Prochaska, DiClemente and Norcross have created a very useful model of the way in which people change bad habits which they call The Stages of change Model. They discuss this model in detail in their book Changing For Good 1 which is on the HAMS recommended reading list. HAMS members have found this model very useful for discussing habits which they would like to change and the ways in which they would like to change them. The stages of change theory is useful for people who wish to reduce harm associated with a habit as well as for people who wish to reduce the amounts which they drink or who wish to quit drinking entirely. People can use the stages of change model as an aid to creating realistic self-change plans and they can also use it as a way to understand how and why others change or do not change. We have adapted the model slightly in ways which we believe make it most useful for our members to discuss their habits and their change plans 2. The stages are:
- Precontemplation - a person is not even thinking about making a change
- Contemplation - a person has started thinking that making a change might be a good idea and is perhaps starting to make plans about how to implement those changes
- Preparation/Action - a person is taking concrete steps which will lead to changing the behavior
- Maintenance - a person maintains the change in the behavior through continued effort
- Termination - the change is now ingrained and the person no longer has to make great efforts to maintain the change
- Recycling - a person returns from any given stage to an earlier stage
Prochaska, DiClemente and Norcross were specifically studying people who were trying to quit smoking--although the model can be useful for lots of behavioral changes including harm reduction for alcohol. They found that only about 5% of the smokers in the study proceeded through in a linear fashion from Precontemplation to Termination without ever returning to smoking once they had quit for the first time.
The other people in the study who managed to successfully quit smoking did so in a spiral process which involved Recycling. Prochaska does not use the term "relapse" because he does not stipulate that bad habits are diseases--and also because the term "relapse" is pejorative. They believe that most people require several attempts to quit smoking and that each time the person quits for a little while and then starts up again that person has learned something which they need to quit successfully. That is why Prochaska uses the term Recycling--Prochaska believes that Recycling is a trial and error learning experience. It is very common to recycle from Maintenance to Contemplation or to Preparation/Action, but it is also possible to Recycle from Contemplation to Precontemplation or from any later stage to any earlier stage. Recycling is not bad per se because one can learn from the Recycling process, but it is important to practice Damage Control (discussed in a later chapter) when one Recycles.
Figure 1 is a graphical illustration of how the stages of change model operates--we have adopted this illustration from the Canadian Government web site http://www.activedmonton.ca/spring_summer/pe_getstart_ad .
Figure 1: The Spiral of Change
As a concrete example of how the stages of change work and how they fit in with harm reduction and change I am going to talk about how I quit smoking cigarettes after 35 years of smoking with never one previous attempt to quit. My first five years was cigars and pipes followed by ten years of factory made unfiltered cigs (American Camels and Japanese Peace) followed by 20 years of hand rolled unfiltered Buglers.
I am choosing to talk about cigarettes rather than alcohol because I was very familiar of the stages of change theory and harm reduction principles when I finally decided to quit cigarettes in 2008. My change plan for alcohol developed more from trial and error because at the time I was changing my drinking (1997 - 2002) I was not yet familiar with the ideas of harm reduction or the stages of change model.
I had long said that I only thought that I could quit smoking if I moved to a country like South Korea where smoking is rampant, because all the government anti-smoking propaganda and clean air laws and such ever did for me was make me want to smoke more. As you can see--I am a true contrarian to the very end. And even at age 50 I was still of a mind set of "live fast and die young". This is me in the Precontemplation stage having no desire or plan to change my smoking at all.
So what kicked me out of the Precontemplation phase and into Contemplation? My best friend and HAMS co-founder is Mizz Ellie. I worked for Mizz Ellie's mom doing some genealogy. Mizz Ellie's mom died of COPD as a result of smoking--she was dying and very sick even as I worked for her--in a wheelchair and on oxygen--and she was a very amazing and strong lady who was very much a part of the inspiration for me to found HAMS. I went to her funeral. Plus several members of HAMS including Mizz Ellie were concerned about me dying a premature death because they really loved me. And Lori--my girlfriend at the time--and later a good friend--felt the same. A lot of the "don't give a damn" attitude had been connected to the lack of anyone who really loved me. Now there were a lot of HAMS members who loved me and did not want to see me die prematurely. And I also thought about how my blues hero Big Bill Broonzy had died of throat cancer at age 56. And the final killer was Mizz Ellie's five year old son who kept ordering me to quit smoking after watching his grandma die from cigarettes. So I promised him that I would quit smoking when he started first grade and when I started grad school at the New School and once again had health insurance. It is bad karma to lie to a five year old--once I promised him I was struck. My final reason--after breaking up with Lori--was that nonsmokers get lots more matches on eHarmony.
