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It can be daunting to start the process of recovering from a substance use disorder. At first, it’s common for people to question whether they really have a problem and if so, whether it’s worth the effort to address it. It’s natural to have questions about what to expect: “What are the stages of change in recovery?” and “How long does it take to overcome an addiction?”
This is where the widely used Stages of Change model, developed by researchers James Prochaska and Carlo DiClemente, helps by offering a framework for understanding the process of change. Also called the “transtheoretical model,” this approach lays out the steps people typically go through when changing a wide number of behaviors, including drug or alcohol use.
The 5 stages of change in recovery
The Stages of Change model can help people understand what change might look like for them. It can also help loved ones and treatment professionals understand a person’s motivation for change in recovery. While there are five distinct stages, people don’t always go through them in order and there’s no particular timeline for each stage.
1: Precontemplation stage of change
In the precontemplation stage of change, people aren’t looking for solutions because they aren’t aware they’re using substances in an unhealthy way. They may defend their actions and have no intention of making a change. People who start therapy or treatment during this stage of addiction recovery often do so at the insistence of concerned loved ones, friends, or the legal system, not because they think they need it.
Common thoughts
- “I don’t have a problem.”
- “My loved ones are overreacting; everything is fine.”
Common behaviors
- Not considering or seeing the need for change
What can help people through this stage
- Encouraging self-reflection through consciousness-raising therapy
- Encouraging people to evaluate the impacts their behaviors are having on various aspects of their lives
2: Contemplation stage of change
In the contemplation stage of recovery, people are aware that their substance use may be unhealthy and they’re considering a change. However, they aren’t yet committed to taking steps toward recovery because they aren’t sure if the problem is “bad enough” or if it’s worth the effort. This recovery stage is marked by ambivalence and indecisiveness. People may stay in this stage for a long time, sometimes moving into the preparation stage of change or back to the precontemplation stage.
In the contemplation stage, people become more aware of behaviors that meet some of the criteria laid out in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, the text used by health care professionals to diagnose mental disorders. For example, they may need more of a substance to get the same effect, face problems in relationships because of their drinking or using, or want to cut down but aren’t able to. “The more criteria a person meets, the more aware they may be that substance use is negatively affecting their life and start to consider making a change,” says Smita Das, MD, PhD, MPH, senior medical director of psychiatry at Lyra Health.
She adds, “Many people wait to seek treatment for themselves or a loved one during the contemplation and preparation stages, but there’s no reason to wait. It can be very effective to start a conversation about goals sooner so people know there’s support and resources available to them at any time.”
Common thoughts
- “I have a problem, and I should do something about it.”
- “My use is really impacting my life, especially work and family.”
Common behaviors
- Evaluating the pros and cons of making a change
- Wanting to cut down or stop using the substance but continuing to use
- Experiencing negative consequences such as problems with health, relationships, or other areas of life as a result of drinking or using
What can help people through this stage
- Non-judgmental education about substance use and treatment options
- Building hope and expectations for better outcomes in recovery
- Therapy and treatment
Approaches like motivational interviewing can be especially helpful in the contemplation stage of recovery, helping people reach their goals at their own pace and on their own terms. Mental health providers also use cognitive behavioral therapy—the gold standard for treating substance use disorders—to understand the function of substance use in people’s lives and develop concrete tools to make measurable change in a reasonable amount of time.
“Participation, engagement, and motivation are all helpful, but they aren’t mandatory,” says Kevin Doyle, EdD, president and CEO of the Hazelden Betty Ford Graduate School of Addiction Studies. “Mental health providers are trained to ‘roll with the resistance’ when people feel uncertain about their willingness to change and can help people identify their internal motivations to recover.”
3: Preparation stage of change
In the preparation stage of change, people know their substance use is problematic and are committed to making a change. They recognize the pros outweigh the cons and begin gathering information so they can create an action plan. It’s important to invest time and energy in this stage—putting together a thorough plan can help set people up for success in later stages of addiction recovery.
Common thoughts
- “Something has to change. What can I do?”
- “I’ve been reading about the 12 Steps and alternatives, and I may try a meeting.”
- “On Monday, I’m going to call for more information about treatment.”
Common behaviors
- Deciding whether to cut down on use or quit completely
- Changing habits, such as planning to only drink after a certain time or on certain days
- Researching treatment options
- Removing triggers from their environment (e.g., people, places, and things that make it hard to avoid drinking or using)
- Telling friends and family about their plan to reduce or quit
What can help people through this stage
- Learning about recovery and treatments
- Identifying sources of social support
- Working with a mental health provider to discuss treatment options and create a personalized treatment plan
4: Action stage of change
In the action stage of change, people put their plan into motion and change happens. Along with it comes stronger resolve, greater confidence, and recognition from others. They may feel great about their successes and also low as they go through inevitable hard times. People in this recovery stage are willing to accept support and take steps to commit to their recovery. Depending on the person’s goals, change can include a major life transformation or smaller, more gradual steps.
Common thoughts
- “This is hard, but I’m proud of myself. I haven’t used in three months.”
Common behaviors
- Engaging in treatment
- Reducing or stopping drug or alcohol use
- Starting to use medication to help with cravings
What can help people through this stage
- Making concrete plans to cope with triggers that could lead to a return to use
- Focusing on the long-term benefits of change
- Recognizing efforts and progress
- Learning effective coping skills
5: Maintenance stage of change
In the maintenance stage of change, people continue reducing or stopping their substance use and feel more confident in their ability to sustain the changes they’ve made. They may have thoughts of returning to use, but they’re able to use their new tools to stay on track with their goals.
