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Is Your Teen Ready to Change? Applying the Stages of Change Model in Wilderness Therapy
By Meghan Vivo
Mike is an alcoholic. He went into drug rehab for 60 days, relapsed twice, and has now been sober for five years. Lisa is also an alcoholic. She spent the same 60 days in an addiction treatment program, but has relapsed multiple times and can't seem to stay clean. What worked for Mike that didn't work for Lisa? The answer may be a complicated mix of genetic, emotional, psychological, and social factors, but it may also be that Mike was truly ready to change and Lisa was not.
The Stages of Change
When approaching a behavioral issue, mental health professionals commonly assess the individual's readiness to change using the Stages of Change Model developed in the early 1980s by James Prochaska and Carlo DiClemente at the University of Rhode Island. Although Prochaska and DiClemente created the model while studying the progression smokers followed when giving up their nicotine habit, their model has been applied to a wide range of behaviors, including weight loss, injury prevention, and overcoming drug and alcohol addiction, among others.
Also known as the Transtheoretical Model of Change, the Stages of Change Model shows that most people change gradually and at their own pace, moving through a series of five stages. There is no timeline for each stage of change. It might take as little as a couple weeks or as long as a lifetime to get through any one stage. In general, the stages of change progress as follows:
- Precontemplation - The individual is uninterested, unaware, or unwilling to acknowledge that there is a problem behavior that needs to be changed.
- Contemplation - The individual acknowledges that there is a problem, but is not yet ready to commit to making a change.
- Preparation - The individual is getting ready to change.
- Action - The individual is ready to take determined action to make a change.
- Maintenance - The individual works to maintain the new behavior over time.
For example, when Phil Scoville, a field therapist at Outback - a progressive wilderness therapy program for adolescents ages 13 to 17 - is first introduced to a new student, he uses the University of Rhode Island Change Assessment and a variety of other tools to assess the adolescent's awareness of her problem behaviors and readiness to change. Knowing that a teen who abuses drugs or alcohol may not be immediately prepared to accept help, Scoville creates a treatment plan that emphasizes awareness and personal accountability in the early stages of therapy, and modifies his approach as the client progresses through the stages of change.
Stage One: Precontemplation
In the precontemplation stage, people are not considering changing and have no interest taking ownership for the problem or accepting any kind of help. They may not be aware that there is a problem at all, and are often defensive, surprised, and angry when others confront them or pressure them to change. While the individual underestimates the benefits of receiving treatment, he overestimates the benefits of the problem, advises Scoville. In the case of drug addicts and alcoholics, this stage is often marked by lying about the existence and extent of the problem and blaming others for negative consequences.
Because the majority of adolescents in wilderness therapy are in the precontemplation stage when they enter the program, the initial goal is to help the students acknowledge that there is a problem. Rather than imposing behavioral change on the students, Scoville uses motivational interviewing strategies, such as empathy, reflective listening, and acceptance, to help them come to the realization on their own. He also points out discrepancies between where students want to be and where their actions are leading them.
"At Outback, we roll with the resistance rather than arguing for change," notes Scoville. "If you simply demand change, the student will resist and put up his defenses. Instead of recognizing that he has a problem, he will blame his parents and everyone but himself. Most of our students are not happy with where their choices have taken them. So we'll give them the reason and rationale for making a change, we'll invite them to set responsible goals and boundaries, and we'll support them the whole way through. But it's up to them to make that choice."
In the company of other struggling teens and nurturing field staff, students realize how their behaviors impact others when faced with group conflicts and wilderness living. As staff and peers point out negative behavior patterns and the student experiences the natural consequences of those behaviors, she begins to take responsibility for areas that need improvement. They also realize they are not alone in their struggles and they have ongoing support during the process of change.
Stage Two: Contemplation
During the contemplation stage, people are considering the possibility of changing, but feel ambivalent and anxious about it. They have some awareness of the problem and are becoming increasingly aware of the benefits of making changes, but they struggle with a sense of loss that accompanies giving up a familiar habit. Although the individual is not yet ready to commit to change, he is gathering information, identifying triggers, assessing the pros and cons, and re-evaluating his personal choices.
"Most students reach the contemplation stage during their time at Outback by exploring their fears, understanding the impact of old behaviors, and recognizing the benefits of change," says Scoville. "Becoming aware of the problem and taking responsibility for it is a huge step for some teens."
