Stages of Change: Treatment Needs & Strategies….

In a previous post, I provide an overview of the Stages of Change from a personalized perspective.  “In the transtheoretical model, behavior change is conceptualized as a process that unfolds over time and involves progression through a series of five stages: precontemplation, contemplation, preparation, action, and maintenance” Norcross, Krebs & Prochaska, 2011, p. 143).  The point of this post was to illustrate that change is a process and not a singular event.  In other words, “Just Do It” doesn’t cut it as useful advice for those attempting to institute changes in their lives.

The purpose of this post is to review the stages of change from a pragmatic perspective.  I discuss each stage and review treatment needs and potential strategies.

STAGE #1: Precontemplation

“Precontemplation is the stage in which there is no intention to change behavior in the foreseeable future. Most patients in this stage are unaware or under-aware of their problems. Families, friends, neighbors or employees, however, are often well aware that the pre-contemplators suffer from the problems” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

“During the pre contemplation stage, individuals are not even considering changing and may not even see advice provided to them as applicable to their lives” (Zimmerman, et al, 2000, 1409).  The goal for a therapist with a client in the pre contemplation stage is to increase their concerns for problematic behaviors and/or situations and provide hope that change is possible (Sullivan & Flemming, 1997).   In order to achieve this goal, the primary task is expanding the client’s awareness of their life situation.  At times, this might entail simply providing the client information, such reviewing symptoms of a diagnosis, or the side-effects of a medication.  However, it is also essential that explore the client’s perspective of things.  How do they perceive their situation & what meaning do they live to current life events?  Have they attempted to change before?  These questions can assess what the barriers to change are.  People are rarely liable to change if there is no benefit to doing so.  Therefore, it is critical that we understand the factors the client is struggling with as they weigh their options (i.e. change vs. no change).

Strategies

  1. Establish Rapport & Build Trust
  2. Assess the client rationale for current life-style choices…
  3. Begin to assess barriers to change.
  4. Elicit the client’s current perception of the problem.
  5. Expand the client’s current perspective by providing factual information
  6. Build up the client’s confidence in the idea that change is realistic & possible.
  7. Examine discrepancies between the client’s perception and how others view things.
  8. Provide personal feedback on assessment findings.
  9. Discuss relevant diagnoses, symptoms, and possible treatment.

Interview Approach

The primary goal is to develop rapport and establish trust.  Take time to discuss the client’s understanding of the problem.  Non-judgmentally provide factual information regarding the client’s problematic and/or self-destructive behaviors and express your concern (Sullivan & Flemming, 1997).   Begin establishing an “agree to disagree” standard in order to begin discussing divergent perspectives of the client’s life-situation (Sullivan & Flemming, 1997).  Periodically assess the client’s readiness to change.

STAGE #2: Contemplation

“Contemplation is the stage in which patients are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. Contemplators struggle with their positive evaluations of their dysfunctional behavior and the amount of effort, energy, and loss it will cost to overcome it” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

“During the contemplation stage, patients are ambivalent about changing. Giving up an enjoyed behavior causes them to feel a sense of loss despite the perceived gain” (Zimmerman, et al, 2000, p1409).  In other words, they are now able to acknowledge that change needs to happen, however remain ambivalent.  The idea of change, is either overwhelming, or highly undesirable.  The therapeutic goal, therefore, is address the client’s feelings of ambivalence.  In other words, what factors weigh in heavily for and/or against the idea of change?  How can this decisional balance tipped in favor of change?  Increasing the client’s understanding of their options can help them make more informed decisions.

Strategies

  1. Acknowledge feelings of ambivalence & normalize this experience as a part of the change process.
  2. Develop a list of factors for & against change.
  3. Provide clear & nonjudgmental messages regarding the client’s need to change.
  4. Examine the client’s personal values in relation to change.
  5. Address intrinsic & extrinsic factors related to the client’s motivation to change.
  6. Assess the client’s feelings of efficacy & expectations regarding process of change.
  7. Ask the client to begin considering small changes and assess their outcome.