It’s important to note that return to use does happen in the maintenance stage and is sometimes considered a sixth stage of change in addiction. “Substance use disorders are chronic conditions that require lifelong vigilance, if not lifelong management,” says Dr. Doyle. “Sometimes people with 10-15 years in recovery return to use. We don’t judge people when their cancer comes back or their diabetes flares up, and we shouldn’t judge people who need more support to achieve long-term maintenance.”
It can take several attempts to achieve long-term maintenance, with return to use rates as high as 60 percent. After a return to use, sometimes people are motivated to engage in treatment right away; other times they may go all the way back to the precontemplation stage of change.
According to Dr. Das, maintenance can be a difficult stage. “People must take care not to get too comfortable or assume they’re out of the risk zone because things are going well,” she says. “This is why relapse prevention is a critical part of maintenance—to reduce the chances they’ll go back to old behaviors.”
Common thoughts
- “I’m proud of how far I’ve come and feel cautiously optimistic about the future.”
Common behaviors
- Practicing healthy self-care and recovery skills
- Reducing the intensity of focus on recovery goals (complacency)
What can help people through this stage
- Getting ongoing, nonjudgmental support such as social support, self-help groups, and treatment if needed
- Continuing to learn about substance use disorders
- Using coping strategies to manage triggers and prevent a return to use
- Setting aside judgment and not giving up if a return to use occurs
“Many people require multiple treatments and that’s OK—try something different, try the same thing again, just don’t give up,” says Dr. Doyle. “Even if change isn’t immediate or permanent, the takeaways from treatment are still valuable and people can take the tools they learned and apply them later. If people are heard, treated respectfully, and have a positive treatment experience, we plant the seeds for future growth and recovery. We often hear things like it wasn’t until the third treatment attempt that it clicked. ”
“People may feel discouraged by a return to use or ‘slip,’” says Dr. Das. “But if someone comes back for care and shows interest in discussing their use and how to reduce the risk of use in the future, that’s an important indicator that they’ll come out stronger and achieve their goals. This process is all about re-teaching the brain.”
Myths about the 5 stages of recovery
There are several myths and misconceptions that can create obstacles as people progress through the stages of change in addiction. Here are a few of the most common:
Myth 1: People have to be ready for treatment.
With nearly 100,000 overdose deaths in 2020, the risk of waiting until someone is “ready” is too high. “It’s wonderful if someone starts treatment motivated, ready, and wanting help, but it’s a myth that treatment won’t work without these things,” says Dr. Doyle. “People often say they don’t need to be here, it’s not that bad, or they’re only getting help because someone else made them—and I tell them, ‘You’re in the right place.’”
Myth 2: People can just choose to stop drinking or using.
“Substance use disorders are brain diseases, not a choice or moral failing,” says Dr. Das. “Much like any other medical illness like depression or heart disease, these conditions are treatable and people can achieve recovery.”
Myth 3: Recovery isn’t possible without a supportive family.
“Supportive loved ones are a great asset, but they aren’t a requirement to enter recovery,” Dr. Doyle explains. “Regardless of their family situation, people have so much strength and resilience to tap into—and with access to good care, so much hope.”
Myth 4: We can force others into recovery.
“While loved ones may want to move someone along the stages of change,” says Dr. Das, “we need to help them find their own way through this process and be a supportive figure in their life.”
Myth 5: Returning to use means recovery failed.
Return to use isn’t a failure. It’s an opportunity for people to re-evaluate their triggers and motivation to change and grow stronger in their recovery. “Slips happen,” says Dr. Das. “It’s not something to be afraid or ashamed of, but rather something to prepare for. Sometimes it’s a sign that the person needs to reinforce a previous stage of change or develop a more comprehensive aftercare plan so they can build recovery into their everyday life for the long term.”
Everyone’s journey is different
As people progress through the stages of change in recovery, the treatment journey can take many shapes. Some people start at the highest level of care, such as a residential treatment program, and then “step down” to therapy and aftercare. Others start at a lower level of care, such as self-help support group meetings, counseling, or outpatient treatment, and move into a more intensive type of care if needed. The process isn’t always linear, and people may go through several treatment episodes before they experience long-term recovery.
“Just as doctors give different types of blood pressure medication to patients with different needs, treatment for substance use disorders isn’t one-size-fits-all,” says Dr. Das. “Not everybody needs a rehabilitation facility; at the same time, not everyone is a good fit for outpatient therapy.”
The Hazelden Betty Ford Foundation and Lyra Health partner together to offer the full spectrum of care to support people throughout their entire recovery journey. “It’s so important for people in outpatient care to have access to higher levels of care such as a residential treatment facility if they need it,” Dr. Das explains. “And it’s also critical for people to have a plan for a seamless transition to outpatient care after receiving care at a facility, so they can get practical experience dealing with stressors and triggers in their day-to-day environment.”
When considering the stages of change in recovery, people often ask, “How long does it take to get over an addiction?” The timeline is different for everyone. “The first year is very important,” notes Dr. Doyle. “Healing starts immediately but it takes time, especially if someone has used for a long time. This is why ongoing care is critical—highly structured support for at least the first six months, followed by ongoing reinforcement and check-ins.”
Recovery is for everyone
Regardless of a person’s stage of recovery or how long the process takes, long-term recovery is possible. And though it may take time to work through the stages of recovery from addiction, the rewards are well worth it.
“When someone comes to us for care, I’m inspired by their bravery,” says Dr. Das. “Having the insight and strength to be able to reach out for help is really important, and I’m very hopeful for everyone who gets to that point.”
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