The idea of pretreatment programming has been discussed by addiction counselors, treatment program directors and public health professionals ever since the “stages of change” model of addiction was introduced 20 years ago. The Transtheoretical Model of Change was created by and has continued to be pioneered by Carlo C. DiClemente, PhD and James O. Prochaska, PhD. Findings based on their observations of cigarette smokers who quit smoking were aptly applied to other addictions, most notably alcoholism and drug addiction.
Their model's five stages describe the process most people who quit an addiction take along their pathway to recovery: pre-contemplation, contemplation, preparation, action and maintenance. Although these are called “stages,” clearly no person takes these in order; over time individuals go in and out of these phases.
The concept of pretreatment
Pretreatment as a clinical concept is a natural offshoot of the Transtheoretical Model of Change's first three stages. The following definitions offer the author's interpretation of the model:
Pre-contemplation is that stage in which an individual is not acknowledging or recognizing any life problems connected to their addiction.
Contemplation is when the individual, having had moment(s) of truth from natural consequences coming from their addictive lifestyle, now begins to consider the possibility of a life problem perhaps connected to their use or abuse of alcohol and/or drugs.
Preparation occurs when an individual begins to consider possible ways in which to deal with their life problem area(s), such as entering a treatment program.
Action is seeking out and entering a treatment program.
Maintenance is living a lifestyle free from addiction.
These first three stages define “pretreatment” as a process that would seem naturally to precede professional care. However, this is not predictably how the stages progress with most people. In an ideal counseling world it would be advantageous for both client and counselor if the majority of treatment time could be spent on personal discovery issues rather than on primarily dealing with problem identification and treatment justification. Still, it is fundamental to recovery that an individual pass through these first three stages thoroughly, whether before or during treatment, if there is any hope for treatment to have an impact and for the patient to have long-term recovery success.
Pretreatment is not a panacea, but a well-designed pretreatment group can have a positive impact on these most important stages of change.
Pretreatment is often referred to as “interim groups” in the research literature. Data point out that those who attend a pretreatment group prior to entering a professional care program have advantages over those who do not attend pre-professional care, in four key areas. Significant identifiable increases occur with the attendees of these pretreatment groups in the areas of:
A higher “show” rate for the first day of scheduled treatment;
Satisfaction with participation in treatment activities;
Higher rates of treatment completion with staff approval; and
Higher rates of long-term recovery satisfaction at all follow-up periods.
Outcome research on pretreatment
A 2009 study conducted at Marquette University had the primary purpose of examining if pretreatment client characteristics were predictive of retention in an intensive outpatient substance abuse treatment program. The principal investigators' report states, “Clinically, this study has relevance as retention is clearly linked to client attributes that are amenable to change through the therapeutic process (e.g., motivation and psychiatric distress).”1
A specific finding in a 2007 comprehensive study points the way to pretreatment as a potential treatment improvement process. The investigators' report states that changes that occurred in pretreatment were significantly and positively predictive of frequency of abstinent days in four follow-up interviews.2
Another recent study conducted jointly by the departments of psychiatry and educational psychology at the University of Utah showed that the efficacy of “interim support groups” did in fact increase attendance on the first day of treatment. A logistic regression revealed that interim group attendance predicted whether a person with methamphetamine abuse would show up for treatment.3
All of these findings strongly suggest that those who attend a pretreatment program are more open to and better prepared for recovery philosophies, counseling wellness concepts and general treatment procedures that are otherwise foreign to the patient's way of life. These outcome studies would indicate that the pretreated individual's participation while actively in a treatment program is above average, more genuine and therefore more meaningful than it is for those who are not exposed to a pretreatment offering.
Waiting list management
Perhaps the best use of a pretreatment program is when it is combined with a waiting list.