This paper is generally adapted from material from the Cancer Prevention Research Center – A research organization dedicated to helping people change their behavior for living longer, healthier lives. It was developed as a discussion paper for an Intermediate Unit to determine the efficacy of developing a substance abused program for middle and high school students apprehended using illegal substances.
The forms associated with this material are packaged into a single archive file available for download. The actual questionnaires are in a single Microsoft Word document. The archive package includes the following documents:
- Decisional Balance – Alcohol & Drug Use
- Alcohol Temptations
- Alcohol: Self-Efficacy
- Alcohol: Stages of Change (Short Form)
- Alcohol: Processes of Change
- University of Rhode Island Change Assessment – URICA (Long Form)
Drug policy in the United States is one of general prohibition in a criminal justice framework. Although the federal government did not regulate drug use until passage of the Harrison Act in 1914, abstinence and prohibition of most substance use has characterized drug policy for most of this century. Although alcohol remains legal for those over age 21, there are similar ‘zero-tolerance’ mandates for under-age drinking. The Drug-Free Schools and Communities Act Amendment of 1989 (P.L. 101-226) requires all elementary and secondary schools and colleges to implement and enforce abstinence-based policies related to substance use by students (U.S. Department of Education, 1999). The Anti-Drug Abuse Act of 1988 (P.L. 100-690) mandates abstinence-based drug policy. Current drug policy is based on section 6201 of this act, which established the goal of a drug-free America and provided congressional requirements to reduce drug abuse and its consequences. This policy states that all nonmedical drug use is illegal, there are fines and imprisonment for substance abuse, and help is only extended to those who have a desire to abstain from all use . Although prohibition has been the dominant drug policy for most of this century, the significant rise in the number of people serving time for drug-related offenses, (more than 1,000 percent between 1980 and 1997), did not begin until 1980 (Bureau of Justice Statistics, 1998).
The Anti-Drug Abuse Act of 1988, which instituted mandatory minimum sentencing, requires that proposals to combat sale and use of illicit drugs by legalization be rejected; and that consideration be given only to proposals to attack directly the supply of and demand for illicit drugs. The second clause often underlies arguments of proponents of abstinence-only programs. Barry McCafferty, director of the Office of the National Drug Control Policy, reported that “at best, harm reduction is a halfway measure, a half-hearted approach that would accept defeat. Increasing help is better than decreasing harm. Pretending that harmful activity will be reduced if we condone it under the law is foolhardy and irresponsible” (McCafferty, 2000).
Implicitly or explicitly, the goal of most substance abuse services is the elimination of nonmedical substance use. While this goal is one that we would all strive to achieve, its philosophical construct stands in the way of actual achievement. This is so, because it inhibits a process of motivational enhancement that might enable ‘hard core’ users to remain in counseling and to begin to contemplate quitting.
A national study of substance abuse treatment centers found that 99 percent reported an abstinence orientation to treatment. In addition, 93 percent of all drug and alcohol treatment centers in the United States(Roman & Blum, 1997). The 12-step model is consistent with current drug policy because it requires a commitment to abstinence on behalf of service users and often relies heavily on confrontation of service users (Miller et al., 1995). The 12-step model also continues the perspective that drug and alcohol use is a disease, rather than a learned behavior. These two perspectives, the requirement for abstinence and the disease model, along with the criminalization of such use, have directly contributed to the rise of a drug culture in the United States and the failure to be able to relieve future generations of this social problem.
Abstinence is not a practical approach for all substance users. The literature on abstinence based substance abuse treatment suggests that most service users do not abstain and often do not complete programs. Research also suggests that substance users are more likely to use ‘low threshold’ programs where admissions criteria are relaxed, few initial demands are made on service users, and punitive sanctions are not placed on continued substance use.
Of particular importance to the present discussion, the abstinence orientation views individuals who are not immediately interested in complete abstinence as resistant or unservable. The failure to provide services to substance users who do not have an interest in abstinence is at least in part related to the concept of enabling, which posits that family members and friends often allow or facilitate substance use. In the enabling concept, any intervention or program that stops short of requiring abstinence is not likely to be effective and may facilitate or enable substance use. the key construct is, of course, requiring, as opposed to encouraging. The reduction of harm approach and the abstinence approach are not mutually exclusive until the requirement for abstinence is supported by suspension, expulsion, or incarceration. The result is a mutually exclusive choice between abstinence-oriented interventions and all other services.
