Before you begin to make changes in your life, it might be useful to understand the process. The theory called the Stages of Change Model (SCM) describes the mind/body stages we go through when we do change.

James Prochaska, Ph.D and Carlo Diclemente, Ph.D (1982) developed SCM  in the late 1970’s and early 1980’s while at the University of Rhode Island. They were studying how smokers were able to give up their habits. The model has been applied to a broad range of behaviors including weight loss, injury prevention, overcoming alcohol, and drug problems among others.

This a model of change which is unique in many ways. First, it is empirically driven: it is based on the researchers’ scientific investigation of change in humans. Second, the model conceptualizes change as entailing a number of stages which all require alterations in attitude in order to progress. Third, the model depicts change as a cycle, rather than an all or nothing step or series of steps. The authors contend that it is quite normal for people to require several trips through the stages to make lasting change. Additionally, each of us progresses through the stages at our own rate.

One of the reason the SCM is attractive, is that it recognizes change as flexible to individual needs. Some people make lasting change quite rapidly, others require a few times through the stages to acquire more knowledge and build skills. Just as some can master skiing on the first try, others require a couple of seasons to get to the intermediate level.

In this sense relapse can be viewed as a normal part of the change process, as opposed to a complete failure. This does not mean that relapse is desirable or even invariably expected. It simply means that change is difficult, and it is unreasonable to expect everyone to be able to modify a habit perfectly with out any slips. Relapses can vary in severity, as can our reactions to them. Some relapses can be so discouraging that people return to a precontemplative stage for a long time before contemplating change again. Others get right back on track, considering the antecedents to relapse, where they need to put more effort, and swiftly move back into action again.

We enter the stages of change from a state of precontemplation– during which the idea of change is not seriously considered. The cycle begins when we start to contemplate the need for change. Hopefully we will tip the scales in favor of change and become determined to take action. Then specific alterations in thinking and behaving will be initiated. It is hoped that the alterations become accepted and eventually ingrained or automatic. If we are able to maintain our accomplishments, we can exit the cycle entirely.

The Stages of Change

In brief, the stages of change are:

• Precontemplation – Not acknowledging that there is a problem behavior that needs to be changed.
• Contemplation – Acknowledging that there is a problem but not yet wanting to make a change.
• Preparation - Planning to make the changes.
• Action - Actively changing behavior and thoughts.
• Maintenance – Maintaining the behavior change.
• Lapses - Returning to old behaviors and abandoning the new changes. This can happen at any point in the stages.

Stage One: Precontemplation

In the precontemplation stage, people are not thinking seriously about changing and are not interested in any kind of help. People in this stage tend to defend their current bad habit(s) and do not feel it is a problem. They may be defensive in the face of other people’s efforts to pressure them to quit. They do not focus their attention on quitting and tend not to discuss their bad habit with others. It would be easy to call this “denial,” but a much more accurate view would be to describe Precontemplation as a state when a person is “uninformed” in the sense that no personally convincing reason for change has been presented as of yet. In this stage people simply do not yet see themselves as having a problem.

Stage Two: Contemplation

In the contemplation stage, people are more aware of the personal consequences of their habit. They start to think about their problem. Although they are able to consider the possibility of changing, they tend to be ambivalent about it. In this stage, people are weighing the pros and cons of quitting or modifying their behavior. Although they think about the negative aspects of their bad habit and the positives associated with giving it up (or reducing), they may doubt that the long-term benefits associated with quitting will outweigh the short-term costs. It might take as little as a couple weeks or as long as a lifetime to get through the contemplation stage. On the plus side, people are more open to receiving information about their bad habit. They become more likely to use educational interventions and reflect on their own feelings and thoughts concerning their bad habit.

Stage Three: Preparation

People in the preparation/determination are planning to take action and are making the final adjustments before they begin to change their behavior. Their motivation for this change may be reflected by statements such as: “I’ve got to do something about this. What can I do?”

This is sort of a research phase as they start taking steps toward cessation of their behavior. They attempt to gather information about what they will need to do to change their behavior, or seek help to understand how to successfully change. At this stage it is important to gather resources and knowledge that will help with success.

It is also important to establish a goal which works with you. A goal which is reasonable for one person, may be unreasonable or inadequate for another. Our goals must be consistent with our capabilities, our values, and our needs. Sometimes, especially by experts in the field of addiction treatment, a successful outcome is mandated as the only realistic goal.

