Diagram 1: Spiral Model of Change (

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1 Objective: This self study module provides an overview of the Transtheoretical Model in relation to the recovery journey. James Prochaska s interest in learning about how people change began when his attempts to help his father, who suffered from depression and alcoholism, failed and ended with his death. While alive, James Prochaska s father did not envision himself as having difficulties with depression or alcoholism and did not believe in psychotherapy. In an attempt to understand why his father could not change, Prochaska began reviewing individual methods of psychotherapy to understand how they encourage change. Prochaska and his colleagues, John Norcross and Carlo DiClemente, found that there were an overwhelming amount (400 +) of methods of psychotherapy available. Many therapies had a very restricted approach but none were clearly better than the others. The Transtheoretical model came out of Prochaska s efforts to find familiar elements within important therapies including psychoanalysis, behaviourism, cognitive therapies, existential analysis and humanism. He tried to segregate the main beliefs and methods of change that each psychotherapeutic approach had to offer. What he discovered was that while each psychotherapeutic approach disagreed on what problems clients have and what they need to change, there was more agreement about how change is effected (Prochaska et al., 1994, p. 25). Prochaska was able to summarize a very large amount of psychotherapeutic theories by a few crucial principles he called the processes of change, which he defined as any activity that an individual initiates to help modify thinking, feeling, or behaviour. This prompted Prochaska to write his first book titled Systems of Psychotherapy in Prochaska determined that all psychotherapies promote change by applying at least two processes of change as seen in Table 1. Each theory of psychotherapy has its own sphere of excellence. For example, psychoanalysis is the preferred approach for raising awareness of both conscious and unconscious motivations, also referred to as consciousness-raising; while behaviourism is the most effective approach for modifying discrete problem behaviours. The Transtheoretical model integrates the best of each approach into a coherent whole. Table 1: Summary of the Principle Theories of Psychotherapy Theory Psychoanalytic Humanistic/Existential Gestalt/Experiential Cognitive Behavioural (Adapted from Prochaska, Norcross, & DiClemente, 1994, p.26) Primary Processes of Change Consciousness-raising, Emotional arousal Social liberation, Commitment, Helping relationships Self-re-evaluation, Emotional arousal Countering, Self-re-evaluation Environment control, Reward, Countering Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January,

2 Having identified the processes of change that were inherent in various psychotherapeutic approaches, Prochaska (1994) now wanted to determine how often individuals who are self-motivated to change (self-changers) employed each of these processes. He engaged a doctoral student, Carlo DiClemente to assist him. They began by interviewing 200 people who were trying to quit smoking on their own. The interviewees came from a wide socioeconomic stratum. Prochaska credits one woman with helping them to understand that change occurs through certain stages. She responded to their inquiry about how often she used each of the different change processes by saying: That depends on when you re talking about, there were times when I used one in particular and times when I didn t use it at all (Prochaska et al.). Prochaska and DiClemente s most surprising discovery was that successful self - changers used certain tools only at specific times and that these specific times were constant from person to person (Prochaska et al., 1994). This phenomenon has now come to be called stages of change. Prochaska and DiClemente also found that there were fewer differences between individuals who use therapy to assist them with change (therapy changers) and self - changers than once believed, that successful change was precipitated by individuals identifying the stage they were in for a particular predicament and matching their challenges to their stage, that individuals progress through the same stages of change regardless of the problem they are addressing, that the same processes of change can apply to any problem and to a combination of problems, that each stage entails a series of tasks that need to be completed before progressing to the next stage, and that undesirable predicaments seem to occur simultaneously (eg. smoking and drinking). There is some evidence that it may be more efficient to apply the processes of change to more than one problem at a time rather than try to change problem behaviours one by one and that people are more likely to be successful in their change attempts when they are given two or more choices of how to pursue change rather than one (Prochaska et al.). Hence, the five stages of change include pre-contemplation, contemplation, preparation, action, and maintenance. The diagram below illustrates the Transtheoretical model as a spiral model of change that includes progress and relapses that is inherent in the individual s journey toward recovery. Diagram 1: Spiral Model of Change ( Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January,