James Prochaska and Carlo DiClemente (1982) developed a model of change that is unique in many ways. First, it is empirically driven. In other words it is based on the researchers’ scientific investigation of change in humans. Second, the model conceptualizes change as entailing a number of stages which all require alterations in attitude in order to progress. Third, the model depicts change as a cycle – as opposed to an all or nothing step. The authors contend that it is quite normal for people to require several trips through the stages to make lasting change. So in this sense relapse is viewed as a normal part of the change process, as opposed to a complete failure. This does not mean that relapse is desirable or even invariably expected. It simply means that change is difficult, and it is unreasonable to expect everyone to be able to modify a habit perfectly with out any slips.
Harm Reduction Perspective
Harm reduction is a conceptual framework that provides for individuals willing to be engaged in services, but not immediately seeking abstinence. Based on a public health model of social problems, harm reduction seeks to eliminate the negative consequences of phenomena for the members of a society without necessarily eliminating the phenomena. Primarily viewed as a policy framework, it is not synonymous with legalization and is, in fact, not mutually exclusive from abstinence. Practitioners using this perspective develop interventions that reduce drug-related harm without necessarily promoting abstinence as the only solution. This is empowering to the clients and often allows them to consider other options, even abstinence. Harm reduction can be conceived as a motivational tool to enable abusers to stay in counseling and stay with self-reflective examination of their own situation in relationship to abuse.
Substance use has and will be as major part of our world, at least until we find ways to effectively rehabilitate the using population. Accepting this reality leads to a primary focus on reducing drug-related harm rather than reducing drug use as the linkage to the most vulnerable, thus using their own strength of will – in a fashion of judo – to move them to where we would ultimately like them to go. Abstinence from substances is clearly effective at reducing substance-related harm, but it is only one of many possible objectives of services for substance users. Substance use inherently causes harm; however, many of the most harmful consequences of substance use (HIV/AIDS, hepatitis C, overdoses, automobile accidents, and so forth) can be dramatically reduced without complete abstinence. The question that is usually raised is whether reduction of harm may encourage continued use, but that is not the reality of the involvement. As users are able to make certain improvements in their lives, they tend to want more. And because the philosophy allows for continued contact with trusted counselors, the continued contemplation of change can continue to occur.
Ultimately services to substance abusers must be relevant and user friendly if they are to be effective in helping people minimize their substance-related harm. Substance use must be understood from a broad perspective and not solely as an individual act; accepting this idea moves interventions from coercion and criminal justice solutions to a public health or social work perspective.
Harm reduction was originally suggested in the 1920s in the United Kingdom as part of the Rolleston Committee’s recommendations regarding drug policy and later emerged as a pragmatic response to a rise in hepatitis C rates related to injection drug use in the early 1980s. Harm reduction plus motivation enhancement plus cognitive skill acquisition is the most likely path to total abstinence. This is because the path to behavioral change is through specific stages. The author has examined and compared four theories of change and believes that the Transtheoretical Model presents the best possible solution to the abuse of drugs and alcohol in student populations.
Prochaska and DiClemente’s stages-of-change model is currently a widespread conceptual framework for understanding the process of addiction recovery and has greatly influenced clinical practice, program development, and research in the field of addiction over the past decade. The model outlines five stages of addiction: denial of a problem with addiction, a state of ambivalence about changing the problem, a period of exploring possibilities for dealing with addiction and developing a plan, enactment of the plan (the first stage involving behavioral change), and the behavioral practice of long-term recovery from addiction. This model as described in greater detail below will provide the framework for the development of the Solutions service and will ultimately be referred to as the Solutions Model of Motivation and Change – of simply, the Solutions Model.
The Solutions Model is a model of intentional change. It is a model that focuses on the decision making of the individual client. Other approaches to health promotion have focused primarily on social influences on behavior or on biological influences on behavior. For smoking, an example of social influences would be peer influence models or policy changes. An example of biological influences would be nicotine regulation models and replacement therapy. Within the context of the Solutions Model, these are viewed as external influences, impacting through the individual.
The model involves emotions, cognitions, and behavior. This includes a reliance on self-report. In smoking cessation, for example, self-report has been demonstrated to be very accurate. Accurate measurement requires a series of unambiguous items that the individual can respond to accurately with little opportunity for distortion. Measurement issues are very important and one of the critical steps for the application of the model involves the development of short, reliable, and valid measures of the key constructs.