Too often, people skip this stage: they try to move directly from contemplation into action and fail because they haven’t adequately researched or accepted what it is going to take to make this major lifestyle change. For example, many people with intentions for change believe that they must undergo a drastic lifestyle and identity change in order to alter a habit. For example, many recovering substance abusers believe that they must abstain not only from the substance they have abused, but also from all past behaviors, deny all pleasure, and assume a stoic lifestyle. Rarely is this drastic a lifestyle change necessary, or even ideal for lasting change. Often with this “all-or-nothing” approach to change, is that people find that it is virtually impossible to bare, or that they just hate it. They eventually become discouraged and stop the whole change process.

So, at this stage, it is important to examine what specifically you want to modify in your life, and what about your lifestyle is better left unchanged. Understand what you want to change, the motivation for the change, and most importantly, have a destination or way-point defined so that you can recognize the change.

Stage Four: Action

This is the stage where people not only have a desire to change, but also believe they have the ability to change their behavior and are actively involved in taking steps to change their behavior.

The amount of time people spend in action varies: but, in general it lasts about 6 months. This step requires the greatest commitment of time and energy. Mentally, they review their commitment to themselves, practice new skills, and develop plans to deal with both personal and external pressures that may lead to slips. They may use short-term rewards to sustain their motivation, and analyze their behavior change efforts in a way that enhances their self-confidence. People at this stage also tend to be open to receiving help and are also likely to seek support from others: this can be a very important element.

As people make conscience efforts to quit or change the behavior, they are at greatest risk for relapsing to old behaviors. Being mindful of triggers, and the reactions to them, is important. This is where actively building skills, changing thoughts toward the old behavior, and developing alternative coping behaviors comes in to play.

Stage Five: Maintenance

Maintenance involves being able to successfully practicing new skills and avoiding the temptations to return to the old habit. The goal of the maintenance stage is to maintain the new status quo. People in this stage tend to remind themselves of how much progress they have made, while still being cognizant of what it took to make the change.

People in maintenance constantly reformulate the rules of their lives and are acquiring even more skills to deal with life and avoid relapse. They are able to anticipate the situations in which a relapse could occur and prepare coping strategies in advance. They remain aware that what they are striving for is worthwhile and personally meaningful. They are accepting of themselves and recognize that it takes time to let go of old behavior patterns and to become proficient at new ones: realizing that ultimately the new behavior will become as comfortable to live with as the old. Even though they may have thoughts of returning to their old bad habits, they resist the temptation and stay on track.

As you progress through your own stages of change, it can be helpful to re-evaluate your progress in moving through these stages.

Lapses

Along the way to permanent cessation of a habit, many people experience a lapse. These are often accompanied by feelings of discouragement and seeing oneself as a failure.

There is a real risk that people who lapse will experience an immediate sense of failure that can seriously undermine their self-confidence. One of the most significant problems with the 12-step model is the all-or-none manner in which lapses are construed. Regardless of the intensity, slips and lapses have been viewed as failure, time to “start over.”

It is important to remember that experiencing a lapse is common.  In fact, most successful self-changers go through the stages three or four times before they make it through successfully without a lapse. Many will return to the contemplation stage of change; others return to the planning stage to implement what they have learned from the lapse. Consequently, the Stages of Change Model considers a lapse to be normal.

Rather than seeing a failure, analyze how the slip happened and use it as an opportunity to learn how to cope differently. People who lapse may need to learn a more effective ways anticipate high-risk situations, control environmental cues that tempt them to engage in their bad habits,  learn how to handle unexpected episodes of stress, or redefine their personal boundaries. Analyzing what happened gives a stronger sense of self control and the ability to get back on track. In fact, relapses can be important opportunities for learning and becoming stronger.

Transcendence

In addition, there is one more stage that Marc Kern Ph.D., CAS added which is not part of Prochaska-DiClemente original Stages of Change model: Transcendence.

Eventually, if you “maintain maintenance” long enough, you will reach a point where you will be able to work with your emotions and understand your own behavior and view it in a new light. This is the stage of “transcendence.” In this stage, not only is your old habit no longer an integral part of your life but to return to it would seem atypical, abnormal, even weird to you. When you reach this point in your process of change, you will know that you have transcended the old habits and that you are truly becoming a new “you”, who no longer needs the old behaviors to sustain yourself.

References

DiClemente, C. C. & Prochaska, J. O. (1982). Self-change and therapy change of smoking behavior: A comparison of processes of change in cessation and maintenance. Addictive Behaviors, 7, 133-142.

When seeking help with substance use problems, people often cite the stigma associated with seeking help as a barrier. The common ways of describing individuals with such problems may perpetuate or diminish stigmatizing attitudes, yet little research exists to inform this debate.

John F. Kelly, Ph.D., associate director of the Massachusetts General Hospital’s (MGH) Center for addiction Medicine, notes that the World Health Organization declared the term “abuser” as stigmatizing three decades ago, but the term is still commonly used to describe people with addictions to illicit drugs.

