The Transtheoretical Model’s central  organising construct is the ‘Stages of Change’. Each of the stages  denotes a certain  orientation towards change that will be reflected in the decisions a young person makes  about  their substance use. By examining these  decisions, youth  AOD  practitioners can gauge a young person’s motivation to change. Motivation is identified as a critical factor  in the success  of people who  modify their substance-using behaviour (Miller & Rollnick, 2002)  and has been  shown to strongly influence help-seeking behaviour and treatment participation (DiClemente, 1999).

Miller and Rollnick  (2002) describe motivation as ‘’...a  state of readiness or eagerness to change, which may fluctuate from  one time  or situation to another’’ (p14).  Fluctuations in young people’s motivation to change are likely to be more  common than  for adults.  Clark  (2001) points  out that young people are constantly changing, as are the severity,  magnitude and frequency of the problems they face.  As such,  it is common for young people in the process of changing to move  between stages.  Youth AOD  practitioners are therefore advised  to continually gauge young people’s motivation and readiness for change and customise their approach accordingly.

Figure 1: The  Stages of Change Model

Adapted from: Prochaska,and DiClemente (1986)

Pre-contemplators are not intending to change their substance-using behaviour in the foreseeable future. Young people in this stage  are not interested in changing and will either  be or appear unconcerned about  their substance-using behaviour. This can be the case even when the adverse consequences of their substance use are obvious and concerning to others.

For this reason  parents, guardians and courts  commonly exercise their duty  of care and compel young people in their care to modify their substance-using behaviour. This often  provokes resistance from  the young person and leads to their erroneous characterisation as “unmotivated”. Rather, resistance signifies  that different motivations are driving  a young person’s actions.

Young people’s apparent motivation can be influenced by a range  of factors associated with  developmental stage  and level of vulnerability. Young people may:

  • Not care about  the consequences of substance use
  • Intentionally give the impression that they don’t  care about  the consequences of substance use to project an image  that they are in control even when they clearly  are not
  • Be uninformed or under-informed about the  consequences of their substance use
  • Have limited  experience and are only beginning to develop the capacity for insight  into the link between actions  and consequences.

Further, young people with  backgrounds of social disadvantage who  continue to live at the margins of society  often  develop a capacity to tolerate adversity. For such  young people and those  closest  to them, problems stemming from  substance use can be seen as a natural  part of life.

In general, young people who  don’t believe  that change is possible are also likely to be pre-contemplative. This orientation towards change can be reinforced when a young person is unaware that programs and services exist that cater  for their needs  and preferences.

Young people in the contemplation stage  continue to focus  on what  for them  are the benefits of substance use; what  they like about  it. However, contemplators have also experienced and give weight to the adverse consequences; the things  that they don’t like about substance use.

People  who  are contemplators may also be considering the benefits associated with  changing but are likely to be acutely  aware  of what  it will cost them  in effort, energy and loss (DiClemente & Velasquez, 2002). This balance between consideration of the costs and benefits of changing can produce profound ambivalence that can keep  young people stuck  in this stage  for long  periods of time.

The desire  to resolve  the internal conflict and dissonance experienced as a result  of this ambivalence can spur a person on to make  changes (DiClemente & Velasquez, 2002), but can also result  in a young person resorting to the short-term solution that substance use offers  (Bruun, 2008).

As with  those  young people who  are not interested in change, contemplators might  also mask  their true state of mind.  Again  there  is potentially a developmental component stemming from  young people’s:

  • Acute need  for privacy  and reluctance to share personal details about  themselves until trust and regard has been  built with  another
  • Sensitivity regarding the image  they project, with both  young men  and women often  feeling it necessary to hide vulnerability
  • Inexperience and being either uninformed, under-informed and/or ill-informed.

Preparation/planning (also known as Determination or ‘Ready for Action’)

The intention of a young person in ‘preparation’ is to make  changes in the immediate future. The model’s underpinning theory holds  that people form  this intention when the costs associated with  substance use substantially outweigh the benefits, and/or the benefits of changing outweigh the costs.  A move  into the ‘preparation’ stage  brings  the model’s ‘Self-Efficacy’ construct into focus. Adapted from  Bandura (1977, 1982), it represents the confidence a person has in achieving a specific outcome.