As students develop communication skills in face-to-face interactions with peers and staff and letter-writing to their parents, they learn to express themselves honestly and listen openly to others. The students track their behaviors and understand the feelings that drive those negative patterns through reading and writing assignments and group discussions, until they ultimately begin to develop new goals, coping skills, and expectations for themselves.
Stage Three: Preparation
The preparation stage is characterized by experimentation, increased self-regulation, and some continued ambivalence, says Scoville. In this stage, people have committed to make a change, are engaging in continued research about what they need to do to alter their behavior, and may be planning small steps toward action, but they are not yet making actual changes. This is a critical time, says Scoville, because people in the preparation stage tend to take action in the immediate future (e.g., within the next month). In order to move to the next stage, individuals must set goals and priorities, devise a plan (like a behavior contract), and create rituals that will spark the process of change (e.g., destroying drug paraphernalia or flushing drugs down the toilet). With increasing confidence in their ability to change and a realistic optimism about future possibilities, students of wilderness therapy are well-situated to continue to the next stage.
Many students are entering the preparation stage when the wilderness program is coming to an end. In order to maintain the students' momentum and avoid early relapse, parents and therapists evaluate the child's readiness to return home and the possibility of continuing care at a therapeutic boarding school or residential treatment center.
Stage Four: Action
When a person reaches the action stage, she not only believes she has the ability to change, but she is actively following through with her plan. She is practicing new coping strategies, receiving positive reinforcement, and finding sources of support.
"Taking action doesn't necessarily mean the person behaves perfectly," advises Scoville. "But they are ready to start saying no to drugs or other problem behaviors, to apologize to others, and to work on their interactions and relationships."
The action stage is the one that requires the greatest commitment of time and energy, says Scoville. The risk of relapse is significant as people learn to cope with many internal and external triggers, so people must be actively learning skills to prevent a reversal to old behaviors. Because they are likely to seek support from others, ongoing treatment in a secure and structured environment at this stage is crucial. According to Scoville, after about six months of consistently maintaining the new behavior pattern, the individual is prepared to move into the next stage.
Stage Five: Maintenance
The maintenance stage involves sustaining the progress made during the action stage, and acquiring new skills to avoid relapse. People in this stage must be patient with themselves, maintain a positive outlook, and remember that following their goals will make life more rewarding and meaningful.
At this point, individuals either exit the stages of change cycle, fully adapted to their new behavior patterns, or they may relapse and cycle through the stages again. According to Scoville, change is not a linear process. In fact, Prochaska and DiClemente described the stages as a spiral, in which success may mean revisiting different stages multiple times over the course of many years.
Because lapses and relapses are a normal part of recovery, individuals in this stage need support and encouragement to resume the preparation, action, and maintenance stages if they slip up. They may need ongoing treatment to rebuild their confidence, improve their coping skills, and treat the relapse like a positive learning experience rather than a failure.
A Work in Progress
The stages of change are an important tool for therapists and families to understand in order to create an effective treatment plan. In wilderness therapy, the stages help parents set reasonable expectations of what progress will look like in their teen. The model also helps parents hold their troubled teen accountable for his actions, and make solid aftercare decisions for their child.
"When a teen promises his parents he'll never use drugs again, and then uses a week later, it can be disheartening," states Scoville. "But when parents understand the stages of change, they'll know how to set reasonable expectations and anticipate a spiral of progress and regression over the course of treatment. They'll also be able to witness the stages of change at work in their own healing process."
Wilderness therapy is one of the most effective ways to help struggling adolescents recognize a problem and commit to making a change. In most cases, wilderness therapy will take teens into the preparation or action stage, setting a firm foundation for further growth at home or in the next stage of treatment.
One Outback student stood out to Scoville as an example of the stages of change at work in the wilderness setting. The student was fairly compliant during the first few weeks of the program, hoping to get home as quickly as possible. But two weeks in, Mother's Day came, and the student had a "complete meltdown, refusing to hike or do anything," recalls Scoville.
The student felt hopeless, saying his parents didn't love him and he didn't need help. A number of weeks later, he graduated from the program and went home willing to follow a home contract and go to family therapy. "He had arrived at the preparation stage in his problem with drug use, choosing to hang out with different friends and make better choices," says Scoville. "We were proud of his progress and his family's commitment to work with him through the difficult and sometimes unpredictable process of change."
Adirondack Leadership Expeditions is a wilderness program for troubled teens that promotes growth through a focus on insight-oriented experiences.
Wilderness programs for troubled teens serve as excellent alternatives to boot camps because teens learn through natural consequences and positive peer relationships.