This section will discuss applications of the Solutions Model. The model has previously been applied to a wide variety of problem behaviors. These include substance abuse, smoking cessation, exercise, low fat diet, radon testing, alcohol abuse, weight control, condom use for HIV protection, organizational change, use of sunscreens to prevent skin cancer, drug abuse, medical compliance, mammography screening, and stress management. Two of these applications will be described in detail, smoking cessation and stress management. The former represents a well-researched area where multiple tests of the model are available and effective interventions based on the model have been developed and evaluated in multiple clinical trials. The latter represents a problem area where research based on the Transtheoretical Model is in the formative stages.
Stages of Change: The Temporal Dimension
The stage concept is the key-organizing construct of the model. It is important in part because it represents a temporal dimension. Change implies phenomena occurring over time. However, this aspect has largely been ignored by alternative theories of change. Behavior change is often construed as an event, such as quitting smoking, drinking, or over-eating. The Solutions Model construes change as a process involving progress through a series of five stages.
Pre-contemplation is the stage in which people are not intending to take action in the foreseeable future, usually measured as the next six months. People may be in this stage because they are uninformed or under-informed about the consequences of their behavior. Typically other people are quite aware of the problems and may even voice their concern. In this stage, however, people with strong addictive behavior problems are almost deaf to their voiced distress. It would be easy to call this ‘denial’, but much more accurate would be to describe Pre-contemplation as a state when a person is ‘uninformed’ in the sense that no personally convincing reason for change has been presented as of yet.
Or they may have tried to change a number of times and become demoralized about their ability to change. Both groups tend to avoid reading, talking or thinking about their high-risk behaviors. They are often characterized in other theories as resistant or unmotivated or as not ready for health promotion programs. The fact is traditional health promotion programs are often not designed for such individuals and are not matched to their needs. In substance abuse, people in this stage are either hard-core and resistant or are learned helpless. The role of the counselor is brief and with limited focus on reduction of harm. The Motivational Interview is the option of choice for intervention, since it empowers the client to focus on contemplation, but makes no demands for action.
Contemplation is the stage in which people are intending to change in the next six months. They are more aware of the pros of changing but are also acutely aware of the cons. What frequently jars people into the next stage, that of contemplating the possibility of change, is convincing, personal and timely information – not coercion or even advice. People not yet contemplating change are not particularly open to advice, much less confrontation. However, learning more about what is problematic for the individual specifically, being afforded data which is very relevant and convincing, very often forces the person to at least consider the option of modifying his/her behavior.
This may seem doubtful, in that the individual has probably received loads of information about this habit – why it is hazardous to your health, family and so on. Yet none of this information seems to have made any difference. The habit endures. It is important to understand that what makes the difference is not generic information, but rather information specifically catered to the individual. The most powerful information is that which is intimately tied to your own addictive behavior, runs contrary to established expectancies and has intimate ramifications for some or many aspects of your life.
This information might come to a smoker in the form of a comment by his 5-year old that she does not want him to die if lung cancer, “Please stop smoking, daddy. I don’t want you to die”. The information provided to these people is important, individualized data from which the individual is unable to distance themselves.
Often times we are afforded information by chance which serves to increase the desirability of change. It is very important not to miss out on the opportunity to use this information to shift gears. It is very easy to miss out on a brief window of opportunity, a moment in which the client is saying to him/herself, “I’ve had it! No more of this! I’m doing something about this right now!” People are very vulnerable to old influences at this time, both external pressures and convincing data from within. It is imperative to tip the scale of ambivalence in order to move from contemplation to determination and action.
The balance between the costs and benefits of changing can produce profound ambivalence that can keep people stuck in this stage for long periods of time. We often characterize this phenomenon as chronic contemplation or behavioral procrastination. These people are also not ready for traditional action oriented programs. These people, may, however, be able to tolerate a brief motivational enhancement counseling or solutions focused counseling regimen of from four to twelve sessions.
Preparation is the stage in which people are intending to take action in the immediate future, usually measured as the next month. Many people have fleeting moments of determination that swiftly vanish when all of the horrors involved come back into awareness. Determination will lead directly into action if the individual has thoroughly considered all aspects of the addictive problem realistically, if s/he has begun to modify expectancies and have established a goal what is conducive to your individual needs and values. Such people have typically taken some significant action in the past year. These individuals have a plan of action, such as joining a health education class, consulting a counselor, talking to their physician, buying a self-help book or relying on a self-change approach. These are the people that should be recruited for action-oriented smoking cessation, weight loss, or exercise programs. This is where a counselor can be extremely helpful in identifying new strategies to achieve the change that the person already is seeking.
