Discovering the Stages People Go Through in Changing Their Behavior

    • July 23, 2009

Carlo C. DiClemente, PhD
Professor and Former Chairman
Department of Psychology
University of Maryland, Baltimore County
Baltimore, Md.

The problem: Understanding the process by which people change is essential to creating effective substance abuse treatment services. Substance abuse researchers and practitioners have only recently begun to study and explore factors that influence peoples' decisions regarding making changes in their lives.

In 2002, Carlo C. DiClemente, PhD, received an Innovators Combating Substance Abuse award and got a chance to advance his work on how people change. The Robert Wood Johnson Foundation (RWJF) created the Innovators program to nurture and promote innovation in combating substance abuse. Between 2000 and 2003, some 20 senior researchers, practitioners and policy-makers received Innovators awards.

DiClemente used his Innovators award to analyze factors that predict progress and relapse in substance abuse treatment. He studied substance abusers attending community-based treatment programs in Baltimore County to examine those factors.

Programee background: DiClemente is internationally recognized as co-creator (with Innovator James Prochaska, PhD) of the Transtheoretical Model of Change. The Transtheoretical model posits that people trying to change behaviors progress through six "stages of change": precontemplation, contemplation, preparation, action, maintenance and termination. People move back and forth across stages as they work to sustain changes.

DiClemente's work on stages of change has emerged as the bedrock of many treatment programs because it recognizes change as a process and enables people to enter and receive treatment at earlier points in their readiness to change. It also provides a framework for how addicts change in their interest and ability to stop using drugs.

DiClemente and his colleagues had devoted more than 20 years to discovering how people change their behavior.

"Clinicians and researchers in the field had assumed that people needed to hit bottom and be motivated to change before they entered substance abuse treatment," DiClemente said. "With the Transtheoretical Model's Stages of Change, we learned that many 'unmotivated' people could still be encouraged to cease their addictive behaviors because the model focuses on where the individual is in the process of change and not simply on the end result of substance abuse cessation."

Results: DiClemente's Innovators project extended the reach of an earlier multi-site study called Project MATCH. In Project MATCH, DiClemente, project director for the Houston site, and colleagues at other sites evaluated treatment outcomes for more than 1,800 people dependent on alcohol.

Under Project MATCH, DiClemente compared profiles of people compiled at the end of alcohol treatment with their drinking behavior one year later. He found that people who remained abstinent in the year after treatment had significantly different "end of treatment" profiles on measures related to stages of change than people who did not remain abstinent.

People who remained abstinent had higher confidence in their ability to stay off alcohol and to and take actions to remain sober, had less temptation to use, and struggled less to refuse alcohol compared with people who did not remain abstinent.

DiClemente and his colleagues used the Innovators award to design and conduct the Successful Treatment Outcome Profiles (STOP) pilot study. This study explored whether the stages of change measures that predicted outcomes for people receiving treatment for alcohol dependence applied to people in treatment for cocaine, or heroin or marijuana dependence.

Under STOP, researchers took profiles of 60 addicted people three, six and 12 months after they entered out-patient treatment in Baltimore. They used standardized measures of demographic characteristics, frequency and intensity of drug use, perceived stress, level of social support and other factors to construct the profiles.

Researchers analyzed differences between profiles of 30 people who were abstinent and 30 who reported using drugs after six and 12 months to identify and explore critical predictors of success.

Findings from STOP were similar to those from Project MATCH. "The idea is that success is very much client driven," DiClemente said. "Some clients walk in the door and they are already doing a lot of things that they need to do. The people who have more problematic profiles need something different. We are doing something in treatment that is not working for them. What it says to me is that we should not let people out of treatment who have these more problematic profiles."

Integrating theory into treatment. DiClemente also used his Innovator award to convene a group of 25 substance abuse researchers and treatment providers who had been using the Transtheoretical Model to assess and treat substance abusers. The group met for two days in June 2006 to explore ways to integrate the Transtheoretical Model of Change into substance abuse treatment practice.

One key insight emerging from the conference was that practitioners tended to focus too much on the stages of changes as labels, that is, saying that a person was a "pre-contemplator" rather than looking more deeply into the underlying process of change that might have been taking place.

"We haven't focused enough on activating personal mechanisms for change in the field," DiClemente said. "What the conference illustrated is that we need to do more work on studying and thinking about those."

Working in the community. DiClemente said that the Innovators award encouraged him to get out and work in his community. In one project, he worked with officials from the HIV/AIDS administration in Maryland to improve the capacity of agencies serving people who are HIV positive and also have substance abuse or mental health problems. DiClemente trained staff about the process of change so they could better engage and retain people in treatment.

He is also helping the Baltimore health department develop knowledge and skills to use the stages of change theory to help people quit smoking.

Importance of the award: DiClemente noted that receiving the Innovators award changed the way he views his work: "The whole Innovators program was a real shot in the arm for those of us working in the world of substance abuse. First of all, a lot of us have a bit of the pretender in us—those of us who aren't egomaniacs. People who have hundreds of articles published are not sure they've made a good contribution. And when you are working with a stigmatized population a lot of times people don't recognize the contributions of those working in the field.

"The Innovators award was a Good Housekeeping Seal of Approval," said DiClemente. "RWJF presented it to us like it was given to people who are geniuses like the MacArthur award. I thought 'Wow, gosh, I guess I really have made a significant contribution and been recognized by my peers.' It made a difference to me in terms of how I felt about what I did. It spurred me on."

RWJF perspective: "The Innovators Combating Substance Abuse program recognized the innovation and creativity of researchers, advocates and providers who have dedicated their professional careers to reducing the toll of substance use and abuse," said Michelle A. Larkin, JD, RN, MS, RWJF senior program officer. "These individuals have had an extraordinary impact on the prevention and treatment of substance abuse, promoting the science and advocating for positive and lasting change."