In short--my life changed and so did my attitude: I went from Precontemplation to Contemplation.
I had seen Chantix, a prescription quit smoking aid, work a miracle in helping my chain smoking employer quit smoking. I checked out the research and saw that Chantix had a 50% success rate which was better than anything else on the market. I figured that if I could combine Chantix with what I knew about harm reduction and the stages of change model, then I had this thing beat. I had no health insurance until school started so it was when school started that I switched from Contemplation mode into Action/Preparation mode. The first thing I did was make an appointment at student health services to get a prescription for Chantix. I could not believe that my insurance would not pay for the one thing clinically proven most helpful--but the cheap-ass bastards did not. So I had to pay for it out of my own pocket which I could ill afford. There appears to be some evidence that people take things more seriously when they must pay. But too many people cannot pay for help so HAMS will always be free.
My preparation/action stage went as follows:
- I made a doctor's appointment and got a prescription for Chantix
- I filled the prescription and started taking the Chantix
- I started charting my cigarettes--keeping a record of how many I smoked each day
- I began chewing on cinnamon sticks and sucking on Hall's cough drops and licorice Altoids as cigarette substitutes
- I gradually cut out more and more cigarettes like the ones after meals the ones after getting off the subway and the ones before sleeping until I was down to two per day
- I went on nicotine free cigarettes for a few days then switched back to regular
- I carried both chewing tobacco and nicotine gum with me as a security blanket but I never used either
- I made a harm reduction plan for use during the upcoming Maintenance phase which allowed me to smoke up to one cigar a week--no inhaling--but no cigarettes
- At the end of 40 days and 40 nights of charting I decided one day that I did not want to spend money on tobacco and didn't buy it
- I didn't buy it again the next day and I was on my first day of quitting and into Maintenance mode
I am including a copy of the chart for your reference.
When I went into Maintenance mode I continued the Chantix for a month. I posted to the HAMS email group and asked them to tell me that I was stronger than a cigarette when I got tempted. But I knew I was done for good. Two days of not buying tobacco and I knew that I was in the Maintenance mode 3. I have not yet reached the Termination stage as of this writing. This is a concrete example of how one can use the principles of harm reduction combined with the stages of change model to create a change plan that works.
Before we leave the Stages of change Model we should discuss the fact that the Stages of change Model can be used to describe all changes in behavior and that it is essentially a morally neutral model. Because of this, being in Precontemplation is not necessarily a bad thing; in some case it can be a good thing, depending on what the change in behavior is and how one tends to view the change in terms of one's personal value system.
For example--I have never used heroin and I never intend to use heroin. I am in Precontemplation regarding heroin use because I am not even thinking of doing it. In my opinion this is a case where Precontemplation is a good thing and we do not want to change it into Contemplation mode--and likely most people would agree with me on this.
Precontemplation is inherently neither a good thing nor a bad thing--it is all relative to the behavior to be changed and the new behavior which will replace the old behavior. Sometimes for some behaviors it can be a good thing to remain in Precontemplation for one's entire life.
1 Prochaska J. O., Norcross J. C., DiClemente C. C. (1994). Changing for good. New York: Morrow.
2 Quite a few people who write about the stages set up their own version of them. Prochaska et al have also set up several different versions of the stages. The HAMS versions combines Action and Preparation into a single stage as the two are hard to separate apart for the person making the changes or making a change plan. We have also defined the points of transition between the stages in a way which we believe is most useful to members of a self-help group whereas Prochaska et al set these up in a way which facilitates their research.
3 Prochaska and DiClemente say that Action mode can persist for three to six months after the last cigarette and only then does Maintenance mode kick in. This may have been useful for their research model but I do not find it useful for self changers so in our self change model we posit maintenance as beginning right after the last cigarette.