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Stages of change

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Brief over-view of the Stages of Change theory, that aids an individual in changing an unwanted behavior

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Stages of change

  1. 1. John G Kuna, PsyD and Associates Applications of Stages of Change Theory
  2. 2. Abstract Arguably the core of CBT, and perhaps of all therapeutic counseling, is assisting the patient in replacing negative behaviors with positive behaviors. The following will present two theoretical systems for describing and aiding patients in the replacement of dysfunctional behaviors with healthy ones. The Transtheoretical Stages of Change (SOC) model as originally proposed by Prochaska and DiClemente (1983), and later revised by Arthur Freeman and Michael Dolan (2001) will be presented.
  3. 3. Table 1: Prochaska and DiClemente’s Stages of Change Model Stages of Change Characteristics Techniques Pre-Contemplation Not currently considering change: Ignorance is bliss! Validate lack of readniess Reinforce personal agency Encourage self-exploration, not change Explain risks vs. rewards Contemplation Ambivalent about change: On the fence. Not considering change within the next month Validate lack of readniess Reinforce personal agency Encourage evaluation of pros and cons of change Identify and promote new postive outcomes Preparation Some experience with change Plan to change within one month “Testing the waters” Identify and assist in evaluating obstacles Help identify social support structures Verify individual skills for change Encourage small, initial steps Action Practicing new behavior for 3- 6 months Focus on restructring cues and social support Bolster self-efficacy for dealing with obstacles Combat feelings of loss and reiterate long term benefits
  4. 4. Dolan-Freeman Revised Stages of Change “As practitioners, planning for the change process with clients is the single most important skill counselors bring to the therapeutic table” (Dolan, 2001). Table 2: Comparison of the Prochaska/DiClemente and Freeman/Dolan Models Prochaska /DiClemente Freeman/Dolan ****************** 1.Non-contemplation ****************** 2. Anti-contemplation 1. Pre-contemplation 3. Pre-contemplation 2. Contemplation 4. Contemplation 3. Preparation 5. Action Planning 4. Action 6. Action ****************** 7. Pre-lapse ****************** 8. Lapse ****************** 9. Relapse 5. Maintenance 10. Maintenance Analysis The Dolan-Freeman model takes into account that some people may be unaware of the existence of a problem or the need to change (Non-contemplation). The first two stages offer recognition that some patients are required to enter treatment (ie, courts). In some instances they may oppose violently (Anti-contemplation) the whole therapeutic process (Dolan, 2004).
  5. 5. Pre-contemplation and Contemplation: are not tied to commitment as described in Prochaska/DiClemente (1982). Rather, they are understood as cognitive functions of the change process. For Freeman/ Dolan, the Pre-contemplation stage occurs when the client begins to consider the consequences, purpose,and the possibility of change. The Contemplation stage indicates that the client is actively considering and is ready to engage change The Preparation stage of Prochaska/DiClemente is timed (within the next month) and requires an unsuccessful attempt at change within the past year. In the Freeman/Dolan model, Action Planning replaces Prochaska/DiClemente’s Preparation stage and is designed as an interactive collaborative process between the counselor and the client. The Freeman/Dolan Action stage requires a treatment focus that initiates active treatment planning. The Action stage is the same for both models and is analogous to going from neutral to drive The next three stages are completely new and reflect the complex cognitive processes of upsetting the homeostasis of a person through the change process. The first of these stages is Pre-lapse, in which the client is evaluating whether the change made in the Action stage is beneficial or even needed. This is a cognitive process with no behavioral components. The concept of Pre-lapse is needed to explain that once changes are made the client initially goes through a rejection process similar to a body going through the rejection of transplanted parts. The Lapse stage is the behavioral manifestation of the unsuccessful resolution of the Pre- lapse stage. This is usually characterized by a single behavioral event, and if therapeutic redirection occurs, the client returns to the change state. If the resolution of the Pre-lapse stage is unsuccessful or if redirection is ineffective, then the process will move to Re- lapse. Relapse includes a reemergence of the behavioral problems, and the cognitive patterns that induce or reinforce the problem behavior. The lack of these additional stages in the Prochaska/DiClemente model prevents accurate identification and the interventions necessary for the resolution of problems unique to these stages.
  6. 6. The Maintenance stage in both models is conceptually similar; however, the focus in Freeman/Dolan is to continually assess and fine tune the changes until they become habitual, and to generalize to other problem areas throughout a person’s life. The Freeman/Dolan model seeks to provide the counselor with a tool that is more efficient and clinically relevant. The model allows the counselor to more accurately determine where his or her client is on the continuum of change and to factor into the change process any special conditions or circumstances such as cultural differences. Empirical basis: In a recent study (Dolan, 2003), the Freeman/Dolan model was found to offer counselors greater ability to accurately identify the stages their clients were in than was true of the Prochaska/DiClemente model. In addition, the participants preferred the Freeman/Dolan model to the original model three to one. Change and Treatment Planning Three components of Treatment planning: (1) Stage or Diagnosis and Assessment; (2) Level or Problem Identification; and (3) Treatment or Strategy Implementation. SLT model refers to a Stage by Level by Treatment interaction of creating change. The Stage component acknowledges when to change or the current stage of change for the client. Stage is established using questionnaires, and/or formal and informal counselor assessment. Methodology may include assessments such as psychosocial history, mental status, risk assessment, presenting problem, and strengths and weaknesses. Level of the change process refers to what change is required and is determined through some form of problem list and/or clinical interview. Most theoretical models for conducting counseling contain the “what” of change within the model. Included in the Level of change are: (1) Cognitive or the mental process of knowing; (2) Affective or raw visceral experiences interpreted as emotions and feelings (cognitive labels); (3) Behavior or the actions or reactions of persons in response to external or internal; and (4) Environment or the context for clients’ living.