Moderation is a legitimate outcome? Many would consider anything short of total abstinence as a goal for a heavy drinker to be a failure. “The person was a heavy drinker, now they are a moderate drinker. They are still drinking, which is unhealthy” – cutting down the amount of alcohol consumed is a tremendous success. It would certainly be nice if everyone engaged only in behaviors that were completely healthy. But in the real world, very few behaviors meet this criterion. Furthermore, goodness and badness occur along a vast continuum and are subject to individual interpretation. Any movement toward better health, no matter how small by outside standards, is a success, whether this movement is part of a larger plan or an ultimate goal in and of itself.
Action is the stage in which people have made specific overt modifications in their life-styles within the past six months. Since action is observable, behavior change often has been equated with action. But in the Solutions Model, Action is only one of five stages. Not all modifications of behavior count as action in this model. People must attain a criterion that scientists and professionals agree is sufficient to reduce risks for disease. In smoking, for example, the field used to count reduction in the number of cigarettes as action, or switching to low tar and nicotine cigarettes. Now the consensus is clear–only total abstinence counts. In the diet area, there is some consensus that less than 30% of calories should be consumed from fat. The Action stage is also the stage where vigilance against relapse is critical.
While we are not aware of any specific standard for reduction points in substance abuse, these may be individually identifiable through solutions focused counseling and/or some of the cognitive behavior management strategies.
Maintenance is the stage in which people are working to prevent relapse but they do not apply change processes as frequently as do people in action. They are less tempted to relapse and increasingly more confident that they can continue their change. The cognitive behavior management strategies can continue to be developed and a fifteen-minute ‘check’ once a month fading into once a quarter then once a year, allows for a booster to morale and additional resources, if necessary.
Two different concepts are employed in the temporal dimension of change. Before the target behavior change occurs, the temporal dimension is conceptualized in terms of behavioral intention. After the behavior change has occurred, the temporal dimension is conceptualized in terms of duration of behavior.
Regression occurs when individuals revert to an earlier stage of change. Relapse is one form of regression, involving regression from Action or Maintenance to an earlier stage. However, people can regress from any stage to an earlier stage. The bad news is that relapse tends to be the rule when action is taken for most health behavior problems. The good news is that for smoking and exercise only about 15% of people regress all the way to the Pre-contemplation stage. The vast majority regress to Contemplating or Preparation. Helping the client to understand the biological, psychological and social factors [e.g., immediate gratification, habituation, creative construction of reality, state learned bias, the attraction to that which is prohibited, and reactance] that pertain in addressing addictive behavior can be helpful to them in negotiating potential regressive behavior (See CBT#13 – Addiction & The Cognitive Path).
In a 1995 study, it was demonstrated that the distribution of smokers across the first three Stages of Change was almost identical across three large representative samples. Approximately 40% of the smokers were in the Pre-contemplation stage, 40% were in the Contemplation stage, and 20% were in the Preparation stage. Professionals might make the assumption that a similar pattern will occur in the referral cohort. However, while the stage distributions for smoking cessation have now been established in multiple samples, the stage distributions for substance abuse behaviors are not as well known.
Intermediate/Dependent Measures: Determining when Change Occurs
The Solutions Model also involves a series of intermediate/outcome measures. Typical theories of change involve only a single univariate outcome measure of success, often discrete. Point prevalence smoking cessation is an example from smoking cessation research. Such measures have low power, i.e., a limited ability to detect change. They are also not sensitive to change over all the possible stage transitions. For example, point prevalence for smoking cessation would be unable to detect an individual who progresses from Pre-contemplation to Contemplation or from Contemplation to Preparation or from Action to Maintenance. In contrast, the Solutions Model proposes a set of constructs that form a multivariate outcome space and includes measures that are sensitive to progress through all stages. These constructs include the Pros and Cons from the Decisional Balance Scale, Self-efficacy or Temptation, and the target behavior.
Performance Outcome Measures
Decisional Balance. The Decisional Balance construct reflects the individual’s relative weighing of the pros and cons of changing. It is derived from the Janis and Mann’s model of decision-making that included four categories of pros (1. instrumental gains for self and others and 2. approval for self and others). The four categories of cons were 3. instrumental costs to self and others and 4. disapproval from self and others. However, an empirical test of the model resulted in a much simpler structure. Only two factors, the Pros and Cons, were found. In a long series of studies, this much simpler structure has always been found.
