What are the 5 Stages of Change in Recovery from Addiction? 

The Transtheoretical Model (TTM), or Stages of Change Model, in addiction recovery, breaks down the journey of behaviors from denial to maintaining sobriety and abstinence. The model has a 6th stage called the relapse stage. In this stage, the patient has returned to old behaviors and substance use and cycles back through the stages of change.   

In this article, we will explain each stage and point out how the stage applies not only to addiction but also to mental disorders and families. We will also touch on what is required to move out of a stage and onto the next stage. The TTM model describes the behavioral changes in stages for the substance use or mental disorder patient; you will see that a dysfunctional family system behaves the same way as the intended patient with a substance use or mental disorder.

The greatest challenge the intended patient and their family will face is the fear and anxiety of change and letting go of their maladaptive coping mechanisms and thoughts. The intended patient is afraid of letting go of their behaviors and substance use, and the family is fearful of what life will look like for themselves if the situation changes. The intended patient and their family cycle and become stuck in the second stage of change.

“What starts as a fear turns to anxiety. Fear is something you see, and anxiety is your imagination. The fear of your loved one having addiction or mental health issues is real. All the what-ifs and buts are anxiety and why the family and the intended patient stay stuck.”

At times, both will backslide as they move up through the stage of change. Families use their acquired dysfunctional family role as a security blanket the same way a substance user uses substances to hide behind their problems. A substance user has a family role in the family system and has its challenges. The family roles within the family system are acquired to cope with the situation and have challenges equal to, if not greater than, the substance user’s challenges. If we were to ask a room full of people who and what the problem was, they would all point at the intended patient and reference the substance use or mental disorders. The room would not be wrong because the behaviors and substance use are a problem. The room would not be correct either because the family roles that form under the substance user are at least equally destructive to the family and the intended patient. Addiction and mental health disorders create an unhealthy family that makes decisions based on fear, anxiety, selfishness, minimization, avoidance, secrets, past experiences, comfort, control, illusion, trauma, family of origin behavioral patterns, cultural beliefs, false beliefs, and distorted perceptions, just like the intended patient. The substance user or loved one with mental disorders and the family are protecting their current solution and are unwilling to part ways with their family role and beliefs due to the fear and anxiety of the unknown change. Families then hide behind the belief that their loved one has to want help or hit bottom, so they wait. The family does not realize that their behavior and roles prevent their loved one from wanting help, asking for help, and, most importantly, getting help. People using substances all want help; that is why they are using substances.

Families always ask us what happens if their loved one says no when doing the intervention. Families never ask us what happens if they say yes and accept help at the intervention; there is a reason for this. Families are afraid their loved ones will go to treatment and get better because they know that will have a significant impact on the family; this is the anxiety you have been living with. Some reading this may say, “How dare he say I don’t want my loved one better?”. We are not saying you don’t want them better. We say you are afraid to address your problems, and your loved one getting better forces you to do that, and your anxiety stops you from addressing the issue. The anxiety and scenarios you have played in your head and built up that aren’t real or have not happened are why families become paralyzed. Families will choose inaction or ineffective baby steps to protect their acquired dysfunctional family role at the expense of their loved one’s downfall. 

“The primary role of the substance user is to create chaos and drama. The primary role of the enabler is to react to it. The result is the other family members acquiring a maladaptive family role to balance the dysfunction between the substance user and the enabler. Nobody means to do this, and this is what happens. Family roles are not labels, nor do they define who you are. You have been driven to the family roles to cope with your fear and anxiety of the situation.”

It is much more difficult for a family to allow help to come into their home for the intervention than it is for their loved one to accept help for their substance use or mental disorder at the intervention. For every family that allows this to happen, at least ten to twenty families will devise an excuse not to address the problem swiftly and effectively. If you were to replace substance use and mental disorders with any other medical problem, nobody would be handling this the way they are right now. When you replace addiction and mental health with any other medical problem, re-listen to these conversations, and listen to family excuses and objections, it makes absolutely no sense. 

Addiction and mental health professionals have the most challenging job in healthcare. It is the only part of health care where the patient and their family fight to stay sick and try to convince the professionals why they need to do that. 

“Anxiety, substance use and mental disorders, and family dysfunction are the check engine lights or smoke alarms telling you something is wrong. Ignoring it doesn’t fix it; addressing the cause does. Families sit in their roles, as do their loved ones, and ignore the alarms, thinking that if they remove the batteries or cover the light, things will go away or improve independently. Families and people with substance use and mental disorders address the symptoms with substances and excuses to feel better. They will find no relief until they address the cause of their behavior.”

The Stages of Change for Both the Intended Patient and Their Family:

1. Precontemplation Stage

Individual Perspective:

Precontemplation is very rare. Most people with addiction and mental health problems are aware they have issues. When someone is in pre-contemplation, there is a lack of awareness or denial of the addiction or mental health problem. If someone were in the pre-contemplation stage, their response would be utterly different from that of someone in the contemplation stage. Someone in pre-contemplation would sincerely be caught off guard at the suggestion of a problem. The response would be aloof or of equal concern. They would not get angry and take your head off like your loved one probably has. Anger comes from fear; this anger your loved one exhibits in the contemplation stage when confronted or asked questions is another reason your family is in a holding pattern. You avoid addressing the issue to avoid the argument. The approach is not only unhealthy and ineffective; it is all about you. 

