Review of Addiction and Change

The highly influential Transtheoretical Model (TTM; often referred to as the Stages-of-Change model) was developed to describe the process of behavior change common to a wide variety of habits ranging from drinking to smoking to sunscreen use. Addiction and Change is TTM co-developer Carlo DiClemente’s review and update of the TTM as it applies specifically to addictive behaviors.

The author begins with a review of diverse models of addiction, and makes a case for change as the integrating principle in the development of the TTM. He then reviews the TTM, presenting the stages, processes, markers, and context of change as a template for understanding intentional behavior change. The introductory chapters conclude with a TTM-based description of the “well-maintained addiction,” i.e., the state of addiction as representing the Maintenance stage in the process of acquiring an addictive behavior. He therefore applies the TTM stages (Precontemplation, Contemplation, Preparation, Action, Maintenance) both to becoming addicted and recovering from addiction.

The next section details the application of the TTM to acquiring addictive behaviors with a focus on the transitions from one stage to the next. I’m not so sure that the TTM stages, designed to describe *intentional* behavior change, are the best fit to the process of becoming addicted (wasn’t there a public service ad to the effect of “nobody says, I want to be a junkie when I grow up?”). However, this section is useful for its comprehensive descriptive model of each step along the road to addiction and the factors that can facilitate or prevent transition from one stage to the next. It also further debunks the notion of addiction as an all-or-none phenomenon.

The largest section outlines the stage-by-stage process of recovering from addiction. The nomenclature of the stages of change has been widely disseminated but too often the distinct dimensions of the TTM are lost. Here, the author describes in detail the basic task of each stage, the change processes at work, the relevant markers of change, as well as the context of change (broad areas of functioning ranging from intrapersonal to societal, that complement or complicate change).

The author then moves on to designing interventions at each stage, both for prevention and treatment. The author’s goal is primarily to frame the existing literature in terms of the TTM as an organizing principle for intervention. On both the prevention and treatment fronts, the take-home message is the TTM implies a need for approaches tailored to each transition on the road to recovery and that interventions may range in scale from the individual to the societal. No specific theoretical orientation is highlighted. Rather, particular approaches may provide effective means of targeting specific stages or contexts of change. TTM-guided treatment has had limited evaluation, but the idea of matching interventions to client stages of change seems like pure common sense.

The final chapter outlines a broad and ambitious research agenda with levels of analysis ranging from the individual to the programmatic to the societal. The focus is on framing questions and measures in a manner so that the data can be useful in understanding the process of change in addiction at a fine-grained level rather than as a static or all-or-none phenomenon. The litany of unanswered questions is somewhat overwhelming and doesn’t even touch on validating the TTM per se but rather assumes it will be useful as a means of organizing addiction research as a whole.

The TTM has become popular because it provides a clinically useful way of understanding what goes on when people decide to make a change. While encyclopedic in scope, this book is clearly written and not overly dense. I recommend it to anyone who wants to understand the stages and processes of change on more than a superficial level.

Deborah H. A. Van Horn, Ph. D. - January 26, 2005