I was introduced to the transtheoretical stages of change model during an intensive training in motivational interviewing (MI) in graduate school. In this model, change is a progressive and rational process dependent on hard work and sustained effort. It is not magic.
While reviewing the “stages” (precontemplation – contemplation – preparation – action – maintenance) I was struck by a similar structural feel between the stages of change and the 12 Steps introduced by Alcoholics Anonymous in 1939. A 2010 article, “Combining the Transtheoretical Stages of Change Model and the 12 Steps of Alcoholics Anonymous to Monitor Treatment Progression,” reached similar conclusions, specifically which Steps fit with each stage.
The 12 Step approach, especially participation in 12 Step groups, does not work for everyone. Thankfully, there are other approaches and strategies. I would like to reflect on a few broad structural similarities and differences between the stages of change and the 12 Steps. The stages of change might be more helpful for those not comfortable with the Steps’ orientation toward powerlessness and reliance on a Higher Power.
Similar in Structure
The most obvious similarity between the stages of change and the 12 Step approach is that both rely on a progressive “linear” approach. Change does not happen overnight nor does it happen miraculously. It moves directionally as a result of conscious, purposeful effort. Second, both approaches emphasize the importance of relationships. The 12 Step approach relies on sponsorship; the stages of change model functions within the therapeutic environment.
Third, both approaches are, if you will, guides or maps offering markers of progress. Above I used the word “linear” in quotes because while there is directional movement in both approaches, the 12 Steps and the stages of change assume the reality of relapse. So, while there is a focus on moving from Step 1 to Step 12 or from precontemplation to maintenance, relapse typically occurs more than once. Rather than an arrow-like unidirectional progression, recovery more often resembles a spiral as one falls back and moves forward again and again retracing ones’s path, hopefully wiser and more knowledgeable than before.
Finally, both Stepwork and therapeutic work effect internal change, but the work itself is self-consciously taking place outside of the individual; that is, there is an externalization that takes place. The “self” is examined, analyzed, and contemplated in conjunction with an Other in sessions, in meetings, or on paper. Distance is put between the recovering individual and his actions. Interestingly, as one goes “deeper,” further distance or space is emphasized by each marker (i.e., the designated stage or Step).
The disease model supporting the 12 Steps can be viewed as fostering internalized shame – “I am an alcoholic” – and yet in practice it functions as a convenient externalizing tool. For example, when a recovering addict says to her sponsor, “that’s my disease talking,” she is able to separate herself from her disease. A similar process occurs in session when a client and therapist explore and process specific experiences as merely one part of an individual’s lived experience.
Different in Use
There are differences, of course. To begin, the stages of change serve as markers enabling therapists or counselors to tailor their interventions, but within 12 Step work tracking one’s own progress is fundamental to recovery. The therapist as guide is marking a client’s journey, but the client does not need to track his progress for change to occur.
In other words, the stages of change are more important to the therapist than the client, but the 12 Steps are necessary accomplishments for the alcoholic or addict. They are crucial to building self-esteem and self-efficacy (i.e., recovery). Working through the stages of change with a therapist is labor intensive and yet self-consciously moving from one stage to another is not a requirement for recovery – a client can remain oblivious to his progression through the stages.
Second, the Steps are explicitly instructional while the stages are merely descriptive. I have heard the Big Book referred to as a textbook enabling alcoholics or addicts to manufacture a spiritual experience. Relatedly, the environment in which both approaches are utilized is unique and exclusive. The 12 Steps are used within specific didactic organizations like Alcoholics Anonymous or Narcotics Anonymous. The stages of change, however, can be utilized by any therapist, counselor, coach, or healer. The Steps are wedded to a specific program while the stages of change remain firmly nonsectarian.
Next, it is important to remember that Step work must be guided by a sponsor who has completed the work herself. The stages of change do not require the guide’s direct experience. Many, perhaps most, therapists have experience with some type of personal recovery, but in order to move a client through successive stages of change it is not necessary for him to have lived a similar experience as his client. The success of the 12 Steps hinges on one alcoholic/addict helping another; moving through the stages of change only requires a therapist’s navigational skills.
Finally, within the stages of change model it is entirely possible for an individual to enter treatment at an advanced stage of change (e.g., preparation). This means that an individual can progress through some stages on his own. This is not possible within the 12 Step approach. The Steps demand that one begin at the beginning, the stages do not. The Big Book is organized sequentially for just that purpose.
Here is a quick summary of the similarities and differences identified:
- Both models offer a progressive “linear” approach.
- Relationships are critical to the success of both models.
- Both approaches offer guides or maps as markers of progress.
- In both, the work itself is externalized; that is, self-consciously taking place outside of the individual.
- The stages of change are more important to the therapist than the client, but the 12 Steps are necessary accomplishments for the alcoholic or addict to complete.
- The Steps are explicitly instructional while the stages are merely descriptive.
- The stages of change are nonsectarian, but the Steps are specific to organizations.
- The 12 Steps require one alcoholic/addict helping another: not true for the stages of change.
- The Steps demand that one begin at the beginning (i.e., Step 1), the stages do not.
In the final analysis, the similarities between the stages of change and the 12 Steps noted above are the most important takeaway. The differences, such as they are, are largely theoretical. They are the stuff of arcane nitpicking.
Successful navigation of either model does not require understanding or being aware of the other. And yet there is something moving about the realization that a group of recovering alcoholics discovered through trial and error what it took trained professionals years of practice and research to isolate and summarize.
Whether viewed as a spiritual awakening or simply as changing one’s lifestyle in order to feel better, change is a progressive and rational process requiring effort, self-reflection, and being in relation with others. It is not an isolated, miraculous, or pull yourself up by your bootstraps singularity.