“The perception that the behavior, substance use, or mental disorder is not problematic is rarely denial. Families confuse denial of needing, wanting, or getting help with denial that there is a problem, and there is a big difference.” 

When your loved one says they do not have a problem, when you know there is a problem, you may be confused about the pre-contemplation stage. They are more than likely manipulating you to back off and are most likely in the contemplation stage, where almost all people with a substance use or mental disorder are. 

Family Perspective:

Some family members struggle with believing the severity of the loved one’s addiction and mental health disorders. Mental block, codependency, and unhealthy and dysfunctional family roles are significant contributors to this struggle. An enabler in the family system may selfishly deny the severity of the problem to feed a hidden agenda of not wanting to lose their role as caretakers or having a purpose. Enabling can and will significantly affect the entire family.

Like the substance user, there is rarely denial of a problem. The denial from a family almost always comes from the denial of addressing the problem or how to address the issue, driven by the desire to stay in dysfunctional family roles and fear and anxiety of conflict and confrontation.

2. Contemplation Stage

We will focus much of our attention on the contemplation stage of change. This stage is where families and their loved ones remain stuck and is the turning point in addiction and mental disorder recovery. Interventions focus on this stage to move the intended patient and their family onto preparing for treatment, taking action, and maintaining a successful outcome.

Before discussing this stage, we will explain the functional analysis, which ties into this stage. The function of behavior is defined by the things that influence it, not necessarily the pros and cons of the behavior; that is, until the cons outweigh the pros. A person with a substance use or mental disorder may see pros and cons differently than the average person who does not have a problem with alcohol, drugs, or mental health. Negative behaviors that seek to produce a positive reward or outcome, also known as a positive consequence, may appear functional. In other words, lying to get what you want and continuing to get what you wish would allow lying to appear functional and have a positive consequence. The behavior would stop if the positive consequence of lying was no longer practical or had negative consequences. The function of behavior is to maximize positive factors for the person and minimize negative consequences. In other words, negative behavior that brings positive aspects is the function of someone with a substance use or mental disorder.

“There is a saying that if something works, do more of it; if it does not, do something different. No change will be made if negative behavior has positive consequences. The science of behavior confirms why telling people they must wait for their loved ones to want help, ask for help, or hit bottom is not helpful. How will anyone arrive at any conclusion of change when their perception is that negative behaviors bring positive consequences?” 

When families enable or stay in a holding pattern of inaction, they allow their loved ones the illusion that negative behavior produces a positive outcome. 

The CRAFT intervention model clearly states that you reward positive behavior and do not reward negative behavior. It implies what you just read. Just because your loved one feels their negative behavior produces positive results for their goal does not mean it is. The same principles apply to families. 

People with substance use and mental disorders will almost always focus on the short-term benefits of behavior over the long-term consequences of a behavior. The reason they do this is because they can. Enabling, codependency, entitlement, comfort, no accountability, no consequences, dysfunctional family roles, misplaced denial, anxiety, and fear are just some of the things families can address to change their loved one’s perspective. One of the biggest lies ever told is that a family has to wait for their loved one to hit rock bottom, ask for help, or want help, or the situation will not improve. 

“Telling a family they have to wait for their loved one to want help, ask for help, or hit bottom is the most selfish, unprofessional, disrespectful, destructive, and incorrect thing you could ever say to them.”

All the clinical data shows what is required for someone to change their behavior and move through the stages of change and recovery. Telling people you have to wait for them to hit rock bottom, asking for help, or wanting help goes against everything that works. We understand what the other side is saying: the person has to feel the consequences on their own. People rarely say it that way, and it would be much better if they did. Stating you must wait for your loved one to want help, ask for help, or hit bottom is a dangerous thing to say. The statement completely disregards the affected people, such as family members, spouses, children, and society. It also does not factor in the family being at their bottom, the family being a large majority of the reason their loved one is not feeling the consequences, and why their loved one considers their negative behavior to have positive consequences. It also states that the family should sit back, wait for something terrible to happen, and live with guilt when it does. 

The point is that the family system of dysfunction, enabling, codependency, inaction, avoiding confrontation, fear, anxiety, secrets, and all the other things we mentioned above are the most significant contributing factors to the intended patient’s negative behaviors appearing as positive consequences. After the family engages in effective intervention services and holds their loved one accountable, then and only then will the intended patient be able to own their problem entirely and see that the consequences are more significant than the benefits. 

We will now explain the second stage of change – Contemplation. 

Individual Perspective:

The intended patient with substance use or mental disorder may or may not be thinking about change. It means they may or may not want to change, and at this time, they do not have to change because their consequences are not yet seen or felt as more significant than their benefits. It is of little importance whether or not they want to; it is significantly relevant that they have to. 

 “All people with substance use disorder and mental disorders want help; it is why they are using substances. It is not about whether they want help; it is about whether or not they see the need to try other forms of help.” 

What is required for the intended patient to move forward with change is acquiring ambivalence in the direction of change away from substance use and toward treatment. What holds the person back is their environment, family roles, family inaction, family excuses, misplaced denial, enabling, comfort, fears, anxiety, routine, entitlement, control, and perception, not to mention the dependency on addictive substances. As long as the intended patient feels they are receiving positive consequences from their negative behaviors, they stay in this stage. Many people with substance use and mental disorders feel entitled to the comfort provided by the family and thrive in the illusion of control they think they have over the family. The intended patient is afraid of what life will look like without alcohol, drugs, and comfort and fights hard to keep everyone the way they are for this to continue. While in this stage, the intended patient has taken their family hostage and has designed a family system that benefits themselves, their choice of help by way of substance use, and their behavior. 