Kelly recently took part in a scientific study to determine whether or not using different  labels evokes different judgments about behavioral self-regulation, social threat, and treatment vs. punishment. In the study, Kelly and colleagues surveyed more than 700 mental-health professionals attending a conference on addiction and mental illness. Half of the a survey referred to a hypothetical patient as a “substance abuser,” while the rest received a survey referring to the patient as having a “substance use disorder.” The surveys were otherwise identical.

The study found no differences between groups on the social threat or victim-treatment sub-scales. However, respondents who received the “substance abuser” version were more likely to say that the patient should be punished for failing to follow a treatment plan and to agree that the patient shouldered blame for having trouble complying with court-ordered treatment requirements.

The study concluded that even among highly trained mental health professionals, exposure to these two commonly used terms evokes systematically different judgments. The commonly used “substance abuser” term may indeed perpetuate stigmatizing attitudes. Whether individuals or mental-health professionals are conscious of it or not, this study suggests that this term perpetuates that kind of thinking.

According to Kelly, “From the perspective of the individual sufferers, who often feel intense self-loathing and self-blame, such terminology may add to the feelings that prevent them from seeking help.”

So, in our own recovery, how we identify ourselves may matter. If we choose, or have forced on us, terms like “alcoholic” or “drug abuser,” we may be buying into a negative stigma. If we choose to use a more technically accurate identifier, such as having a “substance use disorder,” we may be able to break free of old stigmas. We are then better able to focus on our own empowered recovery, without all that stigma.

The study was published in the International Journal of Drug Policy.

By Tim Townsend
Originally published by ST. LOUIS POST-DISPATCH January 30th, 2010

By the end of January, plenty of New Year’s resolutions have been broken.

For those who have ignored pledges to hit the gym every day, or stay away from “American Idol,” a broken resolution is little more than an annual defeat of the will. But for people trying to get their alcohol problem under control, a broken resolution can have devastating consequences.

Alcoholics Anonymous, with 2 million members worldwide, is the largest organization people turn to when they recognize they have a drinking problem. But the religious overtones in AA’s famous “12 Steps” — with their focus on God and the powerlessness of the individual — can be jarring to those whose vision of faith differs from AA’s.

“I knew there was no way in hell this was going to work for me,” said Donna Dierker, a Creve Coeur neuroscientist who considers herself agnostic and who tried AA when she wanted to moderate her drinking in 2002. “I was just ideologically opposed to the 12 Steps.”

Some who struggle with alcohol also struggle with the notion of surrendering to a supernatural force in order to solve their problems — a key component of AA’s 12-step program.

They cringe at the idea that they are powerless to help themselves, and that they must rely on something they don’t believe in to gain control over their lives. Those two ideas are contained in AA’s first two steps:

“Step 1: We admitted we were powerless over our addiction — that our lives had become unmanageable. Step 2: (We came) to believe that a power greater than ourselves could restore us to sanity.”

Dierker — and many others turned off by the religious content of AA — have turned to other programs. Dierker opted for Moderation Management (MM), which calls itself a “behavioral change program.” In language starkly different from AA’s, MM says it “empowers individuals to accept personal responsibility for choosing and maintaining their own path, whether moderation or abstinence.”

AA, which was founded 75 years ago, has roots in a Christian movement called the Oxford Group. It describes the 12 steps — seven of which mention God or spirituality — as the “heart” of the organization’s recovery program. But it also makes it clear that “newcomers are not required to accept or follow” them.

AA also has 12 traditions, or principles — first adopted in 1950 — one of which says: “For our group there is but one ultimate authority — a loving God as He may express Himself in our group conscience.”
MM comes at the problem from a different angle. It relies on research from organizations such as the National Institute on Alcoholism and Alcohol Abuse, and spirituality doesn’t enter the picture. Nearly all of MM’s advisers and directors are doctors.

On a recent Sunday, about 20 people sat in a dark room at the Ethical Society of St. Louis in Ladue watching Dierker work her way through a PowerPoint presentation about moderating problem drinking. Afterward, the discussion continued at a nonalcoholic beer-tasting in the next room.

MM is largely an online network, and therefore its popularity is difficult to measure, but there are face-to-face MM meetings around the country, too. Dierker started one in St. Louis about a year ago; in August, the meeting moved to the Ethical Society every Wednesday evening. Not everyone who attends MM meetings is a secularist, and some who attend also go to AA meetings.

AA says it “is not allied with any sect, denomination, politics, organization or institution,” but court opinions have been mixed on the issue.