The Decisional Balance scale involves weighting the importance of the Pros and Cons. A predictable pattern has been observed of how the Pros and Cons relate to the stages of change and this appears to differ for reduction of distressing behaviors and the acquisition of healthy behaviors. In Pre-contemplation, the Pros of smoking far outweigh the Cons of smoking in the beliefs of the client. In Contemplation, these two scales are more equal. In the advanced stages, the Cons outweigh the Pros. A different pattern has been observed for the acquisition of healthy behaviors. The patterns are similar across the first three stages. However, for the last two stages, the Pros of exercising remain high. This probably reflects the fact that maintaining a program of regular exercise requires a continual series of decisions while smoking eventually becomes irrelevant. These two scales capture some of the cognitive changes that are required for progress in the early stages of change.
Self-efficacy/Temptations. The Self-efficacy construct represents the situation specific confidence that people have that they can cope with high-risk situations without relapsing to their unhealthy or high-risk habit. This construct was adapted from Bandura’s self-efficacy theory. This construct is represented either by a Temptation measure or a Self-efficacy construct.
The Situational Temptation Measure. This reflects the intensity of urges to engage in a specific behavior when in the midst of difficult situations. It is, in effect, the converse of self-efficacy and the same set of items can be used to measure both, using different self-report response formats. The Situational Self-efficacy Measure reflects the confidence of the individual not to engage in a specific behavior across a series of difficult situations.
Both the Self-efficacy and Temptation measures have the same structure. In research it is typical to find three factors reflecting the most common types of tempting situations: negative affect or emotional distress, positive social situations, and craving. The Temptation/Self-efficacy measures are particularly sensitive to the changes that are involved in progress in the later stages and are good predictors of relapse.
Self-efficacy can be represented by a monotonically increasing function across the five stages. Temptation is represented by a monotonically decreasing function across the five stages. Figure 4 illustrates the relation between stage and these two constructs.
Independent Measures: How Change Occurs
Processes of Change are the covert and overt activities that people use to progress through the stages. Processes of change provide important guides for intervention programs, since the processes are the independent variables that people need to apply, or be engaged in, to move from stage to stage. Ten processes have received the most empirical support in research to date. The first five are classified as Experiential Processes and are used primarily for the early stage transitions. The last five are labeled Behavioral Processes and are used primarily for later stage transitions.
A. PROCESSES OF CHANGE: EXPERIENTIAL
1. Consciousness Raising [Increasing awareness]
I recall information people had given me on how to stop smoking
Consciousness Raising involves increased awareness about the causes, consequences and cures for a particular problem behavior. Interventions that can increase awareness include feedback, education, confrontation, interpretation, bibliotherapy and media campaigns.
2. Dramatic Relief [Emotional arousal]
I react emotionally to warnings about smoking cigarettes
Dramatic Relief initially produces increased emotional experiences followed by reduced affect if appropriate action can be taken. Psychodrama, role-playing, grieving, personal testimonies and media campaigns are examples of techniques that can move people emotionally.
3. Environmental Reevaluation [Social reappraisal]
I consider the view that smoking can be harmful to the environment
Environmental Reevaluation combines both affective and cognitive assessments of how the presence or absence of a personal habit affects one’s social environment such as the effect of smoking on others. It can also include the awareness that one can serve as a positive or negative role model for others. Empathy training, documentaries, and family interventions can lead to such re-assessments.
4. Social Liberation [Environmental opportunities]
I find society changing in ways that make it easier for the nonsmoker
Social Liberation requires an increase in social opportunities or alternatives especially for people who are relatively deprived or oppressed. Advocacy, empowerment procedures, and appropriate policies can produce increased opportunities for minority health promotion, gay health promotion, and health promotion for impoverished people. These same procedures can also be used to help all people change such as smoke-free zones, salad bars in school lunches, and easy access to condoms and other contraceptives.
5. Self Reevaluation [Self reappraisal]
My dependency on cigarettes makes me feel disappointed in myself
Self-reevaluation combines both cognitive and affective assessments of one’s self-image with and without a particular unhealthy habit, such as one’s image as a couch potato or an active person. Value clarification, healthy role models, and imagery are techniques that can move people evaluatively.
B. PROCESSES OF CHANGE: BEHAVIORAL
6. Stimulus Control [Re-engineering]
I remove things from my home that remind me of smoking
Stimulus Control removes cues for unhealthy habits and adds prompts for healthier alternatives. Avoidance, environmental re-engineering, and self-help groups can provide stimuli that support change and reduce risks for relapse. Planning parking lots with a two-minute walk to the office and putting art displays in stairwells are examples of reengineering that can encourage more exercise.