Family Perspective:

The family is stuck, just like their loved one. The family must acquire the same ambivalence. Until the family sees the consequences of their inaction or ineffective approaches, they will stick with the benefits of their acquired family role. Families must reach the bottom themselves; until they do, they will stay stuck in the second stage of change. Families do not have to wait for their loved ones to reach the bottom to take action; they can initiate change with the intervention. Families have anxiety and fear of the unknown change that comes with the intervention and the face-to-face meeting between them and their loved ones at the intervention. Families are uncertain about how to support their loved ones after the intervention, and this comes from the fear and anxiety of having to change and look at themselves. Families will come up with more excuses and objections during this stage than at any other time in the process. In this stage, the family’s unhealthy family roles are acting the same as the substance user’s role. The family’s negative behaviors of avoidance, enabling, codependency, and unhealthy family roles and beliefs are believed to bring positive consequences or results. The family feels better staying where they are than doing something different, which would make the family uncomfortable. The family is avoiding the anxiety they have built up in their minds and benefits from avoiding intervention and confronting their loved one. The anxiety and fears must become less than the unknown outcome.

Remember, you will not tell your loved one what to do at the intervention; that will never go well. You will tell your loved one what you will be doing differently and are free to continue without your help or support. As we said earlier, families always ask, “What if they say no to the intervention?”. Help is not specific; it is all-encompassing. When someone refuses treatment at the intervention, they refuse all help, not just the gift of substance use and mental disorder treatment. 

When they say no, they say they want no help. That includes enabling and comfort and all the help you have been providing that has contributed to them not asking for help, not wanting help, and not hitting bottom. It also includes the family no longer sitting idle waiting for them to act. It is not about whether they want help but whether they must change and get help. Anyone self-medicating with alcohol or drugs or avoiding addressing their mental health wants help; the tell is in the substance use and the behavior. The solution they are seeking is destructive to themselves and their family. Consequences help redirect them to another form of help when the consequences become more significant than the benefits of using substances or engaging in destructive behaviors. 

Family intervention helps the family change their behaviors, roles, and perceptions. The changes help their loved one to be held accountable and support the family to stop solving problems for their loved one. The family often believes the loved one is a victim of mental health or a disease of addiction, and they will never accept help from an intervention. It is helpful during this stage for the family to understand the impact of the addiction and mental health both on their loved one and themselves. Not doing an intervention because you think they will say no is a feeble excuse. If it were any other medical problem with success rates far lower than addiction and mental health treatment, you would jump at the chance to try. No family member would tell an oncologist the cancer treatments may not work, so forget it and not do anything; you would give everything you had for both you and your loved one with cancer, and so would your loved one. People only think and speak this way when the medical issue is addiction or mental health. No other medical problem sees this. Families do not backslide after talking to a medical professional about any other fatal illness. They accept the situation because they must persevere no matter how difficult it will be for them and their loved ones. 

“Both the substance user and the family will backslide. At this time, a family will want to seek a second opinion. Families and those with substance use and mental disorders are not always looking for a second opinion; they are looking for an easier one.” 

If you felt that the last comment was us telling you that you can’t get a second opinion, that is not what we are saying. We are saying people do not get a second opinion because they love what they hear and want to talk to someone else who sees it the same way. When it is a medical condition, the patient or their family may wish to speak with other doctors, which is okay; they should. What we are saying is that the treatment of addiction and mental health has too many opinions and models. Too many interventionists will water down the truth to convince you to buy into their curriculum. We could do the same, and we do not. We are saying in this article that almost everyone takes shortcuts with the path of least resistance to get where they need to be.

The results of comforting shortcuts apply to both the family and the intended patient. Family and their loved ones will almost always agree to a solution that is easy to digest, even if it is ineffective. Families try to negotiate and minimize on the phone with us and sometimes after we arrive. The intended patient will do the same when presented with treatment through in-person intervention. The family and the intended patient often seek a more straightforward, softer way; there isn’t one. Some interventionists take a delicate and long approach that allows the family and the intended patient to stay in their role for much longer than they should. They do this because it is best for the business, not the successful outcome. Families who have taken this path and ended up here always tell us we got them where they needed to be in much less time, energy, and money. You must arrive at the same point whether you move quickly or take the long, slow approach. The intended patient must feel consequences greater than benefits and be held accountable for their actions. 

Both family and intended patients fight very hard to stay attached to their family role and substance use. The family states that their loved one is stubborn and then believes this will never work because they don’t want help. The comments and beliefs are all a disguise and an excuse not to change.

The reality is that until your loved one has consequences more significant than their benefits, they will not address the problem. Until your family takes action towards their recovery, they will not feel better or get better. Families play a role in the issue; pretending that is not a significant factor is not an honest approach to substance use and mental disorder treatment.

3. Preparation Stage

In the preparation stage, family and loved ones recognize the need for change and plan on changing, but this does not mean they will follow through or choose a practical path. It also means there has been no decision on when or how to change. Once your loved one moves to this stage, they will do the same thing: realize the need to change and not necessarily do anything about it. Families and their loved ones will almost always make decisions in this stage behind fear, anxiety, false perceptions of mental health, addiction, and dysfunctional family roles.