3 Precontemplation The first stage of the Transtheoretical model is the precontemplation stage. Prochaska et al. (1994) describe precontemplators as having no intention of changing their behaviour as they typically deny having a problem. Precontemplators usually attend therapy only as a result of pressures being placed on them by others. In this situation, the precontemplator may express the most interest in finding a way to relieve the demands being placed on them, on having others change their ways, and have no intention of attending therapy as a result of their own motivation. Because after all, they think they do not have a problem regardless of the fact that everyone else thinks so. Change for precontemplators may occur as long as external demands or pressures are maintained, but when external demands are quieted, the individual may promptly assume the self-defeating behaviour once again. Denial and blame are characteristic of precontemplators, they often see things as outside their control and may be demoralized as well because they feel the situation is hopeless (Prochaska et al.). Table 2: Stages and Processes of Change Stages of Change Precontemplation Contemplation Preparation Action Maintenance (Adapted from Prochaska et al., 1994) Processes of Change Consciousness-raising, Social liberation Consciousness-raising, Social liberation, Selfre-evaluation, Emotional Arousal Social Liberation, Self-re-evaluation, Emotional Arousal, Committing Social Liberation, Committing, Helping Relationships, Environment Control, Rewarding Countering Helping Relationships, Environmental Control, Rewarding, Countering The primary processes of change common to the precontemplative stage include consciousness raising and social liberation. Consciousness-raising includes increasing awareness about the self, and gathering information about the predicament at hand that will enable the individual to think about necessary alterations. The first step in fostering intentional change is to become conscious of the self-defeating defenses used to deflect the predicament (Prochaska et al., 1994). Self-defeating defenses may include denial and minimization, rationalization, projection and displacement, or internalization. The following conversation illustrates rationalization and displacement: Emily: Hey Isabella, I notice that you have been smoking more often lately. Isabella: Yeah, I have been under a lot of stress, plus I have been very busy writing. But enough talk about me, what about you re atrocious eating habits of late? In this example, the response does not address the smoking, but instead displaces the blame on writing and stress; in addition the focus quickly shifts from one person to the other. Precontemplators actively resist consciousness-raising by utilizing well-placed defense mechanisms. Social liberation involves any element in the external environment that supports the change effort being made by the individual which in tandem can increase self-esteem. This process may involve creating more alternatives and choices for individuals, providing more information about problem behaviours, and offering public support for individuals who want to change (Prochaska et al., 1994). Social liberation may be actualized by no smoking signs, Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January,

4 seatbelt reminders in cars, bicycle helmet laws, self-help groups, Operation Red Nose, Safe Grad initiatives, crisis centers and others. Techniques that reflect social liberation may include determining who is on that individual s side, whose side the individual is on, and seeking and welcoming outside influences (Prochaska et al.). For example, new friends with healthy living habits may have a positive influence on someone who is trying to quit smoking. The motivational strategies that health care professionals may use with individuals who are in the precontemplative stage of change may include establishing contact with the client, listening to their story in a reflective manner, and affirming the validity and value of their experience. Box 1: Motivational Strategies for the Precontemplative Stage Establish contact Actively listen Affirm Contemplation The next stage of change is the contemplative stage. In this stage many contemplators have indefinite plans to take action in the next 6 months or so, but may also be far from making a commitment to action (Prochaska et al., 1994). Sometimes individuals move quickly into the next stage of change and other times individuals remain in the contemplative stage for a very long time, even years. Though individuals may know their goal and how to achieve it, the time spent in contemplation may be a result of a fear of failure and individuals may conduct a search with no end for the latest information on their predicament but never engage in the change process. Individuals who eternally substitute thinking for action can be called chronic contemplators (Prochaska et al.). Besides consciousness-raising and social liberation, the processes of change involved in the contemplative stage also include self-re-evaluation, and emotional arousal. Emotional arousal refers to an abrupt emotional response to a predicament that empowers the individual toward the action of changing the predicament. It is the energy that allows individuals to supersede procrastination, and determine what is really in their best interest (Prochaska et al., 1994). Techniques to rouse the emotions may include using provocative movies to stimulate emotions, using your imagination to create hypothetical situations that produce feelings of aversion or misery, or thinking of real life circumstances that encountered losses as a negative result of the problem behavior. Emily: Isabella, wasn t that smoking video graphic? Isabella: Yes, it was graphic enough to make me re-consider smoking altogether. In this example, Isabella seems to have been emotionally affected by the movie that she watched enough to consider making a change to her habit of smoking. Self-re-evaluation, which naturally results from consciousness-raising, would include an individual assessing their feelings and thoughts about themselves with respect to the predicament. Self-re-evaluation will reveal that an individual s essential values are in conflict with their problem behaviours, which contributes to leaving the individual feeling, thinking and believing that life would improve without the predicament/problem behaviours (Prochaska et al.) Evaluating the present and evaluating the future including the change are two forms of self-reevaluation that work well to motivate individuals toward preparing for change. For example, Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January,

