Addiction and the Stages of Healing, Part 9: STAGE THEORIES RELATED TO ADDICTION

We do have previous stage theories in the addiction literature. Substance use disorder-specific stage theories have been presented.

  • Abraham Wikler13 and Shepard Siegel are two that have presented stage theories concerning addiction etiology and progression.
  • Many of you might be familiar with the work of Terrence Gorski14 and of Alan Marlatt15. They are coming from separate perspectives as independent authors, but have both looked at relapse processes (with and without eventual return to use) during abstinence, during recovery, and also after return to use.  Their separate bodies of work are interesting and are both stage theories of regression.
  • William White has presented information16 on stage theory concerning addiction recovery.

In our field there are theories that transcend disorders and are also specifically relevant to what we do.

  • Stages of change17 (the transtheoretical model of change) is widely known.
  • However, many might not be familiar with Fred Osher18 and his work on stages of treatment.  His stage theory examines engagement, persuasion, active treatment and relapse prevention as a framework for understanding addressing primary health or psychiatric problems. One could add stabilization toward the beginning of that array, and recovery management on the back end, and have something nicely suited to our addiction treatment work. 
  • Jellinek19 is not cited often enough.  He did work decades ago that was stage-specific for both addiction onset/progression and for recovery. His work is the closest I have seen anyone come to the whole notion of the Stages of Healing. I should point out that fifty years from now our work might be maligned for the fact that it happened so long ago and looks as it does. We should not malign Jellinek’s work; he was doing what he could then, as we are now. We need to move forward.

The literature is relatively devoid of aggregate information on anything like Stages of Healing from SUD’s. It is just hard to find, if it is there at all. We are generally devoid of markers of healing within stages as well. As a natural result of our medical-scientific view of addiction, addiction treatment, and addiction recovery, we limit our observation, measuring and recording of change to targets we can control through clinical therapy. That is just too limited, but we call it evidence- based.  Our clinical therapies are generally problem-oriented, consist of conventionally defined processes, and are generally limited to clinical targets that are already identified (associated with methods that are known to reliably decrease disease signs, symptoms and related impairments).20

Regardless of how well-defined the activities of addiction treatment and recovery might be, the course identifiers of related healing remain largely unknown. We are just not shining our flashlight out decades ahead of the individual in a comprehensive way.

  • Those working with clinical populations in addiction treatment settings and services could benefit from the knowledge of the aggregate/normed Stages of Healing (if those stages exist) and the markers associated with them. That would be very practical information to have. We do not have it. So, we are not sure where we are topographically with our individual patient over time.
  • Research would benefit as an endeavor. Innovative research would have its own positive results. We would advance our knowledge base in patient assessment processes as well as responses to various treatments. We would develop new worthwhile measures (both the targets and the measures themselves). This would indirectly promote development of new therapies, over time. Regardless, development of measures would mean we would better know where a person resides within a full and relevant constellation and continuum of markers of healing over time.
  • Clinical care would benefit as well by truly promoting a much longer-term recovery and wellness orientation. We would be bolstered by knowing where the individual patient falls within a normed timetable of expected markers. This would ideally include markers that are both currently available and currently outside our limited scope as I have described previously. We would have lengthened and strengthened care in recovery support, if and as needed for the individual. Our recovery management structures and thus long-term outcomes would be improved.

DuPont has written a very interesting paper21 to expand the notion of what we should pursue related to normed benchmarks of long-term healing. In that article he has clearly articulated the value of addiction treatment providers adopting the standard of treatment effectiveness of full recovery five years after the cessation of clinical support as with other serious chronic diseases.

Right now, we are just not pursuing long term models in this way, and not with comprehensive measures.

One practical result of our current general framework of care is the narrow scope of understanding within treatment approaches concerning the long-term benefits of each kind of treatment, relative to normed Stages of Healing.  In other words, we are not sure how the individual patient is doing, and we also do not know how to compare effectiveness on a specifically normed basis, within types of treatment. We are even flying blind relative to that. Normed benchmarks of long-term healing are needed.

Addiction and the Stages of Healing is a needed stage-related, theoretical, academic, empirical and clinical endeavor/goal for our field. 

13Wikler, A. (1965). Conditioning Factors In Opiate Addiction and Relapse. In D. M. Wilner & G. G. Kassebaum (Ed.). Narcotics. (pp. 85-100). New York: McGraw-Hill.

14Gorski, T. & Miller, M.  (1986).  Staying Sober:  A Guide For Relapse Prevention.  Independence Press.

15Marlatt, G.A. & Donovan, D.M. (2007). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors 2nd Edition.  The Guilford Press.

16White, W.  (August 11, 2017).  Stages and Styles of Addiction Recovery.  Retrieved from the world wide web on 11/23/17 at:

17Prochaska J.O, Norcross, J. C. & DiClemente, C.C.  (1994). Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward.  Quill.    

18Osher F.C. & Kofoed, L.L. (1989).  Treatment of Patients With Psychiatric and Psychoactive Substance Abuse Disorders. Hospital and Community Psychiatry40:1025–1030.

19Jellinek, E.M.  (1952).  Phases of Alcohol Addiction.  Quarterly Journal of Studies on Alcohol.  13(4): 673–684.

20Marquis, A., Douthit, K.Z, & Elliot, A.J.  (2010).  Best Practices: A Critical Yet Inclusive Vision for the Counseling Profession.  Journal of Counseling and Development89: 397-405. 

21DuPont, R.L., Compton, W.M., & McLellan, A.T.  (2015).  Five-Year Recovery:  A new standard for assessing effectiveness of substance use disorder treatment.  Journal of Substance Abuse Treatment.  58:1-5.

In case you missed it, Part 8: INVITATION TO A THINK TANK is here.


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