Interview Approach

Continue building the therapeutic relationship.  Validate & acknowledge the client’s feelings of ambivalence regarding the idea of change.  Explore the factors underlying feelings of ambivalence.   Discuss positive an negative factors associated with change (Sullivan & Flemming, 1997).  Create a discrepancy between the client’s values and actions (Sullivan & Flemming, 1997).  Consider making small changes in order to address feelings of ambivalence (Sullivan & Flemming, 1997).

STAGE #3: Preparation

“Preparation is the stage in which individuals are intending to take action in the next month and are reporting some small behavioral changes (‘‘baby steps’’). Although they have made some reductions in their problem behaviors, patients in the preparation stage have not yet reached a criterion for effective action” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

During the preparation stage, patients prepare to institute small changes. Sullivan & Flemming, (1997), note that while pre-contemplation and contemplation work well with motivational interviewing techniques, CBT and/or 12-step approaches are useful for the remaining stages.  During this stage, clients work on strengthening their commitment to change.  Therapists should help client’s work though various strategies to institute planned changes.

Strategies

  1. Assist the client in refining their goals & plans for change.
  2. Help the client review the options available & determine a best course of action.
  3. Review previous attempts to institute changes in order to understand what didn’t work.
  4. Elicit the assistant from the clients social support system.
  5. Encourage the client to take action daily to institute change.

Interview Approach

Acknowledge the significance of the client’s decision to institute changes, and reaffirm their ability to successfully achieve their goals.  Help the client develop a plan of action and examine how the road ahead looks.  Reassure the client that progress sometimes involves relapse.

STAGE #4: Action

“Action is the stage in which individuals modify their behavior, experiences, and/or environment to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. Individuals are classified in the action stage if they have successfully altered the dysfunctional behavior for a period from 1 day to 6 months” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

Helping professionals are really eager to see their clients reach the action stage.  Helping the client implement strategies for change and develop a plan to prevent relapses into old habits.  Therapeutic goals during this stage can center around problem solving, developing a sense of self-efficacy and strengthening your support system.

Strategies

  1. Review the client’s plan for change and revise as necessary.
  2. Develop a relapse plan & prepare the client for this possibility.
  3. Help the client process the difficulties encountered in creating change.

Interview Approach

Be a source of support and encouragement and acknowledge feelings of withdrawal and/or discomfort that tend to accompany efforts to let go of unhealthy habits.  Reinforce the client’s resolve and the importance of remaining in recovery.

STAGE #5: Maintenance

“Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. This stage extends from 6 months to an indeterminate period past the initial action. Remaining free of the problem and/or consistently engaging in a new incompatible behavior for more than 6 months are the criteria for the maintenance stage” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

Treatment needs during this stage involve maintaining changes & preventing old habits to crop up again. For example, I’ve tried to lose weight before, but have yet to realistically sustain it over a significant length of time. Life gets in the way, and I end up slipping and gaining a bit.  Recycling through the stages above is common & it is vital to normalize this experience with clients.  This can help clients examine what hasn’t worked out well in order to learn from past mistakes.

Strategies

  1. Help the client develop a support system that can help the client maintain life changes.
  2. Help the client develop new coping strategies in order to let go of old habits.
  3. Help the client examine behavioral & situational issues that can cause relapse.
  4. Help the client work through the beliefs & expectations that guide their progress.

Interview Approach

Help the client anticipate difficulties in creating lasting change and provide opportunities toward through this struggle.  Should relapses occur, help the client work through underlying factors that may have contributed to it.  Help client develop a sense of self-efficacy so that lasting change an be seen as realistic and achievable.

References

All of the information from this post has been adapted and summarized from the following resources below…

  1. Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of clinical psychology, 67 (2), 143-154.
  2. Sullivan, E., & Fleming, M. (1997). A guide to substance abuse services for primary care clinicians: Treatment Improvement Protocol (TIP) Series 24. Center for Substance Abuse Treatment, Rockville (MD): DHHS Publication, (1997).
  3. Zimmerman, G. L., Olsen, C. G., & Bosworth, M. F. (2000). A ‘stages of change’ approach to helping patients change behavior. American family physician, 61(5), 1409-1416.

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