In March, a Pennsylvania appellate court ruled that AA was not protected by religious land use laws because it could not be considered a religious organization.

“The fact that the 12-step program is used and it contains references to ‘God’ and a ‘Higher Power’ does not mean that all members believe that they are partaking in a religious experience when they are attending an AA … meeting,” according to the ruling.

But in 2007, the 9th U.S. Circuit Court of Appeals in San Francisco said that, because of AA’s religious content, prison inmates could not be coerced to take part in AA meetings as a condition of their release.

Many AA meetings are held in church and synagogue basements around the country. Rabbi James Goodman runs a hybrid meeting called Shalvah (“serenity” in Hebrew) at Neve Shalom, a Jewish Renewal Community temple in unincorporated St. Louis County.

“The purpose is to create a bridge between the 12-step model and the traditional spiritual resources of Judaism,” Goodman said.

The meeting, held on Thursday evenings, attracts from 20 to 40 people, about half of whom are Jewish, according to Goodman.

Moderation Management is not the only group that has taken God completely out of the recovery process.

James Christopher is the founder of S.O.S. — Secular Organizations for Sobriety. Christopher said S.O.S. will celebrate its 25th anniversary this year, and he calls the group the “largest and oldest secular alternative to Alcoholics Anonymous.”

“We have a self-empowerment approach, rather than faith-based approach,” Christopher said. “But we’re not anti-religious.”

Ginger Frank, an addiction therapist at Jefferson Barracks, runs a meeting for veterans called SMART Recovery. On its website, SMART Recovery says it has “a scientific foundation, not a spiritual one,” and “teaches increasing self-reliance, rather than powerlessness.”

Unlike MM, SMART Recovery — which has about 300 meetings worldwide compared with about 90,000 AA meetings — is an abstinence program. Frank said there are several people in training to be SMART Recovery coordinators in the St. Louis area, and there are likely to be other meetings outside Jefferson Barracks soon.

“We don’t encourage the concept of powerlessness at all,” Frank said. “We can prove to people that they do, in fact, have power over their addiction. If they’re in jail, they’re not using. If they’re in the hospital, they’re not using. They do have a choice.”

The word “alcoholism” does not describe a disease but rather it’s a behavior. Behavior is self-determined by choice.  Choice, then, is the cure for alcoholism and any other form of drug abuse.  In fact, personal choice is the only method by which people stop alcohol and drug abuse.

“Men at some time are masters of their fates: The fault, dear Brutus, is not in our stars, but in ourselves, that we are underlings.” ~ Julius Caesar Act I, Scene II

For at least the last 500 years man has tried to blame unwanted behavior on anything and everything but himself: as in, “If there is a disease for overindulging in alcohol or other drug, then I am not really responsible for my drinking and drugging behavior.”

I am not alone in the assertion that alcoholism and drug additions are not diseases. So, let’s set aside the hysteria and look at this from a common sense point of view.

In science, nothing exists that has no proof of existence.  That which has no proof, but is thought to exist, exists as a matter of conjecture and faith, not science.  In the case of disease, meaning “a condition that results in medically significant symptoms in a human,” there exists no credible evidence supporting the notion that regular excessive use of any substance is a disease.  This conclusion is based on the normally accepted understanding of the word “disease.”

Diseases are determined and described by the scientific method.   If, indeed, the excessive consumption of alcohol is a disease there must exist some scientific study that determined it to be a disease.  Such a study would describe a specific and predictable set of symptoms that would involuntarily manifested in the sufferer.  No such study exists.

Consider the facts surrounding the disease theory, and its development, which provides evidence that the “disease of alcoholism,” indeed alcoholism itself, is merely folklore and not established by way of the scientific method.

When adding “alcoholism” to the Diagnostic and Statistical Manual of Mental Disorders in 1956 the American Psychiatric Association was, for the most part, relying on the work conducted by Dr. E.M. Jellinek at Yale University during the  the 1940’s.  Subsequently, Jellinek’s study was determined to be flawed according to Yale University. At the request of Yale University, Jellinek retracted all of his conclusions, stopping just short of admitting that his research was fraudulent.  Later, Jellinek was found to be a fraud:  The schools where he claimed to have earned his degrees had no record of him receiving any. The point here is not to malign Jellinek or Yale, but to merely provide an historical account with respect to the origin of “alcoholism, the disease.”