After speaking to one of the intervention counselors, the family has engaged in pre-therapy change. Pre-therapy change is when you have talked to a professional or made an appointment with your doctor and feel better even though you have not taken action yet. When people make appointments or speak with their doctors, they follow their doctor’s advice and improve. With addiction and mental health, people do not often follow professional advice; they follow their own. Even when someone agrees and intends to follow professional advice, it is common for the family and the intended patient to backslide before making it to the action phase. The more time the family and the intended patient sit in this stage, also known as the “let us think about it,” “let us sleep on it,” and “let us get back to you” stage, the less likely they are to move to the action phase. Moving to the next phase with a shortcut or ineffective plan based on what is best for your dysfunctional role will return you to the beginning stages in a short time. 

“Both the intended patient with a substance use or mental disorder and their family are entirely incapable of making an unbiased decision on their own. Both must surrender to professional guidance. All that is required for the family and intended patient is the willingness to let go of old ideas and allow new ideas from professionals. Until complete willingness to do this and surrender occurs, both family and patient will continue to make destructive situations driven by fear, anxiety, maladaptive behaviors, and dysfunctional family thinking and roles.”

Individual Perspective:

The textbooks say that in the preparation stage, the intended patient has decided to change and plans actionable steps while setting goals and identifying resources for support. In our experience, this rarely happens; when it does, the preparation stage should not take long, especially with an intervention client. The preparation phase is often used as a manipulation by the intended patient. The intended patient frequently agrees to do something to get the family off their back and then rarely follows through. When they follow through, it is often a comfortable plan that allows them to do as little as possible for as short a time as possible. 

There will be many lies the intended patient has told themselves and their loved ones. Many of these lies you have heard before. True surrender for the intended patient is accepting help and taking action as quickly as possible, not agreeing to do something about the problem when it is convenient for them. We understand that there are times when specific affairs need to be in order before going into a treatment center for an extended period. While in treatment, the patient can address these concerns with the help of treatment staff and the patient’s family. Occasionally, people surrender independently, organize their affairs, and head to treatment for the right reasons, not just to fix the problems the addiction or mental health has caused. Unfortunately, many people go to treatment to fix what is broken, not necessarily how their behaviors cause the problems. Nearly every person with addiction issues believes the problems are a result of substance use. The reason for the issues is the behaviors that cause the substance use that causes the problems. Unless that is addressed, the substance user will become a frequent flyer at treatment centers, hospitals, jails, and institutions. In our experience, it is much easier to help your loved one with their affairs while they are in treatment instead of trying to address them while they are stuck in the problem. 

“The concerns the intended patient feels they need to address before seeking help are primarily problems that occurred because they did not seek help.” 

We understand there are times when the intended patient has essential responsibilities. In our experience, nothing cannot be handled while the patient is in treatment with the support of their family and staff.

The point we are making is that the preparation phase is where the intended patient can lure a family with false hope. The preparation phase is when the loved one with substance use or mental disorder can continue to manipulate others because of the promise that they will seek help on their own terms. 

We wish not to make the preparation stage all doom and gloom for the intended patient; unfortunately, it often is. As we stated, it can happen when a person becomes willing on their own, gets their affairs in order, and checks themselves into treatment. Believe it or not, a person who did this had an intervention. In other words, the environment shifted; they saw the consequences were more significant than the benefits, and they prepared for treatment.

Family Perspective:

For families, the preparation stage is supposed to involve active involvement in planning to support themselves so the changes they are about to make can help their loved ones. It should also include preparing to overcome the fears and anxiety of change and understanding how family roles and responsibilities must change. The preparation for families is to learn how to say no to their loved ones and prepare for a better life than they are living now. The family must surrender at this stage, allowing professionals to move them into the following action and maintenance phases. Each family role should understand how it is counterproductive to their loved ones’ growth and seek to address the role and its associated behavior. The preparation phase for families is to let go of selfishness and no longer allow family secrets, fear, and anxiety to prevent you from helping yourself and your loved one. At this stage, the family should be preparing for their recovery and understand they need as much help as their loved ones.

“Unfortunately, what we said in the last paragraph rarely happens because families almost immediately backslide to old behaviors before the miracle can happen.” 

After the conversation with a professional, the family will temporarily understand what we say makes sense. For many families, it is too much to take, and fear and anxiety set in that this is not just about their loved ones with substance use or mental disorders; it is equally about them. As a result of fear and anxiety and not wanting to look at themselves, the family almost instantly backslides into their old ideas, thoughts, perceptions, and unhealthy family roles. When a family is moved out of the contemplation stage and into preparation, they may shut down and stop taking our calls. It often happens because the family cannot and will not continue moving forward because of the changes they know they must make. Families get pulled back and stay there because it controls their anxiety, and they feel safe in their dysfunctional roles and thoughts. For a moment, the family realized the need for change. Families then start discussing options on their own without a professional driven by dysfunctional family roles and thoughts and come up with more ineffective ideas that increase anxiety and protect the unhealthy house of dysfunction. It is where families want to sit and stay. Families make this all about themselves for the wrong reasons. Families do not hear our solutions. They only listen to us trying to take away theirs. 

“One of the biggest mistakes families make in the third stage of change is continuing to try and fix the problems for their loved one before they take action. Fixing other people’s problems is not preparing for action but prolonging the problems. The word decision is not a verb; it is a noun. In other words, a decision means nothing until the person(s) takes action.”