7. Helping Relationship [Supporting]
I have someone who listens when I need to talk about my smoking
Helping Relationships combine caring, trust, openness and acceptance as well as support for the healthy behavior change. Rapport building, a therapeutic alliance, counselor calls and buddy systems can be sources of social support.
8. Counter Conditioning [Substituting]
I find that doing other things with my hands is a good substitute for smoking
Counter Conditioning requires the learning of healthier behaviors that can substitute for problem behaviors. Relaxation can counter stress; assertion can counter peer pressure; nicotine replacement can substitute for cigarettes, and fat free foods can be safer substitutes.
9. Reinforcement Management [Rewarding]
I reward myself when I don’t smoke
Reinforcement Management provides consequences for taking steps in a particular direction. While reinforcement management can include the use of punishments, we found that self-changers rely on rewards much more than punishments. So reinforcements are emphasized, since a philosophy of the stage model is to work in harmony with how people change naturally. Contingency contracts, overt and covert reinforcements, positive self-statements and group recognition are procedures for increasing reinforcement and the probability that healthier responses will be repeated.
10. Self Liberation [Committing]
I make commitments not to smoke
Self-liberation is both the belief that one can change and the commitment and recommitment to act on that belief. New Year’s resolutions, public testimonies, and multiple rather than single choices can enhance self-liberation or what the public calls willpower. Motivation research indicates that people with two choices have greater commitment than people with one choice; those with three choices have even greater commitment; four choices does not further enhance will power. So with smokers, for example, three excellent action choices they can be given are cold turkey, nicotine fading and nicotine replacement.
For smoking cessation, each of the processes is related to the stages of change by a curvilinear function. Process use is at a minimum in Pre-contemplation, increases over the middle stages, and then declines over the last stages. The processes differ in the stage where use reaches a peak. Typically, the experiential processes reach peak use early and the behavioral processes reach peak use late.
The Solutions Model has general implications for all aspects of intervention development and implementation. We will briefly describe how it impacts on five areas: 1) recruitment, 2) retention, 3) progress, 4) process, and 5) outcome.
The Solutions Model is an appropriate model for the recruitment of an entire population. Traditional interventions often assume that individuals are ready for an immediate and permanent behavior change. The recruitment strategies reflect that assumption and, as a result, only a very small proportion of the population participates in the offered services. In contrast, the Solutions Model makes no assumption about how ready an individual is to change. It recognizes that different individuals will be in different stages and that appropriate interventions must be developed for everyone. As a result, very high participation rates can be achieved as each client receives help on whatever level they need help.
The Solutions Model can result in high retention rates. Traditional interventions often have very high dropout rates. Participants find that there is a mismatch between their needs and readiness and the intervention program. Since the program is not fitting their needs, they quickly dropout. In contrast, the Solutions Model is designed to develop interventions that are matched to the specific needs of the individual. Since the interventions are individualized to their needs, people much less frequently drop out because of inappropriate demand characteristics.
The Solutions Model can provide sensitive measures of progress. Action oriented programs typically use a single, often discrete, measure of outcome. Any progress that does not reach criterion is not recognized. This is particularly a problem in the early stages where progress typically does not involve easily observed changes in overt patterns of behavior. In contrast, the Solutions Model includes a set of outcome measures that are sensitive to a full range of cognitive, emotional, and behavioral changes and recognize and reinforce smaller steps than traditional action-oriented approaches.
The Solutions Model can facilitate an analysis of the mediational mechanisms. Interventions are likely to be differentially effective. Given the multiple constructs and clearly defined relationships, the model can facilitate a process analysis and guide the modification and improvement of the intervention. For example, an analysis of the patterns of transition from one stage to another can determine if the intervention was more successful with individuals in one stage and not with individuals in another stage. Likewise, an analysis of process use can determine if the interventions were more successful in activating the use of some processes.
The Solutions Model can support a more appropriate assessment of outcome. Interventions should be evaluated in terms of their impact, i.e., the recruitment rate times the efficacy. For example, a substance abuse cessation intervention could have a very high efficacy rate but a very low recruitment rate. This otherwise effective intervention would have very little impact on substance abuse rates in the population. In contrast, an intervention that is less effective but has a very high recruitment rate could have an important impact on substance abuse rates in the population. Interventions based on the Solutions Model have the potential to have both a high efficacy and a high recruitment rate, thus dramatically increasing our potential impact on entire populations of individuals with behavioral health risks.