How many of you have seen this before? It’s a pretty commonly used model of recovery.
(Adapted from Prochaska and DiClemente, 1982)
The first psychologist I saw as a teenager used this in a group she ran. The group was for adolescents who self harmed, and she had become increasingly frustrated with me for being honest about the fact that, at the time, I didn’t want to or think I could stop. She had been trying to teach us DBT techniques and the group didn’t really seem to be gelling or responding. After I had been very straightforward with her for the second week in a row in my private session with her, on the third week she brought in a copy of this diagram, and asked us all where we thought we were on it. It turned out that I was the only member of the group even contemplating stopping, so I was vindicated! After that things improved a lot, and she stopped threatening to chuck me out 😛 we did some work on self esteem, art therapy, expressing emotions and other coping mechanisms, but it wasn’t taken for granted that all or any of us were ready to really commit.
The model is fairly simple, and is relevant to most mental health problems involving self destructive behaviours – substance abuse, eating disorders, self harm, etc. Precontemplation means that you have no intention of trying to change. Contemplation means that you are thinking about it, but not actually doing it. The third stage is called by several names, but essentially consists of making the decision to try and cease whatever the behaviour is, and mentally/physically preparing yourself. The next stage is action, which is fairly self explanatory. Maintenance means that you are behaviour free and working to keep yourself that way. Maintenance does not always end in relapse, but relapse is a natural part of recovery for many (most?) people. Lapses are temporary returns to behaviours and relapses are returns to full behaviours. If I apply this to myself with my eating disorder I can easily pick out the stages I went through. When I was in York I wasn’t even considering the idea of recovery (1). I toyed with the idea when I decided I had to come home, but didn’t make any real changes (2). At the start of March 09 I made the decision to start gaining weight (3), but I was very timid about it and didn’t actually make all the necessary changes until the end of March (4). Currently I am in stage 5, maintenance, but I have had occasional minor lapses during periods of intense stress or after stomach bugs. I’ve not relapsed or gone back into precontemplation though, I have always bounced back very quickly. When I was a teenager I zoomed through this cycle several times a year, going from being relatively behaviour free to relapsing and not wanting to do a damn thing about it in the space or a week or so.
I can apply this to my self harming as well, albeit more reluctantly because I feel like I’m admitting to something terribly shameful. I am not sure whether I would class my current difficulties as a lapse or relapse. It’s been less than a week so far and I’ve not landed myself in A+E, so lets go for lapse. At the weekend I was definitely back to precontemplation, but having told my boyfriend, my blog readers and started writing about this model, I have pushed myself into contemplation. Contemplation means you are not ignoring the issue, but neither are you acting to change.
The next question is how to move from contemplation to making the decision to change and preparing yourself for action. Sometimes it really feels as if a relapse has to burn itself out before you can move on, but cutting it short prematurely is the preferable option, as relapses into any self destructive behaviour can be very damaging, even short term. When I started contemplating recovery from anorexia I made pros and cons lists, thought about the function of my behaviours, tried to find alternatives for those functions, and talked to other people to hold myself accountable for my actions. I kept my mum informed of how I was feeling and I kept a weight chart in the kitchen of my house, so my entire family could see how I was doing. I know most anorexics would be horrified at that prospect, but I wanted to give the disorder as little wiggle room as possible. I could have lied about my weight, but I’m an almost pathologically honest person – I can’t lie to save my life, and I don’t see the point because I’m an adult and no one can actually force me to do something I don’t want to do.
(This paragraph is a bit graphic, so here’s a trigger warning for you.) With self harming this is a little more difficult. Pros and cons I can do. Pros – it makes me feel better. Cons – everything else. The problem is that the negative aspects of the cleaning up, the shame, the pain the next day, the annoyance of having permanently bloodstained sleeves, the feeling of failure, the fear that I will never get my shit together, and etc – those are all very rational things, and they require me to be thinking rationally. In fact, some of those cons make me more likely to harm myself, as shame and anxiety are pretty big triggers. Most of the time when I have urges to hurt myself (or use ED behaviours), I can keep my head and reason through it. But once I’ve gotten back into the behaviours, all reason disappears. Trying to remember why I’m not supposed to be cutting is like trying to get a good firm grip on a cloud. The desperation to get rid of the anxiety and urges overrules everything.
It was different with my anorexia because that was characterised more by meticulous plans and a slow and steady decline. With restriction being my main ED behaviour I have much more time to catch myself at it and stop it – it’s not like bingeing or self harm, where months of abstinence can be very violently undone in half an hour. There also seem to be much better reasons for stopping ED behaviours than SI behaviours, because the ED is more immediately damaging to my health. I know very well that if I randomly decided to lose 5lbs I probably wouldn’t stop until I landed myself in hospital, and my relationship with my boyfriend would disintegrate, as well as my slightly shaky hold on independent living. But I am already covered in scars, there is no aesthetic reason to stop, and although I have ended up with stitches more times than I can count I never hurt myself so badly that I couldn’t stop the bleeding (even if it took quite a while sometimes) or gone through a tendon. This is a stupid justification because anyone who can cut herself several hundred times in a couple of hours or have to have dozens of stitches in one go clearly cannot control the amount of damage she does to herself – but knowing that intellectually doesn’t seem to knock it into my head that this is not something I can just be careful about.
With my eating disorder, I fought the difficulty of remembering my reasons for recovery by writing out my recovery revision cards (nerd that I am!), and carrying them around with me everywhere. I literally studied them every morning, evening and anywhen in between that I felt anxious and unable to carry on. I still have them in my bag, half from habit and half because they are still occasionally helpful. I guess I can do that again for self harm, and keep them on my desk. But then there’s still the problem of finding a compelling reason to stop. This has never destroyed my life like the anorexia did. It’s not pretty, but I’m already used to being scarred.
Contemplation, people. It’s better than precontemplation, but I’m stuck there for today.