4. Action Stage

The action phase is actively trying to change. There is a change plan at this stage, and now it is about taking action to follow through with the plan. Like the other stages, talking about it is not doing it. When a family or their loved one takes action, there is a change taking place that can be noticeable. The change often occurs when actively engaged in intervention, treatment, and family recovery. Changing the behaviors on your own is difficult, if not impossible. In other words, help is required for families and people with a substance use or mental disorder to address the behaviors.

Individual Perspective:

The intended patient with a substance use or mental disorder has realized the consequences have become more significant than the benefits, is effectively prepared for change, and sees the need to take action and do so. There does not need to be much time between contemplation and action. The longer the intended patient sits in the preparation stage and waits to take action, the more likely they will backslide to the contemplation stage. Action means they are following through and addressing the problem. During an intervention, action is when they accept help, agree to treatment, and leave with the interventionist. When they say no, they are stuck in the second stage, a big difference. The preparation can be for them to pack their bags before heading to treatment with the interventionist. 

Action is when a person with a substance use or mental disorder has felt bottom and has to seek help. Feeling the consequences and taking accountability is a big reason people take action and get help. When someone has had enough, they do something different. The stage of action is not always permanent, and it is not uncommon for the patient to backslide in the action stage. There are times when they leave treatment against medical advice. It is not unusual for people in treatment to get worse before they get better. Even in the action phase, volatile behavior will occur. It is not uncommon for a substance user or person with mental disorders to start drifting back into their old patterns of behavior and start deceiving themselves that the problems that caused them to take action were not that bad. Some believe they can leave treatment early and manage because they think, “They got this.” Some leave treatment because they can; that topic is covered in the family perspective section next.

The most significant determining factor of success at the action and maintenance stage is the reason for going to treatment. Relapse is highly likely if the person only enters treatment to address the symptoms, not the cause. Before anyone panics about the last comment, almost everyone who goes to treatment does so to address the symptoms. When the consequences are more significant than the benefits, there are no longer positive consequences to negative behaviors, and there are symptoms, so they get help. These consequences, or symptoms, are called external factors. Internal reasons are the cause of their addiction, mental health, and behavior, not external reasons. External factors are why people seek help and change. People with substance use and mental disorders often get this backward. The intended patient usually believes all will be well if they address the losses and symptoms. Rarely does the intended patient understand the situation is them and not the substances. 

“Families often state their loved one does not want help; this is false. Anyone using substances wants help; that is why they use substances. Substance use is an ineffective solution used to address internal problems and cause external issues.” 

The goal of a treatment center and the patient is to realize the internal reasons for being there: causes, not symptoms. People often go to treatment to recover their losses, not to learn why they did the things they did to lose the things they lost. If the patient is only going to treatment to rest up and get back things they lost and not address the causes, then they leave treatment and most likely resume substance use. When this occurs, they often lose what they regained and lose more on top of that. The pattern is what is frequently referred to as the vicious cycle.

“When people go to treatment for external reasons and do not address internal feelings while in treatment, it is common for the patient to drift back to contemplation when they start to feel better physically. It is why it is crucial for a family not to let their guard down when their loved one is in the action phase.” 

Preparing for an ineffective plan and acting on a plan riddled with shortcuts will not produce positive outcomes. The real world of these stages is not taught in textbooks. The textbooks make it sound like a simple process that the intended patient will quickly follow. It is never discussed how very few move effortlessly through the stages of change and why families need professional help. Rarely will an intended patient completely surrender at the contemplation stage, all but skip over preparation other than packing a bag and taking action by way of long-term treatment. Our professors, therapists, and those not on the front lines do not see the reality of the real world. People with substance use and mental disorders fight extremely hard to stay sick. Professors, therapists, psychiatrists, etc., believe that a person with a heroin addiction taking action and enrolling in a methadone clinic is a good thing and a successful action. The same people think that taking action and reducing the number of alcoholic beverages from two bottles of vodka a day to one and a half is progress; they don’t get it.  

“The intended patient is the least qualified person to make their preparations and take action on the ideas they have. Intervention and family education are required to help the intended patient move towards an effective plan that is not theirs.“

Family Perspective:

The action phase for families can be equally challenging. Families often take action on plans that may not be necessarily effective. It is amazing how many families call our office beaten down with nowhere to turn, only to call us back within a few days to tell us their loved one has turned a corner and/or our services are not needed at this time. It is not that their loved one turned a corner but that their loved one has instilled false hope in preparing for an action plan or convincing the family that their action plan will work. The false hope and other family members flooded in their dysfunctional family role, convincing you that the intervention is a bad idea or will never work, is why effective action is rarely taken or accomplished. As soon as a solution is on the table that requires families to change, anxiety and playing out roles overwhelm the family system, and it shuts itself down. 

“Neither a dysfunctional family member nor the intended patient should ever be able to convince others not to take action to better themselves and the situation. Those that do that are the real salesmen in all of this. The plan of action is not just about what the intended patient is willing to do; it is equally about what the family is willing to accept.”

An ineffective plan on your loved one’s part does not automatically permit you to accept the plan, especially if it is the same or a failed attempt in the past. Even if it is new and different, it may fail if it feels like a shortcut or doesn’t feel right. We strongly suggest that a family learn how to detach and let go of their loved one until they see sustained sobriety and behavior modification. That is what ultimately determines the effectiveness of the plan of action.

