CFN9885 - SECTION 10: FIVE-STAGE MODEL FOR CHANGE
Motivation for change is best seen as consisting of stages. The most well-developed and empirically supported model is DiClemente’s (2003) five stages of change model. The five stages are: precontemplation, contemplation, preparation, action, and maintenance. The key is to match the therapeutic interventions to the person’s stage of change.
In the “precontemplation” stage, people have no intention of changing their behavior in the foreseeable future. Resistance to recognizing or modifying a problem is the principle hallmark of people at this stage. This applies whether change means modifying or stopping the problem behavior. Despite what other people may say, people at this stage, see change as irrelevant, unwanted, not needed, or impossible to achieve.
A useful distinction can be made between an acknowledged problem that is admitted to by an individual and an attributed problem that others say the individual has. While families, friends, employers, school and legal officials may feel there are problems, people at this stage are unaware or under-aware of their problems or they are unwilling or discouraged when it comes to changing them.
If precontemplators present for treatment, they often do so because of pressure or as a requirement from others. Their first question to the clinician is often: “How can I get these people to stop nagging me about_______?” They may be very resistant to treatment or they may demonstrate what some have called “psychological attrition”, whereby they evidence some degree of behavioral change as long as the pressure is on, but once the pressure is off, they usually return to their old behaviors.
For most people there is a simultaneous sense of both wanting and not wanting to change, of liking and disliking the experience, of taking the risk and not taking the risk. At the beginning, most people generally ignore the negative aspects of their problem behavior and they cling to the part of the experience that produces positive consequences for them.
As the negative consequences increase, people may become more aware of their ambivalence and they may begin to express a wish to quit or control their behavior. Until the person begins to realize that the costs of the behavior exceed the benefits, they are unlikely to want to stop. Meaningful change will not occur until this state of ambivalence is examined.
Because precontemplators have not begun this process, they can often be very demoralized about their problem. They do not want to think, talk, or read about their problem because they either do not feel they have a problem or they feel the situation is hopeless.
When working with people at the precontemplation stage, the challenge is to try to move them to a place where they will begin to seriously examine their problem behavior. A common strategy used by many clinicians and treatment programs is to try to “break through” the person’s “resistance” through various confrontational tactics.
The research consistently shows that using these confrontational tactics typically do not work with most people. If the intervention focuses only on convincing the person to change their behavior, most people at this stage of motivation will then be equally dogmatic that they do not have a problem and they are committed to continuing their behavior.
If the clinician only focuses on the negative aspects of their behavior, most people will be equally adamant about the positive benefits. Most people are more likely to take action to change when they perceive they have personally chosen to do so, not when they are told to do so.
Benjamin Franklin reportedly has his own method for making complex decisions. He drew a line down the middle of a page and then he listed the pros and cons and he estimated their relative importance or weights as a means of reaching a conclusion. A slight variation of the decision balance sheet is to construct four columns with benefits and costs of continuing the problem behavior and benefits and costs of discontinuing the problem behavior.
Research and clinical experience has shown that having clients construct such a decisional balance sheet can begin to influence their motivation for change. It is also useful for the clinician because it clarifies the positive and negative expectations the person has for continuing their problem behavior. The clinician can then discuss with the client alternative ways to achieve the desired benefits the problem behavior provides.
Instead of actively confronting the client’s resistance, many clinicians feel it is better to go along with the resistance as the clinician tries to help the person move through the stages of change. The key is to try to understand people’s ambivalence and resistance, that is, try to learn more about their reasons for being at this motivation stage. The goal should be to gradually help people shift their primary focus from the perceived benefits of their behavior to begin to examine some of the negative consequences of the behavior.
An effective strategy is to discuss with the person their life values and goals - and how their problem behavior may be compromising some of these aspirations. It also is important to communicate to people that you sincerely believe they can take meaningful changes in their lives and you will help them in any way you can.
Case Example: Client in the Precontemplation Stage
It is typical during the first session with a reluctant client at the precontemplation stage to hear some variation of the following: “I don’t think I have a drinking problem, but my wife said she’d leave me if I didn’t come here. So I’m here. But I think it’s more her problem. She is always on my case about something. Every time there is a problem, it is always my fault and it is always a result of my drinking.”
In response to questions about how much he drinks, the client replied: “Well, I don’t always drink every day. I do most of my drinking at home. While during the week I may stop off at a bar after work and have a few drinks with my friends, I am usually home by 6:00 PM. I usually drink between 4 and 8 beers a night and more on the weekends. But all of my friends drink this much, so what’s the problem.”
In response to questions about any negative consequences associated with his drinking, the client replies: “Except for the constant arguments that I have with my wife about my drinking, I guess I would have to say that I don’t see my drinking as being bad for me. I work hard at my job and drinking has always been a way for me to relax after work or on weekends and it is what I do with my friends.”