5 when someone wants to stop smoking they may visualize themselves as a non-smoker and determine the positive outcomes related to conquering their smoking addiction. The motivational strategies that health care professionals may use with individuals who are in the contemplative stage of change may include giving practical assistance for the client s immediate concerns, modeling open and honest communication, expressing empathy, aligning with the client s struggle, explore the client s goals, and support the client s desire to change. Box 2: Motivational Strategies for the Contemplative Stage Give practical help for the client s immediate concerns Model open, honest communication Express empathy Align with the client s struggle with mental health and substance use disorders Explore client s goals Support client s desire to change Preparation While an individual is continuing to work through the processes of social liberation, emotional arousal and self-re-evaluation, they may begin to transition to the stage of preparation which begins with the process of commitment. During the transition, the individual s thinking will begin to focus on the solution to the predicament rather than the predicament itself, and it also directs attention to the future rather than the past. Commitment is taking the responsibility to change. It includes not only a willingness to act, but also a belief in the individual s ability to change, which in turn reinforces a person s will (Prochaska et al., 1994). Techniques that might help consolidate commitment include taking small steps toward the change, setting a date for which the change may begin, telling others outside of the self about the intended change, spending the energy that the change will take, and creating a plan of action (Prochaska et al.). Any lingering ambivalence that undermines the individual s determination must be resolved for the preparation stage to transition to the action stage of change. It is important to allow enough dwelling time in the preparation stage to mitigate the risk of failure. For example, if an individual makes a private promise to themselves one day that they wish to stop smoking immediately and spends little time planning how they are going to proceed with making the change, there is a higher chance that they will not succeed in implementing their change, or that the change will not last very long. Emily: Isabella, when did you say you were going to quit smoking? Isabella: A month ago, I just feel like I don t know how to go about quitting. In this example, Isabella is recognizing that she needs to create a plan to assist her in making the change of quitting her smoking habit. The motivational strategies that health care professionals may utilize with individuals who are in the preparation stage of change include exploring the client s concern about mental health and substance use, and identifying discrepancies between the client s goals and their current behaviors. Box 3: Motivational Strategies for the Preparation Stage Explore the client s concerns about mental health and substance use Develop discrepancies between the client s goals and his/her current behaviors Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January,

