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 Shari Roan
Originally published by The Los Angeles Times, January 6, 2010

Only people with severe depression benefit from antidepressants, says research published in the Journal of the American Medical Assn. Others do better with non-medical approaches.

Antidepressant medications probably provide little or no benefit to people with mild or moderate depression, a new study has found. Rather, the mere act of seeing a doctor, discussing symptoms and learning about depression probably triggers the improvements many patients experience while on medication.

Only people with very severe depression receive additional benefits from drugs, said the senior author of the study, Robert J. DeRubeis, a University of Pennsylvania psychology professor. The research was released online Tuesday and will be published today in the Journal of the American Medical Assn.

Hundreds of studies have attested to the benefits of antidepressants over placebos, DeRubeis said. But many studies involve only participants with severe depression. Confusion arises, he said, “because there is a tendency to generalize the findings to mean that all depressed people benefit from medications.”

The current analysis attempted to quantify how much of antidepressants’ benefit is attributable to chemical effects on the brain and how much can be explained by other factors, such as visiting a doctor, taking action to feel better or merely the passage of time.

Researchers reviewed six randomized, placebo-controlled studies with a total of 718 patients who took either an antidepressant or placebo. The patients were adults with levels of depression ranging from mild to very severe based on the Hamilton Depression Rating Scale, a questionnaire widely used in depression research. The studies did not exclude patients who were likely to have a strong response to a placebo. Researchers then compared the patients’ depression scores at the beginning of treatment with those after at least six weeks of treatment.

The study found that the magnitude of the drugs’ benefit increased with the baseline level of depression. The effect of treatment was similar in people with mild, moderate and severe symptoms, regardless of whether they took an antidepressant or placebo. Only the people who rated very severe on the depression scale at the start of the study showed measurable improvements on antidepressants.

“There is no doubt that there are tremendous benefits from antidepressants, as our study showed,” DeRubeis said. “But this study helps us resolve, to some degree, the question of how much benefit people can expect from the medicines themselves when symptoms are not severe.”

Other research has also found that antidepressants are most effective for severe symptoms, said Dr. Philip Wang, deputy director of the National Institute of Mental Health. Though it could be that antidepressants don’t work well for mild to moderate depression, it’s also possible that people enrolled in antidepressant studies have robust placebo responses that mask some of the impact of the medication.

A severely depressed person who would probably benefit from antidepressants might have symptoms such as frequent weeping, feelings of guilt and sadness, thoughts that life is not worth living, problems sleeping, fatigue and withdrawal from normal activities, DeRubeis said.

Better antidepressants are needed for people with mild to moderate depression, Wang said, as is research on how to diagnose depression with tools, such as biomarkers, that could help personalize treatment.

Of the six studies in the current analysis, three involved selective serotonin reuptake inhibitors, or SSRIs, the most commonly used antidepressants, and three involved an older class of medications called tricyclics. Both classes are thought to be equally effective, although SSRIs are associated with fewer side effects.

One exception to the study findings, DeRubeis said, was people with dysthymia, or chronic, low-level depression. The analysis assessed severity of symptoms, not chronically, he said. Other studies have established that people with chronic depression, no matter how severe, tend to respond well to antidepressants while other treatment may be ineffective.

Study Finds Medication of Little Help to Patients with Mild to Moderate Depression

by Jon Hamilton
Originally published by www.npr.org July 1, 2009

Three new genetic studies are providing some tantalizing hints about what causes schizophrenia.

The studies, published in the journal Nature, identify sections of our genetic code in which small changes can affect a person’s risk for developing the disorder.

The studies found such changes in stretches of code involved in brain development, memory and the immune system.

The findings are important because schizophrenia has been so hard to study, says Kari Stefansson, CEO of the Icelandic company deCODE Genetics and an author of one of the studies. One reason is that schizophrenia doesn’t occur in animals.

“It’s a disease of thoughts and emotions,” Stefansson says, “the two functions of the brain that define us as a species and define us as individuals.”

Scientists have tried for decades to find differences between the brains of typical people and those with schizophrenia, but without much success. So Stefansson and a consortium of researchers from around the world decided to look for subtle differences in the genes of thousands of people. Some had schizophrenia; some didn’t.

One place the studies found a clue about what might be going wrong in the brains of people with schizophrenia was in a gene responsible for a protein called neurogranin, which can affect memory and thought.

“The neurogranin pathway could be one of the biochemical pathways that lead to this disturbance of thought,” Stefansson says.

But he says a more provocative finding is a genetic hot spot in a stretch of code that affects the immune system.

“It raises the question that somehow the tendency to develop schizophrenia may have something to do with infections of mothers during pregnancy.”

The idea is that some families carry a genetic variation that affects the way the immune system responds to infection, Stefansson says. If a mother gets the flu while she’s pregnant, this immune response may affect her child’s brain.

It’s also possible that the immune system is involved in schizophrenia in some other way, says Dr. Tom Insel, director of the National Institute of Mental Health, which helped fund the new studies.

He says the stretch of genetic code affecting immunity is pretty mysterious.

“In some ways it’s a little bit like the Bermuda Triangle of the human genome,” he says. “It’s an area with tremendous amounts of variability. And it’s an area where we often find variation that’s associated with many different disorders: diabetes, rheumatoid arthritis, Crohn’s disease.”

In those diseases, the immune system attacks the body’s own cells, a process that could also affect the brain. Researchers have suspected the immune system before, Insel says. Now, they’ll probably take a harder look.

Insel says he’s particularly intrigued by the finding that some genetic variations linked to schizophrenia are also linked to depression and bipolar disorder.

“It suggests, potentially, that when we’re talking about the genetic factors that contribute, what we’re really thinking about are genetic factors that contribute to how a brain gets built,” he says.

That would mean problems in the brain start very early in life, even though the symptoms of schizophrenia may not appear for decades.

One thing the genetic studies clearly show is just how many different systems in the brain may contribute to schizophrenia, says Harvard’s Dr. Pamela Sklar, an author of one of the studies.

“That’s a hopeful finding because the implication is that there may be more places to intervene,” she says, “if we understand the biology.”

Schizophrenia May Be Linked To Immune System