Families who take action behind the lenses of codependency and dysfunctional family roles take action just like their loved ones behind the lenses of substance use and mental disorders. Families must take directions from a professional. A professional’s greatest asset outside their education and experience is their unbiased viewpoint. Families who prepare for action and take action with the ideas of the intended patient or their flooded judgment often find themselves beaten down after several attempts to get their loved one’s help. Why is this? It is because family and patients have made decisions in a maladaptive mindset. 

“Driving across the country for a trip may sound like a great idea until you decide to take the journey without GPS.”

The most prominent mistake families can make at the action phase is letting their guard down. Just because your loved one is in treatment does not mean the nightmare is over. Families must stay the course of their recovery. Whether you did an intervention or your loved one went alone, do not believe you are out of the woods. One of the most significant ways family intervention services can help is by supporting your family after the intervention, whether your loved one accepts help or not. Family boundaries are equally crucial regarding where your loved one is in the stages of change and certainly not less so because they are in treatment. The maintenance phase we will get to next requires boundaries to be held, too.

The family perspective is quite interesting. There is the reaction of their loved one taking action, and then there is the family taking action, often similar to their loved one. In other words, all these stages are more of an illusion than factual. That comment is because most people believe their plan and their loved one’s action plan are reasonable. False hope is responsible for these stages of change being grand theories, with rarely the substance user or their family choosing productive paths. 

We are making a point that families and loved ones come up with more excuses not to address the problem and convince themselves this will never work; this would not happen with any other medical problem. Families and loved ones do this at every stage. Action is not action if it is an ineffective plan. Families often let their guard down when their loved ones get to the action phase, whether it is a good plan or not. Family of origin dysfunction, usually generational, is responsible for much of this. People hang on to their maladaptive behaviors and dysfunctional family roles as an identity. 

“The family roles do not define who you are, nor are they a diagnosis, so don’t hang on to them like they are. Nobody would hang onto anything that was making their problem worse or preventing it from improving.”

Addressing addiction and mental health should not be this hard. When we try to help you, you don’t like what you hear and call us a salesman because you’re uncomfortable. Families call professionals a “salesman” when they have run out of excuses or realize they cannot sell their ideas to the professional. The only people selling anything are your loved ones with a substance use or mental disorder and your other family members talking others out of helping to keep the family dysfunction going. Families and their loved ones are often far greater salespeople than us professionals. That is why most families repeatedly take little to no action or ineffective action. The family will keep believing in their loved one and themselves, or they will believe in the professionals.

“The true salesman is the family of origin dysfunction convincing families to stay in their role and their loved one with a substance use or mental disorder, selling families false hope, guilt, victim, and fear tactics so the family does not make any changes that would disrupt the negative behaviors producing positive consequences. The fear that is sold turns to anxiety, and people become paralyzed.” 

5. Maintenance (Growth) Stage

The maintenance stage, also known as aftercare, allows the patient or their family to continue making progress after the action phase. The maintenance stage should be called the growth stage because people do not get better with maintaining; they get better with continuous improvement and growth. Like the other stages, the maintenance stage has its challenges. As we mentioned in the action stage, the family must not let their guard down too soon, and the person with a substance use or mental disorder is not cured. Aftercare is not an afterthought; aftercare and the maintenance stage are discussed and planned before discharge from treatment. The suggested recovery methods from your loved ones’ clinical team and the family intervention team have a significant impact on the likelihood of a successful outcome for both patient and family. It is not nearly as challenging to stay abstinent from alcohol and drugs or med-compliant for mental disorders in treatment as it is when you leave. Nobody becomes sober in treatment, and they maintain sobriety when they leave. In other words, what helps people find sobriety is the work they do outside of treatment. People who relapse after treatment were not sober; they were abstinent, and there is a difference. When people leave treatment and do not follow aftercare suggestions, they do not relapse; they resume. The difference between abstinence vs. sobriety and relapse and resuming will be discussed in detail in the relapse stage in the next section. 

Individual Perspective:

As we mentioned in the action phase, people are almost always led to addiction and mental health treatment for external reasons. Once the patient can learn and understand the why, when, and how of the addiction or mental health problem, they can start to address the underlying problem. When the person with a substance use or mental disorder maintains the problem is everyone else’s fault, they are headed for failure. When the reality of the problem is discovered, the patient can carry momentum into their aftercare. The most compelling evidence-based treatment for substance use disorder is twelve-step facilitation. The most popular, most effective program in which all other twelve-step groups are built is Alcoholics Anonymous. Alcoholics Anonymous has many resources and is highly effective for any substance use disorder, not just alcohol. There are twelve-step groups for most process addictions, such as eating disorders, sex, gambling, etc. Most people state they hate twelve-step programs because they hate what it represents. Resistance to trying is a warning sign of not wanting to follow directions in the maintenance stage or a possible reservation to resume substance use; the relapse is always in the behaviors. We are not saying the twelve steps are the only way to sobriety, but they are the most effective way, so if someone were serious, why would they resist trying it out? Most negative experiences with twelve-step facilitation were at a time when the person was not sincerely ready to surrender and get well. When the person is sincere, they rarely speak ill of twelve-step facilitation. 

The greatest challenge for the individual at this phase is complacency. When substance users believe they have it all figured out and stop their aftercare in the maintenance phase, they are headed for heartache. Depending on how long they have been abstinent or if they have become sober determines how quickly they relapse. The more work the patient puts into their aftercare, the higher the likelihood of a successful outcome. The maintenance phase is for people with substance use and mental disorders to continue working towards changing behavior and perceptions while addressing traumas, beliefs, perceptions, thoughts, and experiences that lead to self-medication. The substance users’ families may not always know when the person is using alcohol or drugs, and they will always know when they are not. The same goes for mental health; the family may not always know when they are medication-compliant and in therapy, and they will always know when they are not. In the maintenance phase, providing the person is active in their recovery, they will start to see great results and happiness. There is no greater joy in our career than hearing from a family member to let us know that their loved one is still sober or has their mental disorders under control since the intervention. 