Intending to change is very different from  making changes. A strong sense  of self-efficacy increases the likelihood of transition from  the ‘preparation’ to the ‘action’ stage.  This transition is particularly challenging when substance use has been  ubiquitous in a young person’s life and when it continues to be for others  in their immediate social network.

These  young people may need  assistance to understand that alternatives to a substance-using lifestyle  exist and could  be a realistic  option for them. If and when such alternative pathways are embraced, specific goals  may be set and alternative strategies for pursuing them explored and mapped out.

A young person may have been  at the point  of changing several  times  in the past.  Change is motivated either  by the desire  to resolve  or escape  problems (avoidance) or to achieve  some  benefit (approach). Where a young person’s lifestyle  has featured problematic substance use, avoidance rather  than approach factors are likely to have a stronger influence. The decision to change is often  made  when young people reach  or exceed the limits of their tolerance for the complications associated with  substance use.

Practitioners are advised  to be mindful of how demoralising it can be for young people who  have formed the view that change is required but not possible. Substance use might  be used  as a mechanism for coping with  these  feelings and there  is a strong possibility of regression. Further, there  is heightened potential that a young person in such  circumstances will engage in other  ‘risk’ behaviours and may feel suicidal.

‘Action’ is the stage  in which people apply  themselves to the task of changing a behaviour and make observable modifications to their lifestyle.  Action requires considerable commitment and an investment of energy into change processes. It involves implementing viable strategies to achieve  goals  set in the preparation stage.

In the action  stage,  self-efficacy is expressed through coping with  high-risk situations and not regressing to an earlier  stage.  Youth AOD  practitioners should remember that the changes a young person makes  on the first attempt may not last. It is far more  common for people to make  multiple attempts to change substance- using  behaviour before finally succeeding (Polivy & Herman, 2002).

Maintenance is the stage  in which people consolidate the achievements attained during the action  stage.  The transition from  ‘action’ to ‘maintenance’ is gradual, requiring sustained change for a sufficient period. Maintenance is signified by a young person feeling relatively  stable  and more  confident in continuing to pursue their goals.

Even so, those  in maintenance remain attached in some  way to their former substance-using behaviour. This necessitates ongoing efforts to prevent ‘lapsing’ or ‘relapsing’, but less frequent application of change processes than  would be required in the action  stage.

While  young people’s decision to change is most  often made  in response to the negative consequences of substance use (avoidance motivation), it is essential that young people have constructive options to work towards (approach motivation).

People  can overcome their emotional and physical attachment to substance-using behaviour (Prochaska et al, 1992). This signifies  a completion of the change process, also known as ‘exit’.  This is typically  associated with  significant lifestyle  change and reflected in the achievement of several  significant treatment goals. Even so, for some  the attachment to substance-using behaviour is continuous. In such  cases,  people remain in maintenance.

Lapse and Relapse
Relapse  involves  regression from  action  or maintenance to an earlier  stage  and is evidenced by a return to previous problematic patterns of behaviour. Relapse is both  an outcome and a process that at some  stage involves  an initial setback or ‘lapse’  (Witkiewitz & Marlett, 2004). A lapse is a brief  or limited  incident of substance use. This brief  return to substance use does  not constitute a relapse. Further, lapse does not automatically lead to relapse  but is a step in that direction.

Most  young people in the process of changing and significant others  in their social network will invariably view any regression negatively. The loss of perceived control often  results  in self-blame and a diminished sense  of self-efficacy. The presence of these  feelings after  the breaking of a strong resolution to change is known as the ‘abstinence violation effect’ (Curry, Marlatt  & Gordon, 1987).

Both  ‘lapse’  and ‘relapse’ present an excellent opportunity for the kind of self-discovery and learning necessary for sustained changes over the long  term. People  generally learn  more  from  their setbacks than from  their successes. Further, studies  repeatedly demonstrate that attempts to modify a range  of behaviours, including substance use, result  in at least one lapse followed by relapse  (Polivy & Herman, 2002). While  lapse and relapse  are not guaranteed, both should be seen as a natural  part of the change process.