The model assumes that although the amount of time an individual spends in a specific stage varies, everyone has to accomplish the same stage-specific tasks in order to move through the change process (Prochaska & Prochaska, 2009). There is an unofficial sixth stage that is variously called "relapse," "recycling," or "slipping" in which an individual reverts to old behaviors. Examples include having a beer after a period of sobriety, or smoking a cigarette a year after quitting. Slipping is so common that it is considered normal. Social Workers are encouraged to be honest with clients about the likelihood of backsliding or reverting to old behaviors once the change process has started, not because we expect our clients to fail, but because it normalizes the experience and takes away some of sense of failure and shame.
Although the "Stages of Change" model was identified and developed during a study of smoking cessation (Prochaska & DiClemente, 1983), the model has been applied to and studied with numerous bio-psycho-social problems, including domestic violence, HIV prevention, and child abuse (Prochaska & Prochaska, 2009). The "stages of change" model is one component of the "Transtheoretical model of behavior change" (Prochaska & DiClemente, 1983). It is called the "transtheoretical model" because it integrates key constructs from other theories. The TTM describes stages of change, the Process of Change, and ways to measure change. In today's podcast, I'm going to focus on the Stages of Change. If you are interested in learning more about the broader Transtheoretial Model, there are dozens of resources online and in print. The University of Rhode Island's Cancer Prevention Research Center website has a clear and concise overview of the TTM: https://web.uri.edu/cprc/detailed-overview/
. If you are looking for a social work-specific application of the TTM, there is an excellent chapter in the second third edition of the Social Workers' Desk Reference
on the TTM and child abuse and neglect (pp. 707 - 715).
The purpose of this podcast is to provide a brief overview of the five stages of change and what intervention approaches are most appropriate at each stage of change. I drew on a number of resources in the preparation of this podcast, including a chapter on the stages of change and motivational interviewing by DiClemente & Velasquez in Miller and Rollnick's second edition of their book, Motivational Interviewing (Miller & Rollnick, 2002) [note: Miller & Rollnick published a 3rd edition of Motivational Interviewing
in 2013, after this episode was recorded. If you'd like to learn more about MI-3, here's a link to the podcast episode with Mary Velasquez about the changes to the 3rd edition
]; A 2002 article by Norcross and Prochaska (2002) from the Harvard Mental Health Letter called "Using the Stages of Change;" and the chapter by Prochaska and Prochaska (2009) in the second edition of the Social Workers' Desk Reference that I just mentioned. All of these references can be found on the podcast website at http://socialworkpodcast.com/
In today's podcast I'll talk about how to figure out what stage someone is in, and identify a couple of interventions that are most effective for the person in that stage. I'm not going to go into great detail about interventions because there is a major treatment approach called Motivational Interviewing that addresses dozens of intervention techniques. Along the way I'll provide examples of things that social workers can say to people in different stages of change. I've drawn most of my examples from situations other than addictions. I've done this because the Stages of Change model was developed out of addictions research and there are a lot of examples with addictions. Since the Stages of Change is applicable to behaviors other than addictions, I wanted to focus on some of those examples. I end the podcast with a brief critique of the model.
People in precontemplation do not see their behaviors as a problem and therefore see no need to change. This is sometimes called the "ignorance is bliss" stage. Clients in the precontemplation stage have traditionally been thought of as "resistant to change." You might be thinking, "well, if someone doesn't see their behaviors as a problem and are not interested in changing, then why would I need to know how to work with them – after all, they are not likely to be in treatment." Although many people in precontemplation will, by definition, never present for treatment, research has found that between 50 – 60% of clients are in the stage of Precontemplation, which means they don't see a problem and therefore see no need to change their behaviors. These include any client who is pressured or coerced into services. Examples might include the mother whose child has been removed by the state; because it was her partner who abused the child and not her, she doesn't see how her behaviors would need to change. However the State, and possibly others, see her parenting as neglectful and not adequate to justify returning the child to her care. Another example is the child who is brought for services by a parent because of problems in school or at home; the child might see that everyone else has a problem – the teachers, the other kids, or even the parents. Other examples include clients who in treatment because they were court-ordered, required by employers, or even by their partners. In all of these situations, there is someone else who recognizes a problem and has the power to make the person enter treatment against their will. Norcross and Prochaska (2002) call these clients "uninformed."