When further questioned about the consequences of his drinking, the client replies that he had been arrested for one DWI in the past year, he has missed some work because he was too sick to go to work the day after a night of heavy drinking, and his drinking has become a constant source of arguments with his wife and kids.
Four major factors have been found to contribute to meaningful therapeutic change: 1) accurate assessment of the client’s drinking and its consequences, 2) enhancing self-efficacy by introducing a series of small, successful changes in the client’s behavior, 3) increasing positive reinforcers for controlling the drinking, and 4) learning new cognitive and behavioral skills for coping with high-risk situations.
For a client like this one at the precontemplation stage, the primary goal of the first few sessions is to try to convey to him that you (and other people in his life) feel he has a drinking problem. Feedback about the severity of his drinking problem must be imparted in a respectful manner. It is important that the counselor remain aware of his ambivalence about modifying his drinking and convey understanding of the difficulties involved in making such difficult decisions and not try to talk him into believing he has a drinking problem.
You might try a response like this: “It sounds like, compared to what your friends drink, you don’t think you drink too much. However, I must tell you that, compared to a wide range of clients I have seen, and based on the severity of the negative consequences you have experienced, I see your drinking as a problem for you and your family. Most people don’t drink 4 to 8 beers at night after work. Most people come home after work and think about what’s for dinner, or what’s on TV that night, or what they need to repair around the house, or if their kid has a baseball game—not how many cold beers are left in the refrigerator, and how many they can drink before an argument starts between them and their wives and children. The major reasons I see your alcohol use as a problem is that you’ve had two DWI’s in the past 3 years, you have missed work and other responsibilities because of your drinking, and your alcohol use is negatively impacting your relationship with your wife and kids.”
The therapist’s only goal with this type of client is to try and move him to the contemplation stage. At this stage you are not trying to force him to admit that he has a significant drinking problem, but your goal is to try to begin to shift the positive/negative balance whereby he begins to think more about some of the negative consequences of his drinking for himself and his family and he might contemplate some changes.
Consideration of the value and the need for change represents movement into the “contemplation stage.” People who say “I want to stop feeling so stuck” or “I am tired of feeling like a drunk” are at the contemplation stage.
At the contemplation stage, people become aware that they may have a problem and are beginning to think about doing something about it, but they are struggling with the problem and they have not yet made a commitment to take any serious concrete action. Contemplators can remain that this stage for long periods of time as they seriously struggle with weighing the positive aspects of continuing their behavior with the amount of effort and energy it will take to overcome the problem.
At this stage, part of the person wants to change and part does not. Fear of failure can keep people contemplating change for long periods of time.
The contemplation stage involves a process of evaluating risks and benefits, the pros and cons of both current behavior patterns and the potential new behavior patterns. The task for contemplators is to resolve their decisional considerations in favor of change. It is very important for treatment personnel to be comfortable with, and recognize, ambivalence as a vital part of the contemplation stage of change.
When working with contemplators it is important to assess how long people have been considering change and whether they have made significant past attempts. It is important to remember that contemplation does not mean commitment. (DiClemente, 1997)
It is important to remember that it can be hard to give up the known, no matter how distressing and painful, and to travel to an unknown place that will require change and risk. (Joe, Simpson, & Broome, 1998) The key is to assist contemplators in thinking through the risks and consequences of their behavior and the potential benefits of change and to instill hope that change is possible.
Personal feedback based upon a thorough assessment on the nature and extent of their problem can have a strong motivational effect to tip the scales in favor of change. In highlighting the negative aspects of their behavior, the clinician should be careful not to paint such a negative picture that it further discourages people from thinking that change is possible. Overcoming the ambivalence and shifting the decisional balance requires time and patience. (Trotter, 1999) The decision to try to change marks the transition out of the contemplation stage and into preparation.
In the “preparation” stage, most people have progressed through the weighing process to conclude more or less in favor of change. They come to the point of saying that something has to change. People at this stage of change may make their intentions public announcing that they are going to “stop drinking tomorrow,” but they do not get rid of all of the alcohol in their house.
People at this stage of change may still need to convince themselves that taking action is what they truly want to do. They feel they cannot go on like this, but they are not sure what they can or are able to do. People at this stage often report making some reductions in their problem behaviors, but the changes are not sustained and they do not feel they have gained sufficient control over their behavior.
Being prepared for action does not mean that all ambivalence is resolved. The challenge is to help people at this stage develop a change plan that is acceptable, accessible, and effective. Clinicians can do this by gently warning against change plan strategies that seem inappropriate or ineffective and guiding them toward more productive alternatives.
It is critical in the engagement process to construct an individualized rationale for counseling and treatment. The basic approach is to communicate to people that there is something here for them, a place where they will get a chance to tell their story, to be heard, to be taken seriously. One means of enhancing desire for entering and remaining in treatment is to identify any existing motivating forces in people’s lives and use these forces to get them more motivated for treatment.