The most effective suggestion is for the patient to surrender through the stages, including the maintenance. Not everyone wants to continue programming. Very few people want to live elsewhere; most like to go home; this is not always a healthy or practical option. Professionals’ most significant challenge is helping patients understand that their ideas may not be the best, even at the maintenance stage. 

Family Perspective:

Like the substance use or mental disorder patient, the family often believes the problem is solved because treatment is completed. The family usually thinks it is okay for their loved one to return home directly from treatment. Returning home after treatment is on a case-by-case basis. Families should never let their guard down. Families have a long way to go in the maintenance stage, too. Although it is monumental getting to this stage, both you and your loved one are in early recovery. Leaving treatment is where the rubber meets the road. It is not uncommon for families to revert to codependency and enabling. Reverting to old behaviors by the family can hinder the 12-step and overall recovery process for their loved one. We understand the family and the loved one are eager to get home. Please know that they are abstinent and getting sober. You may now wonder if they will still love you; we empathize and understand more than you know. Families must stay on the course. 

“We have seen people get well whose families have not returned at all, and we have seen others slip when their families come back too soon.”

Alcoholics Anonymous, Working with others – Chapter 7, Page 100

The authors of Alcoholics Anonymous knew this in 1939, and we still know it today. Families and their loved ones will want to backslide to how things were for a while, just like the backslide in the early stages. In other words, the patient instinctively wants to drift back to their old behaviors, and the family wants to drift back to their dysfunctional family role; this happens unconsciously and involuntarily. That is why vigorous recovery immediately following treatment programs for patients and the family is a remarkable predictor of successful outcomes. It is also why it is a poor idea for anyone, primarily a clinician or therapist, to believe or state to a family or patient that the patient and family are the most qualified people to know what they need, what is best, and what will work. 

The spouse often wants their husband or wife home too soon for selfish reasons. The enabler is done with silence and wants to return to being the person’s caretaker or fulfill the purpose they had before. Other family roles get pulled, too. Self-awareness and family recovery are significant deterrents to this and are the foundation of our S.A.F.E.® Intervention and Family Recovery Coaching Program. 

When families go about this themselves or tell themselves they will do the intervention without a professional, they do not understand what an intervention is. The most comprehensive support and guidance a family needs is after the intervention, during their loved one’s treatment, and after treatment. An intervention is not someone talking to your loved one and inspiring them to go to treatment. Intervention is about families following through on their recovery while being supported during the turbulence of their loved one’s recovery. 

In the maintenance stage, the family’s goals are silence, peace, and happiness. We strongly suggest families seek out self-help groups such as Al-Anon and a sponsor, CoDA (codependency anonymous meetings), and ACOA (adult children of alcoholics and dysfunctional family meetings) and seek an individual therapist or marriage counselor in addition to our services. There are many helpful books families can read on addiction, enabling, and codependency too.

Regardless of whether or not a loved one gets well, the family can. Basing the family’s recovery in the maintenance stage on whether the patient stays on track will compromise the family’s growth. Determining family involvement and recovery on the loved one’s outcome will compromise your loved one’s outcome, too. It is essential for families not to let their guard down or allow themselves to revert to dysfunctional family roles and ineffective behaviors such as enabling and codependency.

“Families must stop taking their loved one’s temperature to see how the family feels.”

6. Relapse Stage (if applicable)

The Transtheoretical Model (TTM), or Stages of Change Model, sometimes includes the relapse stage. The relapse stage means the patient cycles back through the stages of change. Relapse does not have to happen and does not have to be part of the recovery process. Relapse occurs behaviorally and long before the patient starts consuming alcohol or drugs again. Relapses for the family happen when they overlook the behavioral warning signs of their loved one’s relapse behaviors, let their boundaries down, and stop their recovery program. Either way, family and patient will return to the beginning of how things once were when a relapse occurs. For some, it can be a slip; for most, it will be a complete reversion backward, and it will get worse than it was before. 

The definition of relapse means to return to a previous state. If the patient or their family never changed their behaviors, is that a relapse; no, the current state never changed, and that is called resume. Our point is that to relapse, you must have changed your previous behavior before returning to old behaviors. If the person only goes through the motions and does not address the behaviors that cause the symptoms and conditions, they resume. There is a significant difference between sobriety and abstinence. A substance user who goes to treatment and stays angry, continues to blame everyone else for their problems, claims to not know why they are there, continues to manipulate everyone and everything, does not sign a release of information (ROI), or leaves treatment against medical advice (AMA) does not relapse, they resume. Relapse is when someone has changed their behavior, has become sober, not abstinent or dry, and reverts to old behaviors later on. Relapse back to alcohol or drugs when a significant amount of sobriety was present does not happen in one day; it happens over time. Nobody slips on a banana peel and ends up drunk or high. The behaviors that lead someone back to active substance use happen long before the substance use. The same principles of relapse apply to someone with mental disorders. The behaviors change before the relapse.