Now, it is possible that these clients tried changing their behaviors in the past but were unsuccessful. Because the change didn't work or didn't stick in the past, they now see change as unrealistic or impossible and therefore not worth pursuing. Norcross and Prochaska (2002) call these clients "underinformed." Examples might include people who have tried to give up smoking or drinking, people who have tried to leave abusive relationships, youth who have tried and failed to leave gangs, or even have failed to be successful at school.
So, the group of people who have never seen their behaviors as problems are considered "uninformed," and the group of people who have seen their behaviors as problematic in the past but are not currently interested in changing are called "underinformed." Neither group is interested in changing their current behaviors.
Norcross and Prochaska (2002) suggest assessing precontemplation by asking if the person is considering making a change in the next six months. If they agree to statements like, "I guess I have faults, but there's nothing that I really need to change" and "As far as I'm concerned, I don't have any problems that need changing," then they are in precontemplation. Prochaska and Prochaska (2009) note that people in precontemplation AND maintenance believe that their behaviors do not need changing, but for very different reasons. So, it is important to find out why. The parent who says, "Yeah, I'm not perfect, but I'm no worse than anyone else, so why should I change?" is telling you that there is no problem, and therefore no reason to change. This parent is in Precontemplation. In contrast, the parent who says, "Yeah, I'm not perfect, but I'm so much better than I used to be and I'm really trying hard not to fall back into my old ways of behaving" is telling you that he or she changed the problematic behavior and is trying to maintain it. This parent is in maintenance. If the difference between the two stages is a little confusing, no worries; it will make more sense by the time I've finished the podcast. Just remember, there are only two stages in which someone doesn't see a problem: precontemplation and maintenance. In the other stages, contemplation, preparation and action, the person sees a problem.
Clinicians have to tailor their interventions to match the clients stage of change. For people in precontemplation research has found that it can be helpful to increase awareness about the problem. For a parent involved in child welfare, the mere presence of protective services can sometimes be enough to increase awareness (Prochaska & Prochaska, 2009). Another intervention is to move people emotionally. I ran a group for parents trying to reunify with their children who had been removed by protective services. One of the first assignments asked parents to write about the abuse or neglect from the child's perspective. This assignment was often very emotional and for many parents helped to move them from a place of being defensive about what they had done (or not done) to a place of feeling really sad and remorseful. The emotional shift was key in getting them to move towards permanent change in their parenting behaviors because they were able to acknowledge a problem. Prochaska and Prochaska (2009) mention three other interventions that can be used with precontemplators, including discussing the benefits of changing, encouraging the individual to look at the consequences of what is happening now, and pointing out discrepancies between the way the individual would like to be and the way they are.
So, let's say you do all of this and your client starts saying things like, "yeah, I guess that's a problem," or "I'm sure it would be better if I didn't do that," then they have moved out of Precontemplation and are in stage 2 – contemplation.
The second stage is called contemplation. In this stage, people recognize a problem and are contemplating a change, but haven't yet committed to changing. For example, you want to lose weight and have looked into joining a gym but haven't yet signed up. People in contemplation are sitting on the fence – part of them wants to change, but an equally compelling part of them wants to stay the same. When you are sitting on the fence, we say you are ambivalent about change. The contemplation stage is all about ambivalence. Prochaska and Prochaska (2009) note that people can stay in contemplation for a very long time. Change is tough. It is hard to take that first step. Chronic contemplators spend lots of time thinking and not much time doing. This is in part because "contemplators struggle to understand their problem, to see its causes, and to think about possible solutions" (DiClemente & Velasquez, 2002, p. 208).
You can assess for contemplation by listening for statements like, "I know I have a problem, but I'm not really sure I want to do anything about it." or "I'm not really sure what I can do about it." For example, a parent in the child welfare system might say something like, "I know I can do better by my kids, but I'm not really sure how." Once you've established that your client is ambivalent, then you can decide what types of interventions are most appropriate.
The most important thing to remember about intervening with someone in contemplation is that they are evaluating the pros and cons of change, but haven't yet decided to change. If you start making suggestions about how to change, the part of your client that wants things to stay the same will bring up all of the reasons why change is not possible. The last thing you want to do is have your client talk themselves into not changing their dysfunctional behaviors. Miller and Rollnick (2002) call the social worker's instinct to fix the situation the "righting reflex." So, how do you talk with your client so that they talk themselves into change? Prochaska and Prochaska (2009) suggest a number of interventions including: 1) talking with your client about the pros and cons of changing, also called the Decisional Balance technique; 2) Pointing out the discrepancy between how your client would like to be and how they are, also known as Developing Discrepancy; and; 3) Instilling hope.