It is important to understand that the disease theory is just that – a theory. Additionally, it is important to understand that this theory is only accepted as fact by the treatment industry here in the United States. The rest of the world considers the disease theory for alcoholism unsubstantiated. In his book Why We Should Reject The Disease Concept of Alcoholism, Herbert Fingarette, Ph.D., makes the following observations:

“…In the United States, but not in other countries such as Great Britain (Robertson and Heather, 1982), the standard answer is to call the behavior a disease – ‘alcoholism’ – whose key symptom is a pattern of uncontrollable drinking. This myth, now widely advertised and widely accepted, is neither helpfully compassionate nor scientifically valid. It promotes false beliefs and inappropriate attitudes, as well as harmful, wasteful, and ineffective social policies.”

The myth is embodied in the following four scientifically baseless propositions:

1. Heavy problem drinkers show a single distinctive pattern of ever greater alcohol use leading to ever greater bodily, mental, and social deterioration.
2. The condition once it appears persists involuntarily: the craving is irresistible and the drinking is uncontrollable once it has begun.
3. Medical expertise is needed to understand and relieve the condition (“cure the disease”) or at least ameliorate its symptoms.
4. Alcoholics are no more responsible legally or morally for their drinking and its consequences than epileptics are responsible for the consequences of their movements during seizures.

The idea that alcoholism is a disease has always been a political and moral notion with no scientific basis. It was first promoted in the United States around 1800 as a speculation based on erroneous physiological theory (Levine, 1978), and later became a theme of the temperance movement (Gusfield, 1963). It was revived in the 1930s by the founders of Alcoholics Anonymous (AA), who derived their views from an amalgam of religious ideas, personal experiences and observations, and the unsubstantiated theories of a contemporary physician (Robinson, David, 1979)

Another observation is offered by Jeffery Schaler, Ph.D.  in June of 1995:

“Extensive research supports the idea that addiction is a voluntary process, a behavior that is better explained by individual psychological and environmental factors, than physiology and the chemical properties of drugs.”

In another article authored by Dr. Phil Stringer entitled Disease, Victimization, and Personal Responsibility, he raises the question:

“How many people who never decide to drink would ‘catch’ the ‘disease’ of alcoholism?”

The obvious answer is none. In the traditional meaning of the word “disease,” a chosen behavior does not define a disease because one can just as reasonably choose not to drink or use drugs. The disease theory simply provides the person with a drug or alcohol problem an easy out from taking responsibility for themselves, their behavior, and the problems they cause.

There are hundreds of researchers who have looked carefully at the alcoholism disease theory. Most have rejected the notion that alcoholism is a disease. The only studies that support the disease theory are those conducted by organizations and individuals who have a vested interest in the over consumption of alcohol or other drugs being a disease (e.g. Alcoholics Anonymous, NIAAA and NCADD). The studies that have touted alcoholism as a disease are researchers who derive a living, in one way or another, from the treatment industry. These are hardly sources that can be trusted.

Finally, consider the paradoxical nature of the disease theory: the theory contends that once the disease is in place (diagnosed), the alcoholic has lost the power of choosing not to drink or the drug addict to not use drugs. But, how can that be true when millions of “diagnosed” alcoholics have stopped drinking and never return to problem drinking and drug addicts have stopped using drugs? If, indeed, they lost their power to choose to not use alcohol or other drugs, how did these millions of people with drug and alcohol problems stop drinking or drugging? Are we to believe that counselors and other professionals can make the choice for their patients because their patients have “lost their personal power of choice?” Or perhaps Alcoholics Anonymous and other 12-step programs provide some “magic” that gives members their choice back, but only “one day at a time.” Or maybe we are to believe that there is some universal power (choice power) that is channeled only through licensed counselors and other would-be professionals.

When common sense prevails, often the right answer is what we have known all along: The fault, dear Brutus …is in ourselves. Alcoholism and drug addiction is not disease. There is not now, nor has there ever been, any scientific evidence of such a nonsensical assertion.

I want to be clear: I am in no way asserting that physical addiction to a substance does not exist. It is a fact that the human body does become accustomed to, and even learn to relay on, unhealthy and even poisonous substances. The human body is extremely adaptable, even to extremely adverse conditions. The result of physical drug addiction can be observed as the withdrawal symptoms seen when drugs or alcohol stop being introduced to body: it is caused by the body trying to again learn, or adapt, to regulating body functions without the interference of the substance. However, once the sustenance has been cleansed from the body, only the psychological effects remain. Just as drug use is a learned behavior, overcoming the habitual and destructive thought processes associated with  drug use are skills that can be acquired, practiced, and eventually mastered. It is not a lifetime disability; it’s a choice.

Don’t be fooled by the propaganda that attempts to make you believe you are helpless and have a lifetime incurable disease. You can choose to learn how to be well, and stay well for the rest of your life. While it can be difficult, and take time to learn to how to overcome unhealthy habits and thought processes, it is possible.