The stages of change are a transtheoretical model of behavior change. It assesses a person’s readiness to act and incorporate healthier behaviors. It was developed by James O. Prochaska and colleagues at the University of Rhode Island beginning in 1977. (Wikipedia, 2014) Learn about the stages of change and how to use them in your therapy.
The stages in the model are precontemplative, contemplative, preparation, action and maintenance. In addition, some people add a relapse stage but in the model, relapse is considered a return to an earlier stage. Plus, an additional stage called termination was added in later years. (Wikipedia, 2014) It means that the client has no temptation to return to old behavior and is confident they will maintain the change. I’m not sure I agree with this stage. I think that whether the behavior is addiction or mental health related, people have a tendency to return to old behavior in times of stress. I believe it is dangerous to let someone believe there is no chance of returning to old behavior. This kind of thinking can lead to relapse if the client is over-confident and ignores warning signs.
Why use the Stages of Change?
Before offering any suggestions to a client, you have to build rapport with them. People are more open to what you have to say if they feel connected to you. I think the best way to build rapport is to really listen to the client, empathize and meet them where they are. Nothing can damage a relationship more than if a client is in the precontemplative stage and you jump in with suggestions. When you don’t see the connection between your behavior and your problems, you won’t take to suggestions for what to do to change your behavior.
The best way to meet a client where they are is to consider what stage of change they are in. You can work with a client differently depending on what stage they are in. Be aware that people can move back and forth between stages so you have to continually assess what stage they are in.
They are not ready to change in the next 6 months. They may not even be thinking about changing or realize they need to change. They may be unaware of their unhealthy behavior, how it connects to the problems in their lives and the effect it has on others.
Ask open-ended questions aimed to make them think about the effect of their behavior. Explore the pros and cons of healthy behavior and unhealthy behavior. Explore how their behavior affects their thoughts and feelings. Empathize with the client’s feelings. Encourage them to explore the effects of their behavior on others. Elicit the emotional impact of their behavior on themselves and others. Point out the difference between their goals and actions in an empathetic way. If family is involved in treatment, encourage them to explain how they see the problem and how they are affected by it.
They are getting ready to change. They intend to make changes in the next 6 months in this stage. They are aware that changes are needed and are starting to see the pros of changing. They may be ambivalent and use words like “yes, but.” In their minds, the cons for changing are starting to equal the pros.
Work on reducing the cons for changing. Educate client about healthy behavior. Explore what their life would be like if they did change. Have them try a few steps toward change. Elicit hopeful emotions that change is possible. Work on clarifying values and how their values are aligned with the change. Role models can be useful is showing the client that change is possible and that it is positive. Guided imagery can help them imagine what life would be like if they changed.
They are ready to change in the next 30 days at this stage. They start taking small steps toward changing. They start to see how the changes will improve their lives. They may begin to start talking about changing and sharing their progress with family and friends.They may have fears that they will fail.
Encourage them to talk about the change in therapy and with family and friends. Address anything that might get in the way of change. Process the steps they are taking and how it impacts their lives. Process their fears about failing. Educate them about the process of change. Let them know that even if they take a step back, they are still making progress when they take a step forward. Educate them about how to prepare for change to limit failures. Encourage them to use their support system.
A client at this stage has changed their behavior within the last 6 months. They have taken action and made changes. They are working to keep moving forward.
Encourage continued use of support systems. Reinforce positive changes and healthy behavior. Educate client about coping skills and other techniques to stick with new, healthier behavior. Encourage them to reward themselves for progress and practice using new coping skills and techniques in life situations. Encourage them to keep up the changes they have made and keep moving forward. Explore how the people in their lives either help them change or hinder them. Encourage then to avoid people who are engaged in unhealthy behavior and would encourage them to do so as well.
A client at this stage has changed their behavior for at least 6 months. They need to be aware of anything that could lead them to revert to old behavior.
Encourage them to use their support systems. They need to be aware of anything that could lead them to revert to old behavior. They should work on a plan for lasting change. They need to continue to avoid people who are engaged in unhealthy behavior and would encourage them to go back to their old ways. Process the positive emotions they have about the changes they have made and how it has improved their lives. Explore any negative emotions and how they can cope with them. Continue to reinforce progress and growth. Encourage self-efficacy.
After the Maintenance Stage, some people add a stage called Relapse. This is when a client returns to their old behavior and ways of thinking. However, it may not be a stage of its own but a return to an earlier stage of change like precontemplation or contemplation. I think relapse, especially in regards to addiction, needs to be addressed on its own.
Client returns to old behaviors or ways of thinking. They may begin to see the change in a negative light. They may begin to see their old behavior as attractive and think that it meets a need or will make them feel better. Relapse may begin before they actually return to old behavior. It involves thinking about returning to old behavior and other behaviors that may lead to a return such as being around people involved with the old behavior.
Process their thinking about returning to their old behavior. Process any behavior that could lead to relapse. Explore the pros and cons of old and new behavior. Encourage them to get opinions from their support system. Family could remind them of what life was really like before the change. People have a tendency to forget how bad things really were. Review what was working for them before and how they can get back to it.
The client has no intention of returning to old behaviors and is confident they can maintain the change for the rest of their life.
There really isn’t much work to be done with someone in the termination stage. This is when therapy would end. However, you can have a session to wrap up therapy and discuss the client’s long-term plans if they ever feel like they could return to old behavior. You can review coping skills and stress management techniques. You can review a plan for relapse if one was made in the maintenance stage. I think it is prudent to educate the client that relapse can happen and they should be ready to look for signs no matter how confident they feel in the moment.
“Transtheoretical Model.” Wikipedia. Wikimedia Foundation, 21 May 2014. Web. 27 May