Pros and cons: For the parent involved with child welfare, you can ask, "What are the benefits of changing your approach to parenting? What problems do you see with changing?" Your client might respond by saying, "I will get my kids back and child welfare will be out of my life," and "My kids only respond to spanking. I've tried time out and it doesn't work, so I'm never going to be able to control my kids without being able to spank them." You also want to explore the pros and cons of maintaining the status quo, also known as staying the same. You can ask, "What reasons can you come up with for not changing your parenting style? What are the downsides of keeping your parenting style the same?"
Developing discrepancy: You can confront clients in this stage and expect to have some impact. But, you have to focus on the discrepancy between how they would like to be and how they are. For example, you can say to the parent involved with child welfare, "You say that getting your kids back is your #1 priority, but you've missed the last two supervised visitations. Since actions speak louder than words, you're telling me that being with your kids is not your first priority." Now, that might sound harsh, but it points out the discrepancy between the way the parent wants to be and the way they are. Your client is not likely to be motivated to change if they don't see a difference between how they would like to be and how they are. Another way of developing discrepancy is by providing your client with education about how things could be, such as books or videos that illustrate new behaviors. This kind of information is useless in Precontemplation because people don't see a problem, but it works well in contemplation because they've partially bought into the idea that they want to change, but are not sure how.
Instilling hope: This is essential because people in contemplation have a voice inside saying, "change is too hard, it is not worth it, as bad as things are now it is easier than changing..." When you instill hope that your client can change, it supports the voice in your client that says, "I don't like how things are going, I want to change."
The third stage is called preparation. In this stage, people have decided to change their dysfunctional behaviors within a month. People in preparation have taken little steps towards changing their behavior – they are "testing the waters." Those little steps might have failed, or they might have worked, but they have not resulted in the kind of behavior change that the client wants. For example, you want to lose weight, have said no to desert for the last few months and even dusted off a workout tape. But you haven't lost any weight, don't have a comprehensive plan, and find yourself mostly engaged in the old behaviors, even though you don't want to.
When you assess for preparation, you want to listen for statements like, "I really want to change because..." and "I wish I could just figure out how to..." Prochaska and Prochaska (2009) suggest that a parent involved in the child welfare system might indicate preparation by making statements like, "I have questions for my caseworker about how to parent differently," and "If I don't change, I'll never be the parent I want to be." Because your client has already taken small steps towards change, but hasn't been successful, you want to find out how much support he or she has to make the change, and if he or she has the skills needed to make the change. For example, your client wants to stop spanking her children but lacks the social support to do that. Her friends and family all spank and believe it is an appropriate intervention. When mom is not around they spank her kids. This mom has no support to parent differently. Furthermore, because she has no examples of how to discipline without spanking, she lacks the skills to follow through. For example, when you ask how she might discipline her child without spanking, she comes up short.
Prochaska and Prochaska (2009) suggest four interventions for people in preparation: Encourage your client's commitment to change; support self-efficacy; generate a plan and set action goals.
You can encourage your child welfare client by saying something like, "Your decision to change how you parent tells me that you are dedicated to not only getting your kids back, but also to strengthening your family to prevent future abuse and neglect."
When you generate a plan and set action goals you want to make sure your setting up your client for success. If you have identified deficits in supports and skills, an appropriate plan would be to establish these as part of the goals for change. You don't want to set up your client with unreasonable expectations for finding friends and family who will support their new behaviors or else they will move away from wanting to change. The same is true for new skills. You can set up small and attainable behavior goals for your in-office services so that at the end of every session they feel like they have accomplished something and are one step closer to their goal. Social workers should be aware, though, that just because a client is preparing to make change, doesn't mean that they are willing to participate in the program that the social worker has identified for the client. I might be prepared to join a gym lose weight, but as a man in my late 30s, I won't join Curves or Lady Fitness. So, it is important not to confuse willingness to change with an automatic buy-in of existing programs or services.