Few people enter treatment without having experienced messages from people around them to get some help. Involving friends, family members, and others in the recovery process can not only help to bring people to treatment, but it can also serve the function of educating these people about problems this person faces, reduce their own interpersonal distress, and help to decrease any of their behaviors which may be enabling the problem behavior.
The action stage is one where people begin to make the overt changes in themselves and their surroundings. Action to stop the old patterns of behavior and begin to engage in new ones is the action stage.
However, action is not the first step or the last step in the stages of change. Many people, including treatment professionals, erroneously equate action with willingness to change and, as a consequence, overlook the requisite work that individuals must do to maintain the changes following action.
In the action stage, people begin to modify their behaviors and their environment in order to begin to overcome their problems. Modification of the targeted behaviors to an acceptable level and significant overt efforts to change are the hallmarks of the action stage. It is also important not to assume that once a person has reached the action stage, it is all downhill from here on.
The new behavior must be sustained in order to create the new habits. People in the action stage may still have some conflicting feelings about the changes they are beginning to make. Careful listening and monitoring what they are doing is important in this stage including affirming what they are doing that is working and helping them to overcome any barriers they may be experiencing.
There are three common developmental factors in most types of therapy and treatment: support, learning, and action. The assumption is that the support functions precede changes in beliefs and attitudes, which precede attempts at action.
Techniques cannot be separated from the human encounter. When clients are in the action stage they have done the prerequisite work to actively work on making significant changes in their lives. The research shows that clients are more motivated with they are given choices in the type of treatment.
As a result, clinicians need to work with the client to develop an active change strategy where observable changes can be realized. At this stage, continuing to focus on heightening ambivalence or reflective strategies would probably be a mistake. Clients at this stage need a treatment plan with specific short-term and long-term goals.
Change never ends with action. Maintenance is the final stage in the process of change. In the maintenance stage, people try to stabilize their new behaviors and work to prevent relapses.
Sustaining behavior following therapy can be difficult. In this stage, people work to consolidate the gains they have made during the action stage and prevent relapse. Programs that promise easy and quick change usually fail to acknowledge that maintaining change can be a long, on going process.
With some clients there should be ongoing discussions about the potential for relapse. This is particularly true for clients who are trying to recover from substance abuse, eating disorders, gambling problems, and other addictive behaviors.
Researchers who followed contemplators for two years found that only 5% of them made it through the cycles of change without at least one setback. (Prochaska, Norcross, & DiClemente, 1997) These relapse or setback experiences can contribute information that can facilitate or hinder subsequent progression through the stages of change.
A relapse should not be considered an utter failure, but, rather, a step back. After a relapse, people often regress to an earlier stage and then begin progressing through the stages again. Frequently, people who do relapse have a better chance of success during the next cycle. Hopefully, based upon these experiences, they have learned new ways to deal with old behaviors, and they now have a history of partial success to build on.
It is important for the clinician to help these clients see the crisis as an opportunity to learn rather than a failure, to problem-solve the failed plan in order to create a more effective one.
One way to approach the discussion of the potential for relapse with clients is to talk about recovery as a journey which involves continual discovery, dealing with novel situations, improvising when things do not go well, and learning new and useful ways to cope with problems along the way.
It can be useful to tell clients that recovery usually proceeds along unremarkably until the person encounters a high-risk situation. This could be anything that threatens the person such as an awkward, stressful social situation or an internal affective state such as anger, anxiety, or depression. The person is then told that handling these high risk situations in an adaptive way is the key to ongoing recovery and how he/she perceives, interprets, and understands a high-risk situation can directly affect the outcome.
Discussion of automatic thoughts and cognitive distortions such as overgeneralization (one slip therefore cannot stop), selective abstraction (focusing on one’s failures), excessive responsibility (personally do not have what it takes to stop using), assumption of temporal causality (if true in the past will always be true in the future), self-reference (I am the sole cause of your problems), catastrophizing (anticipate the worst), and dichotomous thinking (black and white thinking focusing on the negative) can help in this process. (Marlatt & Gordon, 1985)
Clinicians should prepare themselves and their clients for the termination of counseling or treatment. The counseling relationship can be a powerful presence in people’s lives, and they may feel anxious about the counseling or treatment process coming to an end.
Going over the gains that the person has made, affirming the relationship between the clinician and the person, offering follow-up sessions if needed, going over any anxieties about the end of treatment or counseling, and giving referral sources if needed can all help to stabilize the gains that have been made during counseling or treatment.
In conclusion, for most people, moving through these stages of change is not linear. Before meaningfully addressing their problems, most people will make several attempts including trying to address their problems on their own without formal help or trying a number of different counseling or treatment approaches.