Lenio, n.d., p. 75) noted that the primary way to determine that an individual is in the action stage is through their efforts to change as well as changing their problem behavior according to acceptable criterion levels. Individuals progress to the maintenance stage when they experience a positive affective state, improve performance, positive performance, and social feedback (as cited in Lenio, n.d., p. 75). 2.1.5 Maintenance Stage In the maintenance stage, individuals are driven to avoid relapse. Clients prevent relapse through effectively negotiating various psychological stress (Disclemente, Bellino, & Neavins, 1999). They attempt to secure gains or progress made during the action stage. These individuals have lesser likelihood of being tempted to relapse. They gain confidence that they are capable of continuing their changes. The ability to be free from the undesirable behavior and adopt new behavior in the period of six months is utilized by researchers as the criteria to classify an individual in the maintenance stage. They further reiterated that maintenance stage represents a continuation of change (as cited in Lenio, n.d., p. 75; Jakybowski & Dembo, 2004). Martin and Fell (1999) added the last stage which is referred as the termination stage. Individuals at this phase do not have the desire to return to the problem behavior. An Individual can be classified in this termination stage when he or she is successfully freed from the problem behavior. However, only few individuals successfully progress into this last phase. 2.2 Processes of Change 2.2.1 Consciousness Raising Consciousness raising pertains to the need of an individual to strengthen his/her awareness of the causes, cures, and undesirable consequences of the problem behavior. Awareness among individuals can be increased through education, interpretation, feedback, media campaign, and confrontation (as cited in Lenio, n.d., p. 75). Karoll and Poertner (2003) consider consciousness raising as an individual’s attempt to gain understanding about oneself and the problem behavior. 2.2.2 Dramatic Relief Dramatic relief refers to the need of an individual to express his/her emotions and feelings regarding the problem behavior. Researchers suggest that life events, which include death of a close friend or a family member, may impel an individual into pre-contemplation. This commonly occurs when death is related or due to the problem behavior (cited in Lenio, n.d., p. 75). 2.2.3 Self-Reevaluation Lenio (n.d., p. 75) considers self-reevaluation as the affective and cognitive appraisal of individual’s self image without and with the problem behavior. Paten et al. (as cited in Lenio, n.d., p. 78) noted that self-reevaluation is essential when individuals are progressing from contemplation phase to the preparation stage. Self-reevaluation can be enhanced through imagery, corrective emotional experience, healthy role models, and value clarification. 2.2.4 Environmental Reevaluation Environmental reevaluation refers to individual’s appraisal of how the absence or presence of problem behavior influences his/her social environment. Prochaska and Velicer (1997, cited in Lenio, n.d., p. 78) noted that environmental reevaluation may include an individual’s awareness of how he/she serves as a negative or positive role model to others. The strategies that facilitate environmental reevaluation include family interventions, empathy training, and documentaries (as cited in Lenio, n.d., p. 78). 2.2.5 Self-Liberation Self-liberation pertains to the belief that an individual can change, and he/she possesses the commitment to undertake necessary actions to accomplish that belief. Self-liberation can be undertaken through logo therapy techniques, New Year’s resolution, decision-making therapy, and commitment enhancing techniques. Previous studies indicated that individuals who adopt several strategies have higher commitment to modify their problem behavior (as cited in Lenio, n.d., p. 78). 2.2.6 Social Liberation Social liberation refers to the need for alternatives or opportunities for desirable behaviors in the society (as cited in Lenio, n.d., p. 78). 2.2.7 Counter-conditioning Lenio (n.d.) considers counter-conditioning as the need of individuals to adopt desirable behavior for their problem behaviors. Counter-conditioning can be enhanced through positive self-statement, relaxation, assertion, and desensitization. 2.2.8 Stimulus Control Stimulus control involves the elimination of the stimuli related with the problem. Self-help group, avoidance, and restructuring one’s environment reduce the likelihood of relapse (Lenio, n.d.). 2.2.9 Contingency Management Contingency management presents the consequences of engaging or avoiding the problem behavior. Techniques for contingency management include group recognition, self-reward, and contingency contracts (as cited in Lenio, n.d). 2.2.10 Helping Relationships This entails helping individuals to trust others who are involved in helping them modify their problem behavior. Therapeutic alliances, self-help groups, and buddy systems can offer such support (as cited in Lenio, n.d.). 3.0 Criticism Wilson and Schlam (2004) noted that the problem of the transtheoretical model lies on how the stages of change are measured and defined. Simple algorithm is utilized to classify individuals into one of the stages of the transtheoretical model. However, Sutton (2001, as in cited Wilson and Schlam, 2004, p. 363) argued that this method is logically unsound. Researchers stress the need for a stage theory to be able to classify individuals into a single stage category. Previous studies suggest that individuals do not fall into one stage but into two different stages of the transtheoretical model (as cited in Wilson and Schlam, 2004, p. 363). Researches modified the definition of the stages of change for several times. Several questionnaires were employed to assess the different stages. The lack of standardization limits the likelihood of empirically testing the transtheoretical model as well as replicating previous studies. Previous studies demonstrated that different questionnaires generate large differences in the stage distribution (Etter & Sutton, 2002). 