The fourth stage is called action. In this stage, people have changed their dysfunctional behavior at least one day and no more than 180 days. People in the action phase have put into practice the plan developed in the preparation phase. They are consciously choosing new behaviors, being confronted with challenges to the new behaviors, and consequently gaining new insight and developing new skills. For example, the mother who no longer uses corporal punishment tells her social worker, "In the last few weeks of not hitting, I've realized that it is easier to hit than to not hit, and when I am tired and the kids are driving me crazy, it takes all I got to not hit them. I really appreciate my one friend who doesn't spank – she's so good to be around." People in the Action stage are enthusiastic and motivated. When social work students and most of the public think about what it would be like to do therapy, they usually think of working with people in the action phase. Prochaska and Prochaska (2009) noted that most treatment programs are built around the action phase, even though only a small percentage of clients are actually in action. (Story about pregnant woman and how easy it was).
Social workers should listen for statements that indicate both an acknowledgement of a prior problem and new behaviors. Again with the child welfare example, a father might say, "I'm doing something about the behaviors that got me involved with child welfare in the first place."
Intervention in the action stage includes a lot of verbal reinforcement and supporting the person's belief that he or she can sustain the change. In motivational interviewing this is called "supporting self-efficacy." You want to identify specific behaviors that your client has changed and connect them with the changes you're seeing in their life. For example, if a mother has changed her parenting style and you notice that her children are responding better as a result, you can make encouraging statements that explicitly support the mother's ability to change her behavior and get the results she wants as a result of the change. For example, you could say something like, "I notice that during supervised visitation you are using more encouraging statements with your kids, and are less likely to withdraw when they start fighting. I've also noticed that ever since you've been doing that your kids have brought up the subject of coming home more often, and are more excited about the family getting back together. They also seem genuinely happy when you pay them compliments rather than ignoring them. All of these things suggest that as hard as it is to parent differently, you're really making a lot of changes and they seem to be making a big difference for your children and your family."
The fifth stage is called maintenance. In this stage, people have been engaged in the new behavior for at least six months and are committed to maintaining the new behavior.
You know your client is in maintenance when they report there is no problem and are able to describe how their current behavior is different from their past dysfunctional behavior.
Intervention at the maintenance stage looks different than at the previous four stages. You will probably be meeting less frequently. Your conversations will revolve around how your client is sustaining their commitment to the new behavior. You will talk about how he or she might cope with a relapse and ways to avoid relapse. Clients in this stage of change tend to be confident about their ability to maintain the change. You can help your client to identify when they have become overconfident, and consequently might put themselves in a position to relapse. As an example, I was working with a gay man in his late 40s who reported 12 months of sobriety. I knew this client was in maintenance because he described his past behaviors and distinguished them from his behaviors from the past year. He was confident about his ability to stay sober, but had decided to go into therapy as he started to get back into the dating scene. He was looking for a committed relationship that was supportive of his drug and alcohol free lifestyle. In our first session he said that he could think of three places he could find a partner, and each place presented some challenge to his sobriety: bars and clubs, the AA meeting he'd been attending, and online. We talked about how frequent contact with his AA sponsor would be one way of demonstrating commitment to sobriety, as well as a source of support while stepping out into situations that might trigger a relapse. For example, we talked about what he would do if he met a man online who suggested they get together for a drink. He was clear that he wouldn't drink and was confident that he could be around someone who was drinking, but had concerns about how his sobriety might look to his date. So, we addressed situations that might trigger him to want to drink, including the desire to take the edge off of meeting someone new, the desire to conform to social expectations, and the fear of not being able to perform sexually sober. We came up with a plan that included support by his sponsor, self-affirming statements, and an honest talk with his date. I also had him describe what his life was like prior to becoming sober, including losing his job and being homeless for a period. I contrasted that with his current situation and emphasized how easily he could lose it all. Since he was in maintenance, emphasizing these differences served to reinforce his commitment to sobriety and added a sense of urgency to the plan.
There is an unofficial sixth stage – relapse. This is the "falling off the wagon" stage. A relapse is defined as resuming the old behaviors. So, you have to engage in new a behavior, which means you are in action or maintenance, before you can "relapse" into old behaviors. The longer someone is in maintenance, the more devastating relapse can be to the person and those around him or her. People who relapse often feel disappointed and frustrated. Watching a client go through relapse can be painful for the provider. But, as I mentioned before, it shouldn't be unexpected. Relapse is considered the unofficial sixth stage of change for a reason – it occurs very frequently. So, you shouldn't rest on your laurels and wait for your client to relapse. But, when it happens, don't over react and make the situation worse.
