Combining the Transtheoretical Stages of Change Model and the 12 Steps of Alcoholics Anonymous to Monitor Treatment Progression

Numerous researchers have identified a gap between empirically based findings on alcohol and other drug (AOD) treatment interventions and their utilization within clinical practice. Although there are various reasons for this lack of dissemination and implementation of proven practices, it is important to provide front-line clinicians with a user-friendly and measurable tool that evaluates and monitors clients’ progress during treatment. Because many AOD treatment facilities include some form of 12-step group attendance, particularly Alcoholics Anonymous (AA), the natural fit of the transtheoretical stages of change model (Prochaska & DiClemente, 1986) would seem a viable option for connecting research and practice within existing treatment programs. We propose a plan for social work clinicians working in the AOD treatment field to integrate the transtheoretical stages of change model into the process of monitoring clients who attend and work the12 Steps of AA.

While the stages of change (SOC) model and the 12 Steps of AA (Alcoholics Anonymous, 1976) seem to be complementary, specific connections are not found in the literature. Connecting SOC and 12 Steps can assist treatment providers with client assessment, case formulation, treatment planning, and treatment implementation, along with evaluating and monitoring the client’s SOC process and 12 Step involvement.

STAGES OF CHANGE AND 12 STEPS

Being in the precontemplation stage indicates the intention of not taking action in the foreseeable future, possibly due to being uninformed or under-informed about the consequences of drinking behaviors. To process through the precontemplation stage, one must become aware of and acknowledge that a drinking problem exists. This is the time when AA literature could be useful in informing the client about the consequences of drinking. Having clients attend AA meetings as part of their treatment is often the first and best introduction to AA members and the 12 Steps. Having someone outside the treatment program openly discussing the consequences of drinking allows the client to evaluate his or her self-regulatory activities, and according to AA, “if he is alcoholic, he will understand you at once” (Alcoholics Anonymous, 1976, p. 92). A measurable sign for the clinician that the client is progressing through the precontemplation stage is the client’s conversation with sober members of AA and the awareness of days and times of local meetings.

The contemplation stage is a place where clients can become stuck, embodying a struggle between the costs and benefits of changing and thus creating profound ambivalence. This is similar to those working through the 12 Steps, particularly when contemplating Step 3 and deciding between a problematic life of continued drinking or seeking out a spiritually based solution. The movement through the contemplation stage occurs when there is a clearer awareness of the pros and cons of changing. The process of moving through the contemplation stage can be identified by a client’s knowledge of Steps 2 and 3. As Step 1 requires no action other than admitting to a problem, Steps 2 and 3 only require believing in a power greater than oneself and making a decision to alter thinking and actions, as they relate to drinking alcohol.

The client moving through the preparation stage will have developed a plan of action and the intention of taking specific action in the immediate future. By this time the client should have obtained an AA sponsor, and began discussions regarding the first three steps. The plan of action being developed is Step 4, a searching and fearless moral inventory.

At this point, the client should have begun Step 4 inventory on paper and become immersed within the AA recovering community. Although there could be setbacks in AA, just like through the SOC, the client will have obtained some knowledge of AA and begun working on the steps regularly.

Action is the stage in which people have made specific overt modifications in their lifestyles. Because action is observable, behavior change is generally equated with some level of action taking place for an average of 6 months. This 6-month time frame is sufficient for clients to have completed work on Steps 5 through 9. Having earlier completed their personal inventory related to resentments, fears, and harms to others, the observable action will be the client’s time spent with a sponsor going over his or her inventory (e.g., Step 5).

The self-efficacy boost associated with completing Step 5 must be built upon. After completing Step 5, clients should have more confidence about their involvement in AA and other recovery-related actions. An active relationship with AA sponsors is also a good indication that progress is being attempted. This is a good time to begin asking about their efforts of preparing a list of people they have harmed. This is Step 8; attempts at making amends for past behaviors are done in Step 9.

The maintenance stage, which is similar to AA’s Steps 10 through 12, is the stage in which people are working to prevent relapse. Having immersed themselves in the recovery community provides great opportunity to continue forward and experience a sober life within supportive communities. Steps 10 through 12 allows clients to continue taking personal inventory regarding any resentments, harms to others, and so on, along with practicing a spiritual-based recovery life. The overall goal of the maintenance stage and Steps 10 through 12 is the continuation of past successful behaviors and remaining within the protective environment of a sober community.

The natural fit between the progression and expectations of behavioral changes found within the SOC and AA’s 12 Steps can be used to better evaluate a client’s treatment progress. Combining the SOC and the 12 Steps provides clinicians with a measurable treatment plan along with a treatment tool.

Table 1 is a grid combining the SOC and AA’s 12 Steps for quick reference.

TABLE 1.

Stages of Change Model and Alcoholics Anonymous (AA) Steps Comparison

Stage of change	Processes of change associated with stage	AA steps	AA activities that can promote movement to next stage
Precontemplation	Acknowledge problem Increase awareness of negatives of problem Evaluate self-regulatory activities	1	Calling AA Central Office for local meeting times and days Meeting AA members
Contemplation	Make decision to act Engage in preliminary action	2–3	Attendance of an open AA meeting Introduction as a visitor at a meeting
Preparation	Develop a change plan Set goals and priorities to achieve change	4	Obtaining temporary sponsor Discussion of Steps1–3 with sponsor Beginning work on Step 4 with sponsor Statement of being an alcoholic in a meeting
Action	Apply behavior change methods for average of 6 months Increase self-efficacy to perform the behavior change	5–9	Completion of Steps4–9 under guidance of sponsor Obtaining AA home group Helping set up, clean up, and chair home group meeting
Maintenance	Maintain supportive contacts	10–12	Attendance of weekly home group meetings Meeting and greeting people coming into meeting Sponsoring others Making a 12-Step call Speaking at a meeting