Stages of Treatment

Abigail Barthel, Jennifer Wiseman, Tanya Freedland, MSP, LADC, Julie Rohovit, Ph.D., Piper Meyer, Ph.D., LP.
It is common for people to experience ongoing ambivalence when making a change. A model of behavioral change, known as the “Stages of Change” assesses a person’s readiness to make any change in behavior (e.g., health diet, exercise), and there is consistent support for use of this model in treatment approaches for substance use and mental illness. In stage-matched care, clinical interventions are selected and can be adapted based on a person’s Stage of Change. This effective approach supports and enhances a person’s motivation while increasing the likelihood that a person can sustain a behavior change. Stage-matched interventions, referred to as the Stages of Treatment, describe a person’s process through recovery. Each Stage of Treatment includes a range of motivational interventions matched to support a person’s recovery. Below is a description of the Stages of Change paired with the corresponding Stage of Treatment. This is followed by an example of how to use the Stages of Treatment to effectively treat co-occurring mental illness and substance use disorders.

Stage-Matched Care

Developed from the Trans-theoretical Model of Change1, the Stage of Change model includes five stages: pre-contemplation, contemplation, preparation, action,
and maintenance. These stages of change have four Contemplation and Preparation Persuasion complementary stages of treatment each with specific strategies tailored to enhance client engagement and motivation. Research supports the use of stage-matched care to help implement health-behavior changes related to substance use, physical activity, and taking medication(2). Individuals with co-occurring mental illness and substance use disorders have complex needs that may be more effectively addressed by utilizing the stages of treatment as opposed to using a strategy outside of the individual’s Stage of Change.

Stages of Treatment in Practice

Stage of Change (SOC) = Precontemplation  »  Stage of Treatment (SOT) = Engagement

Erica reluctantly agreed to engage in substance use care after receiving a second DWI in the past year. She currently meets diagnostic criteria for major depression and alcohol use disorder and is having difficulty seeing any future for herself. Bill, her counselor, recognizes that Erica is in the precontemplation Stage of Change related to her substance use and depression and that he should use strategies related to the Engagement Stage of Treatment. Bill uses reflections to acknowledge Erica’s feelings of distress and enhance their rapport. He is careful to explore her feelings and experiences without providing advice. Eventually, with Bill’s use of motivational interviewing skills (open ended questions, affirmations and reflective listening) she reveals her drinking and low mood is causing problems.

Bill: “What’s going on with you today?”
Erica: “Life is so hard and probably won’t ever get better for me. But, I shouldn’t be here, my drinking isn’t a problem.”
Bill: “What do you mean life is so hard?”
Erica: “I don’t talk to anyone and nobody wants to be around me because I’m no fun anymore.”
Bill: “Things probably weren’t always like this. How do you think it’s gotten this bad?”
Erica: “It just sort of happened. Drinking helped me at first, but now it is hard too. I have to keep drinking so I don’t get hungover and sick.”

Stage of Change (SOC) = Contemplation and Preparation  »  Stage of Treatment (SOT)Persuasion

Erica has been attending individual and group counseling and is aware of the pros and cons of her alcohol use. Erica can recognize reasons for change but has not committed to a plan. Bill, recognizing that Erica has moved to the Contemplation Stage of Change, uses motivational strategies, such as developing discrepancies, to help Erica resolve the ambivalence and move toward Preparation and then the Action stage.

Bill: “Tell me about some of the good and bad things about drinking?”
Erica: “Drinking helps me unwind at the end of the day. I used to like going out with my friends, but they won’t go out with me anymore and I am really sad about that. Last time I tried to stop drinking, I started to feel really sick and shaky.”
Bill: “So you feel relaxed while drinking, but afterwards you feel sad and sometimes sick.”
Erica: “Yeah. I miss my friends. I just don’t know how to stop, I don’t know if I can do it.”
Bill: “So you want some things in your life to change, but you’re not sure if they can.”

Stage of Change (SOC) = Action  »  Stage of Treatment (SOT) = Active Treatment

Erica feels ready to make some changes in her life and has already taken steps toward recovery. She is taking an antidepressant and reducing her alcohol use, but doesn’t yet feel stable. Now that Erica is in the Action stage, Bill’s adjust his strategies to Active Treatment by providing support, education, and suggestions,. He continues to elicit reflections from Erica as she implements new changes and coping skills in her life.

Bill: “How have things been going since the last time we talked?”
Erica: “Things are a little better. I only drank twice last week, but sometimes the cravings are really bad and I struggle to get through the day.”
Bill: “You have done such great work so far, I hope you are proud of yourself! What coping skills do you use to deal with the cravings?”
Erica: “I have tried going for walks or chewing gum when I get the urge to drink. When it’s really bad, I go to support meetings to hear the stories. I like the support too.”
Bill: “That seems to work pretty well for you in most situations, but you struggle sometimes. What is it about those times that are difficult?”
Erica: “I start to feel really anxious at the end of the day and it seems worse on days that I do have a few drinks.”
Bill: “Relaxation strategies can be helpful for people who feel anxious. Would you like to try one?”
Erica: “Sure, I am open to it.”

Stage of Change (SOC) = Maintenance  »  Stage of Treatment (SOT) = Relapse Prevention and Recovery

Erica has established new behaviors since coming to care and decided to stop consuming alcohol because she realized it increased her feelings of anxiety and sadness. Bill recognizes that it will be important to help her develop relapse prevention strategies and to focus on additional ways to enhance and maintain her recovery.

Bill: “You’ve done a great job getting to this place of recovery! How can you continue to support your changes and prevent relapse?”
Erica: “Yeah, things have been going really well for me. Exercising has helped me cope with urges and I love the relaxation work we do, so I am going to check into yoga. I am kind of worried about going out with friends in the future, though.”
Bill: “Those are all excellent strategies to use moving forward. What do you think you might use to deal with social situations?”
Erica: “Well, I have developed a lot of skills and have a lot of support now. Maybe you can help me figure out how to use them so I can continue my progress.”
Bill: “That’s a great idea, let’s work on updating your relapse prevention plan.”

The Center for Practice Transformation is sponsored by funds from the Minnesota Department of Human Services Adult Mental Health Division and Alcohol and Drug Abuse Division.