There are a couple of specific areas to address when intervening with someone in the Relapse stage. The first is to find out what triggered the relapse. Have your client describe the moment he or she engaged in the old behavior, and then work backward to find out how he or she got to that point. Next, you can review your client's motivation for engaging in new behaviors and identify what barriers exist that might prevent your client from "getting back on the wagon." If you have been working with your client for a while, you can review the motivations identified during work in a prior stage. Listen for new motivators. Sometimes people in relapse gain insight into why they do what they do and are able to come up with new motivators as well as barriers. The third area to address is your client's coping strategies. Clearly his or her coping strategies were insufficient to maintain the change, so you'll want to help him or her identify and implement new coping strategies. Since your client is likely to be feeling like a failure for relapsing, acknowledge his or her feelings and then reframe the relapse as an opportunity to learn and become stronger. You can say something like, "I realize you feel like a failure, and I understand why. But I want to suggest that perhaps this relapse is a wake-up call to some of the problems with the strategies you've been using and an opportunity to fix them and improve on them." The client I talked about who presented in maintenance had a relapse during our treatment. Although our sessions had gone well in the beginning, he had been unsuccessful finding a partner. One of the people he met online had invited him to go sailing. He ended up drinking a wine cooler on the boat. Although he stopped after one drink, he felt horrible about himself and his recovery. He was so ashamed that he had not yet called his sponsor. When we talked about what happened he said that he had been out on the boat all day without eating, that he was so grateful to have some company that he threw caution to the wind, and that he was exhausted from being in the sun all day. He said that he had not taken care of his basic needs and was Hungry, Angry, Lonely and Tired –the four states that make up the AA acronym, HALT. He even said that he thinks his experience had taught him that there was a fifth basic need that hadn't been met – that he was horny. He laughed and said that HALT should be renamed HHALT. Our intervention addressed his new insight into how he could maintain sobriety and some of the unexpected challenges of improving his romantic life. We came up with a new plan and he implemented it. Given that he had a relapse, once he engaged in the new plan, what stage was he in? If you said, Action, you'd be right. So, our sessions changed focus somewhat to address the needs of people in the Action phase.
To review, the stages of change model is a way of thinking about how someone goes about changing his or her behavior. The stages of change model assumes that change takes time, that there are common tasks in each stage, and that by tailoring your intervention to match the stage of change, you will be more successful in helping your client to make lasting change. The stages of change model is the key construct of the broader Transtheoretical Model, which also includes Processes of Change and ways to evaluate change.
There are five official stages and one unofficial stage. The Precontemplation stage is the "ignorance is bliss" stage. People in this stage don't see a problem and consequently are not interested in changing their behavior. The second stage is Contemplation. People in this stage are "on the fence:" they acknowledge a problem, but are not sure it the benefits of change outweigh the benefits of staying the same. The third stage is Preparation. People in this stage see a problem and "testing the waters;" they taking small steps towards change. The fourth stage is Action. People in this stage have identified a plan for changing the behavior and have started to implement it. The fifth stage is maintenance. People in this stage have been engaging in the new behavior for at least six months. The unofficial sixth stage is relapse. People in this stage have "fallen off the wagon" and are engaging in the old behaviors.
Critiques of the model
Like all popular models, the Stages of Change model has been subject to numerous criticisms. In 2002 Julia Littel and colleagues published a review of 87 studies using the Stages of Change model and concluded that there was no evidence to support assertion that there are consistent stages of change across a range of situations, problem behaviors, and populations. There is no conclusive evidence that change occurs in stages, rather than as a continuous process. And finally, there are no known studies that follow the progression through all five stages. Prochaska and Prochaska (2009) countered these criticisms, stating that it was misleading to evaluate the stages of change model outside of the broader TTM, which the acknowledge has been subject to far fewer studies.
In 2004, Adams and White suggested two reasons why the stages of change model may not be applicable to complex behaviors, such as those commonly presented by social service clients. 1) The model was developed around changing single behaviors, such as smoking cessation, and does not clearly account for changing multiple related behaviors, such as changing parenting styles. 2) Identifying the stage of change depends almost entirely on client …