4.0 Implication for Clinical Practice Variations on the level of motivation were found by other treatment-seeking groups. The recognition of these differences serves as the initial step in assessing how variation in motivation influences participation in the treatment programs (Disclemente, Bellino, & Neavins, 1999). Intervention facilitates behavior change when it is designed based on the client’s phase of readiness (Bouis et al., 2007). Transtheoretical model posits the need for intervention strategies that address barriers and stage-specific psychosocial interventions (Cho, 2006). The progress of an individual into succeeding stages increases the probability that he/she will move into the termination stage. Thus, it is essential to effectively tailor different self-change strategies for each stage (West, 2005). Gintner and Choate (2003) stress the importance of motivational interventions for addressing the indifference exhibited by individuals in the pre-contemplation stage. The tasks at this stage include acknowledging the harm related with the problem behavior, recognizing that change can be possible and beneficial, and increasing commitment to the process of counseling. These tasks can be accomplished through enhancing the value of change and increasing the confidence among clients (Gintner & Choate, 2003). It is essential to develop a working relationship with clients in the pre-contemplation stage. Emphatic therapeutic style is beneficial to those who are defensive about their problem behavior and resist counseling. Studies showed that emphatic therapeutic styles are correlated with improve communication, long-term change, and low level of resistance among clients (Gintner & Choate, 2003). It is beneficial for therapists to practice self-reflection in order to grasp client’s model of the problem behavior and determine means for motivational change. Reflection represents the willingness of the therapist to understand the point of view of the client (Gintner & Choate, 2003). Traditional practice stresses the need to confront an individual with drinking or drug problem with the “true facts’ about his/her problem behavior. However, empirical evidence suggests that such response leads to resistance and poor outcome (Gintner & Choate, 2003). Individuals with drinking or drug problem may experience psychological reactance or the sense of being confine. These individuals may resist the pressure and undertake the very behaviors which are being prohibited. Thus, it is highly beneficial for therapists to avoid arguments and employ reflective statements (Gintner & Choate, 2003). The manner that counselors respond to client’s resistance determines treatment outcome. One way to address resistance is for therapists to “back off and come alongside.” This strategy sought to sidestep potential argument and align with the point of view of the client (Gintner & Choate, 2003). The therapists concentrate in helping clients gain an understanding of the nature and extent of their problem during the contemplation stage. The client becomes more willing to reflect aspects of their problematic behavior and consider change at the contemplation stage. Researchers stress the need to eliminate ambivalence towards the problem behavior to facilitate commitment among clients. The goal of the therapist in the contemplation stage is to help clients grasp the nature of their problem, as well as the implications of change for those individuals around them and for themselves (Gintner & Choate, 2003). Open-ended questions and simple reflections can be employed by therapists to concentrate on the relevant harm related with the problem behavior. Therapists can also ask clients to monitor their problem behavior. This can offer a precise index of the problem behavior and its associated harmful consequences. In addition, it is essential for therapists to provide information pertaining to the problem behavior at this contemplation stage. Most individuals at this stage are interested in knowing more about their problem behavior; thus, they are more receptive to information associated with their problem behavior (Gintner & Choate, 2003). The therapist, along with the client, outlines the plan of action in resolving the problem behavior at the preparation stage. Martin and Fell (1999) reiterated that devising a quit plan should be a priority at the preparation or action phase. A Client should set a date within the next two weeks to quit engaging in problem behavior. He/she must inform others on the plan to quit and seek for social support. The client should remove smoke or drugs at home, and review previous attempts to quit. Lastly, he/she should anticipate challenges during the first few weeks. The action stage is concerned with performing the plan of action to eliminate or reduce the problem behavior (as cited in Anshel & Seipel, 2009). Therapists can help clients devise a self-reward system and find supporting relationships at the action or maintenance phase (Martin & Fell, 1999). 5.0 Conclusion Transtheoretical is based on the assumption that there are five stages of readiness for behavioral change. Individuals progress each stage through “consciousness raising, dramatic relief, self-reevaluation, environmental reevaluation, self-liberation, social liberation, counter-conditioning and stimulus control.” Therapists tailor different interventions for each stage to facilitate behavior change. However, several researchers argued that transtheoretical model suffers from logically unsound definition and not standardized methodology. References Anshel, M., & Seipel, S. (2009). 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