6 Action The action stage requires the greatest dedication and is the most visible to others thus lending to the stage that receives the greatest recognition (Prochaska et al. 1994). Still engaged with the social liberation and commitment processes of change, individuals may concurrently focus on the countering, environment control, reward and helping relationship processes as they move into the action stage of change. The use of these processes continues throughout the action stage, which usually lasts for months (Prochaska et al.). Countering is a term that describes when an individual will replace unbeneficial behaviors with beneficial behaviors. Countering involves changing one s responses to a given situation (Prochaska et al.). Effective countering techniques that individuals have used successfully include active diversion (redirecting attention to engage in another activity), exercising (since urges are physical sensations, it can be helpful to use physical activity to overcome urges or cravings), relaxation (sometimes exercise is not feasible because of the environment an individual is in at the time), counter thinking (replacing negative thoughts with positive thoughts), and assertiveness (effectively communicating your thoughts, and feelings when you feel you are not being respected). An example of countering may be evident if someone who has a craving to drink defies that urge by engaging themselves in meditation and visualizing that they are lying on a beach. While using meditation as a countering method might not work for everyone, the challenge lies in determining which countering method fits. Environment control includes restructuring the environment so that the probability of a problem-causing event is reduced (Prochaska et al.). Effective environmental control techniques that successful self-changers have used include avoidance (staying away from environments that encourage unbeneficial behavior), cues (desensitizing oneself to triggering items), and reminders (placing friendly reminders in your environment to control unwanted behaviors). For example, an individual who is trying to quit smoking may avoid buying cigarettes, place pictures of a smoker s lungs around the house as a reminder that smoking damages lungs, or place positive affirmations of success in high traffic areas. Placing No Smoking signs has helped some individuals as well. Rewards modify the consequences that follow desirable behavior and reinforce it (Prochaska et al.). Rewards include treating oneself in the event of beneficial behaviors. Effective reward techniques that individuals have used successfully include covert management (when resistance to temptation occurs and a private kudos is offered to oneself), contracting (devising a rewards plan for each step taken towards one s goal), and shaping behavior (this happens gradually). Self-praise, buying a gift, or investing the money saved as a result of beneficial actions describe rewarding oneself. For example, in the event of quitting smoking the individual may find that they have extra money from not buying cigarettes, and decide to treat themselves and their family to a day at the water park. Helping relationships can mean recruiting outside help, which may be friend, family, spouse, partner or other, to provide support, caring, understanding and acceptance (Prochaska et al.). Engaging with another individual who has the same goals works well, as does receiving praise from designated family members or friends. Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January,

7 Emily: I noticed that you quit smoking. Isabella: Yes, I finally came up with a plan. When I have the urge to smoke, I chew sugarless gum instead and I completely avoid the cigarette counter when shopping. Also, my cousin quit too so we give each other support. I haven t smoked in 32 days! In this example Isabella outlines the elements of her plan that help her to resist temptation and continue taking action in relation to her goal of not smoking. The motivational strategies that health care professionals may utilize with individuals who are in the action stage of change include starting the action plan, eliciting change talk, rewarding progress, using relapses as learning opportunities, involving, nurturing and sustaining social supports, developing specific action steps to work on target behaviors, encouraging selfefficacy and identify examples of same, reviewing and reinforcing actions that are producing behavior change, reviewing and identifying new goals as client continues to change, and emphasizing healthy alternatives. Box 4: Motivational Strategies for the Action Stage Start action plan Elicit change talk Reward progress. Use slips as learning opportunities. Involve, nurture and sustain social supports Develop specific action steps to work on target behaviors Encourage self-efficacy and identify examples of same Review and reinforce actions that are producing behavior change Review and identify new goals as client continues to change Emphasize healthy alternatives Maintenance The maintenance stage is as essential as the action stage, but it is much more difficult to attain. It is during the maintenance stage, which may last from six months to as long as a lifetime, that an individual must work to consolidate the gains achieved during the action and other stages, and struggle to prevent lapses and relapses which is most likely to occur in the first month or two (Prochaska et al.). The factors that are significant to successful maintenance include sustained, long-term effort and a revised lifestyle (Prochaska et al.). To succeed in maintaining a change that was made, one must be able to identify the danger signs that could lead to a relapse. The most common threats to maintenance are social pressures, internal challenges, and special situations (Prochaska et al.). Social pressures are evident when self-changers spend time with those who engage in the undesirable behavior, and those don t understand its impact, internal challenges usually result from overconfidence, temptation, and self blame, and special situations arise when confronted by an unusual, intense temptation (Prochaska et al.). During the maintenance stage of change, the individual must keep up their commitment to the change and avoid people, places, and things that could compromise the change, work to create alternative behaviors, and be aware of their attitudes toward the change. Secretly coveting a relapse is an example of a practice that will inevitably lead to engaging in unhealthy behaviors once again. Patience and persistence is key. Helping relationships, environmental Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January,

