Stages of Change

By: Craig Harling, Vice President, Clinical Services

How often have we heard or said, “Why are we taking that patient again? They never change their behavior.” Having worked in hospital settings of all kinds for over 30 years, I have worked with many patients and families who seem resistant to change. Understanding the Transtheoretical Model of Change (TTM), or Stages of Change, helped me better manage those treatment-resistant patients and families. The Stages of Change model is the basis behind Motivational Interviewing, which is briefly explained below, and has been successful in helping patients manage healthier lifestyles, addictive behaviors, negative behaviors, and mental health issues. It has even been used in managing employees. There has been success in using this model to assist caregivers in managing their loved one’s progressive dementia and behavior.

Motivational Interviewing is an evidenced-based counseling method that increases a person’s motivation to make positive behavioral changes by helping people resolve ambivalent feelings and insecurities to find the internal motivation they need to change their behavior. Used with the Stages of Change, it increases positive outcomes and decreases staff burnout. It helps people realize the impact and consequences of their behavior on themselves and others, addresses the ambivalence the patient might have about changing, and provides things patients can do to begin to make changes.

TTM was developed by Drs. James Prochaska, Carlo DiClemente, and John Norcross. Dr. Prochaska was motivated after watching his father suffer and die from depression and alcoholism. He was inspired to learn why his father chose not to use the services and treatments available to him. The traditional approach of thinking that the patient just needs to “hit bottom” before he’s willing to change didn’t work for his father. TTM began in 1977 and involved over 35 years of research and the review of different theories of psychotherapy. To change, a patient must believe they can influence their environment (Locus of Control) and be motivated to make necessary changes. Without those, the patient will continue to engage in negative behaviors. Behavior change is hard for most patients. Sometimes, it seems to work because it’s a payoff for their current behavior. For others, the payoff for changing their current behavior for healthier behaviors may not be as intense, or it may be delayed. Change takes time and effort, usually after many failed attempts. Some patients just give up on changing.

Understanding the stages of change, where our patients are, and helping them move to the next stage is the most effective way to bring about permanent change.

The Five (or Six) Stages of Change:

  1. Precontemplation: Typically, patients in this stage don’t think they have a problem, or they think that everyone/someone else is the problem. Some may feel that their problem is beyond help. They do not intend to change and may even be very resistant. 35-40% of patients are believed to enter treatment at this stage.
  2. Contemplation: Patients in this stage recognize that there are problems with their current behavior, but they are usually ambivalent about changing. They begin to weigh the positives and negatives of changing. An estimated 35-40% of patients enter treatment at this stage.
  3. Preparation: Patients are convinced of the need to change and are ready to make changes. They begin to make small changes and evaluate whether they are working. Only 20% of patients enter treatment at this or the next stage.
  4. Action: Multiple attempts to change are made, and the patient begins to make behavior changes. Specific and overt modifications to behavior are implemented.
  5. Maintenance: Most patients in this stage are no longer in treatment, or there is minimal treatment. The patient is creating new behavior patterns, and sustained change is tested. Patients build on their successes.
  6. Recycling: This refers to relapse. Most patients will struggle with making permanent changes and return to old behaviors. Typically, 15% of patients will return to the precontemplation stage and 85% to the contemplation stage.

Most people learning new behavior patterns will go back and forth between the stages before reaching permanent change. Negative behaviors are learned and developed over time, so we shouldn’t expect new behaviors to stick quickly. Many of our patients will be in and out of treatment several times before they succeed. Meeting them at the stage they are in and helping them move onto the next stage will have the best success.

A great deal of what we do when patients enter treatment at our facilities is to focus on taking medications and engaging in new behaviors. However, considering that most people entering treatment are only in the precontemplation or contemplation stages, they are not ready or willing to make sustained changes to their behavior. Our goal needs to be to move the patient to the next stage. That means we will continue seeing the same patients (frequent fliers) in and out of treatment. Changing our tactics to move the patient to a different stage of change will have much more success than expecting that the patient will not return to treatment.

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