The Stages of Change

Change can be difficult to initiate. Fear kicks in, along with doubt and hesitation. If we look at one of the most common resolutions people make annually, going to the gym, we are all at different stages in our process of change. You may be an avid gym rat at your local CrossFit establishment, while the thought of a gym membership has never crossed your neighbor’s mind. Folks have different lived experiences and come to change in different ways. Substance use follows the same process; the only difference I see is the stigma our culture associates with the process of recovery.

The stages of changes are as follows:

Pre-contemplation: The thought of change has not crossed your mind. You are oblivious to the consequences of continuing the behavior. If someone brings up discontinuing use of alcohol and/or drugs, you state something along the lines of “I don’t think I have a problem.” Or “I don’t know what you are talking about.” The changes remain in the person’s subconscious.

Contemplation: The thought has maybe crossed your mind from time to time. What would it be like if I stopped using? People in your life may bring it up to you and you give it some thought, but no decision to initiate change has been made.You start to see the consequences of unhealthy behaviors, but you are not ready to make changes. There may even be a level of fear and intimidation, stating things like “I want to stop, but I can’t.” This can be a time of vulnerability in the change process because you tend to be at high risk for unsafe behaviors or worn down by a behavior you want to change emotionally, but physically cannot.

Preparation: A decision has been made, “I am going to change this behavior.” You start to discuss how you plan to create change. You ask others how they prepared to make this change in the past. This is traditionally the stage where someone gets their ducks in a row.

Action: You start to create change. You discontinue use of alcohol and/or drugs. Maybe you attend a recovery support meeting for the first time. You are taking action! This stage in the recovery process traditionally lasts between 1 minute to 1 year.

Maintenance: This stage is the timeframe when you maintain the change you have already succeeded in making. If your goal was abstinence then you are maintaining it. If your goal was to safely use, then you have abstained from unsafe behaviors.

Why are the stages of change so important in harm reduction?

“Harm reduction incorporates a spectrum of strategies that includes safer use, managed use, abstinence, meeting people who use drugs ‘where they’re at,’ and addressing conditions of use along with the use itself.” - National Harm Reduction Coalition

These stages allow a person to identify where they are in the change process and utilize the continuum of care to identify the harm reduction best practices most effective for the stage.

Someone who is pre-contemplative or contemplative about discontinuing use would benefit from the ability to access clean syringes, fentanyl test strips, naloxone/overdose prevention. They would also benefit from the many kits that our organization makes: Safe Injection, Safer Sniffing, Safer Smoking, wound care, and Safer Sex kits. People in this stage should not be coerced or pressured into treatment. Evidence shows that people are only successful in a goal if they have chosen the goal themselves.

As someone moves through the stages eventually entering preparation and action, it is important to utilize compassionate language and recognize people using substances, as individuals with rights who deserve respect and compassion. In the action and maintenance stages, even people who embrace abstinence, benefit from harm reduction strategies. Opioid overdoses are preventable with the use of Narcan (naloxone).

“190 people die from an overdose every day. That equals 70,000 avoidable deaths every year.” - National Harm Reduction Coalition. Those at highest risk for overdose include people who have had a period of abstinence due to discontinued use, incarceration, or attending an inpatient treatment program. Why? Tolerance is greatly impacted by discontinued use and people often return to the amount they were using previously.

It is important to allow individuals to make their own goals and decisions. Just like the person who is pre-contemplative about going to the gym, someone who is not thinking about stopping their use is not going to be convinced, even through punitive practices and legal measures. So why do we treat goals around substance use differently? Why do we believe we can take autonomy away from others? The reason people feel so justified in making these decisions for others is because substance use is seen as a moral issue and those using it are seen as less than human.

If we expect our overdose numbers and the public health crises we are up against to decline then we must meet people who use drugs where they are at.

If you or a loved one are looking into recovery options, The Doorways offer assistance with accessing every level of treatment. Call 211 to be connected with a Doorway or use the Doorway locator map for access to a Doorway at one of nine trusted community hospitals.

If you or a loved one are looking for harm reduction services you can find the Syringe Service Programs of NH here.