Individual Perspective:

Relapse does not have to happen, and unfortunately, it can. The silver lining of a relapse is the patient can learn from their mistakes when they get back to recovery and sobriety. For the intended patient to become sober, they must address the reasons why they used alcohol or drugs. For those with mental disorders and substance use disorders, it would be beneficial to work with professionals to address thoughts, feelings, experiences, etc. Many people with a substance use disorder may be self-medicating mental disorders, and many substance use disorder clients may not have mental disorders and are showing mental disorder symptoms due to substance or medication-induced psychosis. There are plenty of instances where medication worsens the symptoms of mental disorders. There are even more instances where mental disorders are misdiagnosed in patients with a substance use disorder. 

 The point is that the relapse lies in behavior, not the diagnosis. Whatever the problem is, the problem must be addressed. In the book of Alcoholics Anonymous, it uses the word, suddenly. It refers to a feeling of drinking that suddenly comes out of nowhere. That does not happen suddenly; it happens gradually. Gradually, the patient reverts to old behaviors and beliefs, and suddenly, they find themselves with little to no defense against the next drink or drug. In our experience, when working with patients who relapse, we can work together to find when, where, how, and why the behaviors shifted. The longer someone is sober, the longer their behavioral relapse lasts before resuming substance use. Another factor is the significance of behavior change. The worse the behavior, the quicker the road back to resuming substance use. Relapse behaviors often start as subtle or small and intensify over time.

Addiction and mental health Recovery is a lifetime of change. The negative behaviors that lead someone to use drugs and alcohol are not an afforded luxury like someone who does not have a substance use disorder. Many people can walk through life angry and resentful and not end up destroying their lives with alcohol or drugs. They will most likely not be happy and may ruin their life another way, and not with drugs and alcohol. Even though the substance user must address the behaviors, there is still something different about them. Someone with a substance use disorder cannot stop themselves from starting, and once they start, they cannot stop. That is until they are in recovery and address the cause of the behavior that leads to substance use. The biggest mistake a substance user can make is believing that they can return to controlled alcohol or drug consumption after a period of long-term abstinence or sobriety. One of the first behavioral changes is the feeling or statement of “I got this.” Once the person with a substance use disorder believes “they got this” and stops their maintenance step and aftercare, they are on their way back to relapse. 

Family Perspective:

How a family handles a relapse by their loved one has a lot to do with the family’s recovery. A family should allow their loved one to navigate their relapse on their own and not intervene with old behaviors. Running to your loved one to help save them is what you did before. Going back to enabling and unhealthy family roles puts you and the others right back to where you started. The TTM model of change states that relapse is cycling back through the stages of change. When a loved one relapses, the family does not have to. Similarly, a relapse by the family does not have to mean a relapse by the patient. 

Abstinence applies to families, too, in the same context anyway. If a family never changes their behavior, it will stay the same. When your loved one stays the same, they resume substances after treatment. The family just never changes, period. There is a strong correlation between sobriety for the loved one with a substance use disorder and family recovery. A healthy family in recovery is a strong predictor of outcomes for the loved one needing addiction and mental health help. The best thing a family can give themselves is closure; they do all they can to help themselves and their loved ones in a healthy, productive way. Anything beyond that keeps the family in an illusion of control over themselves and their loved ones. Both family members and loved ones with addiction or mental health concerns must individually clean their sides of the street. Neither the intended patient nor the family can control the other’s recovery. Much of what both sides do can and will influence recovery in tandem, whether negative or positive. Families and the substance user must stop trying to control the lives of the other. When you realize that and stop doing that, recovery is possible. 

Interventions Can Help Move Families and Their Loved Ones Through the Stages of Change

The stages of change are a guide, not an absolute, as to how things will go. They do not factor in the substance use or mental disorder patients’ impaired thoughts and perceptions, nor do they factor in the families’ dysfunctional roles. The textbooks make it sound like the intended patient will come to a moment of clarity, prepare for treatment, and take a successful route toward treatment. Nowhere in the stages of change does it discuss families interfering with the stages. The volatility of the situation is so significant that these stages can’t be applied easily. The intended patient wants to do as little as possible and take as long as possible, and the family encourages it by enabling and believing in their loved one’s false hope. Anyone reading this who has watched their loved one go in and out of treatment or struggle with addiction and mental health over the years understands. There are too many moving parts that can affect the stages.

The best thing a family can do is address their volatility, anxiety, and fears and allow their loved one to navigate their problem without your counterproductive help. The family can and will compromise the growth of the loved one, moving through the stages of change with enabling codependency, fears, anxiety, and unhealthy family roles. Anytime anyone or anything gets in the way of the intended patient seeing the need for change, it stops the forward progress. Inaction does the same thing. Families who brag that they don’t do anything to help their loved ones are equally interfering with the stages of change. There is a way to do this professionally that increases the likelihood of a successful outcome for both family and their loved one with a substance use or mental disorder. The way is not doing things your way without a professional. Families do not see this until they realize the anxiety needs to stop and their role needs to change, too. The best gift you can give your loved one is not helping them stay where and how they are—much of what the family does and can influence change at some point. Our S.A.F.E.® (Self-Awareness Family Education®) Intervention & Family Recovery Coaching addresses these moving parts. Other interventionists do a great job of talking their loved ones into treatment. Many claim to have family recovery services now because they have to. Very few interventionists have credentials or can help a family more deeply. Most can only state the obvious and regurgitate other people’s information. When a family would like to learn more about how to change the situation and move it in the right direction, we are here to help and guide you in the right direction.