  7. 7. Treatment refers to how clients change and is composed of the strategies and techniques that are most effective for dealing with specific problems at a certain stage and level of change. Example: the counselor might use the strategy of refutation for a client’s cognitive distortions when the client is in the Contemplation stage and is ready to change.
  8. 8. References (and Recommended Readings) Freeman, A., & Dolan, M. (2001).Revisiting Prochaska and DiClemente’s Stages of Change theory: An expansion and specification to aid in treatment planning and outcome evaluation. Cognitive and Behavioral Practice, 8, 224–234. Kazdin, A. E. (2000). Psychotherapy for children and adolescents: Directions for research and practice.New York: Oxford University Press. Kendall, P. C., &Chambless, D. L. (Eds.). (1998).Empirically supported psychological therapies [Special section]. Journal of Counseling and Clinical Psychology, 66, 3–167 Nathan, P. E., & Gorman, J. M. (Eds.).(1998). Treatments that work. New York: Oxford University Press. Norcross, J. C., Krebs, P. M., &Prochaska, J. O. (2011).Stages of change.Journal Of Clinical Psychology, 67(2), 143-154. doi:10.1002/jclp.20758 Prochaska, J. O., &DeClemente, C. C. (1982).Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice, 20, 161–173. Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), 1102-1114. Prochaska, J.O., Velicer, W.F., Rossi, J.S., Goldstein, M.G., Marcus, B.H., Rakowski, W., Fiore, C., Harlow, L.L., Redding, C.A., Rosenbloom, D., & Rossi, S.R. (1994). Stages of change and decisional balance for twelve problem behaviors.Health Psychology, 13(1), 39-46.
  9. 9. Appendix A Expansion of Prochaska and DiClemente’s Stages of Change Model I. Pre-contemplation Stage "Ignorance is bliss" "Weight is not a concern for me" Goals: 1. Help patient develop a reason for changing 2. Validate the patient’s experience 3. Encourage further self-exploration 4. Leave the door open for future conversations 1. Validate the patient’s experience: "I can understand why you feel that way" 2. Acknowledge the patient’s control of the decision: "I don’t want to preach to you; I know that you’re an adult and you will be the one to decide if and when you are ready to lose weight." 3. Repeat a simple, direct statement about your stand on the medical benefits of weight loss for this patient: "I believe, based upon my training and experience, that this extra weight is putting you at serious risk for heart disease, and that losing 10 pounds is the most important thing you could do for your health." 4. Explore potential concerns: "Has your weight ever caused you a problem?" "Can you imagine how your weight might cause problems in the future?" 5. Acknowledge possible feelings of being pressured: "I know that it might feel as though I’ve been pressuring you, and I want to thank you for talking with me anyway." 6. Validate that they are not ready: "I hear you saying that you are nowhere near ready to lose weight right now." 7. Restate your position that it is up to them: "It’s totally up to you to decide if this is right for you right now." 8. Encourage reframing of current state of change - the potential beginning of a change rather than a decision never to change: "Everyone who’s ever lost weight starts right where you are now; they start by seeing the reasons where they might want to lose weight. And that’s what I’ve been talking to you about."
  10. 10. II. Contemplation Stage "Sitting on the fence" "Yes my weight is a concern for me, but I’m not willing or able to begin losing weight within the next month." Goals: 1. Validate the patient’s experience 2. Clarify the patient’s perceptions of the pros and cons of attempted weight loss 3. Encourage further self-exploration 4. Leave the door open for moving to preparation 1. Validate the patient’s experience: "I’m hearing that you are thinking about losing weight but you’re definitely not ready to take action right now." 2. Acknowledge patient’s control of the decision: "I don’t want to preach to you; I know that you’re an adult and you will be the one to decide if and when you are ready to lose weight." 3. Clarify patient’s perceptions of the pros and cons of attempted weight loss: "Using this worksheet, what is one benefit of losing weight? What is one drawback of losing weight?" 4. Encourage further self-exploration: "These questions are very important to beginning a successful weight loss program. Would you be willing to finish this at home and talk to me about it at our next visit?" 5. Restate your position that it is up to them: "It’s totally up to you to decide if this is right for you right now. Whatever you choose, I’m here to support you." 6. Leave the door open for moving to preparation: "After talking about this, and doing the exercise, if you feel you would like to make some changes, the next step won’t be jumping into action - we can begin with some preparation work." III. Preparation Stage "Testing the Waters" "My weight is a concern for me; I’m clear that the benefits of attempting weight loss outweigh the drawbacks, and I’m planning to start within the next month." Goals: 1. Praise the decision to change behavior 2. Prioritize behavior change opportunities 3. Identify and assist in problem solving re: obstacles
  11. 11. 4. Encourage small initial steps 5. Encourage identification of social supports 1. Praise the decision to change behavior: "It’s great that you feel good about your weight loss decision; you are doing something important to decrease your risk for heart disease." 2. Prioritize behavior change opportunities: "Looking at your eating habits, I think the biggest benefits would come from switching from whole milk dairy products to fat-free dairy products. What do you think?" 3. Identify and assist in problem solving re: obstacles: "Have you ever attempted weight loss before? What was helpful? What kinds of problems would you expect in making those changes now? How do you think you could deal with them?" 4. Encourage small, initial steps: "So, the initial goal is to try nonfat milk instead of whole milk every time you have cereal this week." 5. Assist patient in identifying social support: "Which family members or friends could support you as you make this change? How could they support you? Is there anything else I can do to help?" Prepared by Phillip J. Kuna for John G. Kuna, PsyD and Associates (570)961-336