8 control, rewarding, and countering are the processes that remain important to the maintenance stage of change. Emily: How long has it been since you quit smoking. Isabella: It has been seven months now and I couldn t have done it without the support of my family and friends. I am so happy. Emily: That s wonderful. Good job! In this example, Isabella indicates that she has maintained her goal of not smoking for three months. She also mentions that although she has been successful to date, without the extrinsic support of her friends and family she would not have been able to accomplish what she has. This statement reveals that she knows her own limits in regards to smoking and uses family and friends to guard against those limits. The motivational strategies that health care professionals may utilize with individuals who are in the maintenance stage of change include keeping focus on the client s goals, reinforcing links between change behavior and accomplishment of client s goals, identifying continuing high risk situations, developing relapse prevention plans, reinforcing self-efficacy, focusing attention on client s gains, reviewing for new areas of risk, supporting continued social engagement for mutual aid, leisure, spirituality, learning & volunteering. Box 5: Motivational Strategies for the Maintenance Stage Keep focus on client s goals Reinforce link between change behavior and accomplishment of client s goals Identify continuing high risk situations Develop relapse prevention plans Reinforce self-efficacy Focus attention on client s gains Review for new areas of risk Support continued social engagement for mutual aid, leisure, spirituality, learning & volunteering Recycle Although relapse is undesirable, it does show that movement toward change can be nonlinear, even circular and is usually the rule rather than the exception. Once an individual relapses, they might slide back to the contemplation stage of change most commonly and begin making plans to institute the change again, working their way forward. Prochaska et al. (1994) outline ten lessons of relapse as follows: Few changers remain in the maintenance stage of change only about 20 percent of the population permanently conquers long-standing problems on the first try. Trial and error is inefficient using relapse as a guide to effective learning can help benefit from experiences. Change costs more than budgeted what is needed is a commitment over time to an action plan that exploits all that the processes have to offer. Using the wrong processes at the wrong time by becoming misinformed, misusing willpower, and substituting one bad behavior for another. Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January,

9 Be prepared for complications problems often coexist; changing one can exacerbate another. The path to change is rarely a straight one self motivated behavior change follows a cyclical pattern. A lapse is not a relapse in changing problem behavior there is a possibility of slipping back into old habits, which does not necessarily mean failure or that a complete relapse is inevitable. Mini decisions lead to maxi-decisions making poor mini-decisions related to the problem behavior can easily lead to a complete relapse. eg. keeping beer in the house for company. Distress precipitates relapse researchers consistently find that distress (including anger, anxiety, depression, loneliness, and other emotional problems) is involved in 60 to 70 percent of relapses in alcohol, drug, smoking and eating problems. Learning translates into action learning from relapse and using the experience to prepare for success by basing another attempt on informed change principles. Most successful changers go through the stages of change at least three to four times. Substance Abuse Treatment Scale Revised Prochaska et al. s stages of change are very important to know when working with clients who have an addiction, whether it is a substance addition or a process addiction. The stages of change are very similar to the Substance Abuse Treatment Scale as is used with individuals with an addiction (Conners, Donovan, & DiClemente, 2001). The Substance Abuse Treatment Scale - Revised (SATS-R) was developed to standardize the assessment of clients motivation to change their substance use behavior (McHugo et al., 1995; Mueser et al., 1995) The SATS-R is an 8-point scale based on the four stages of treatment: engagement, persuasion, active treatment and relapse prevention. Each stage of treatment is broken down into two substages. Behavioural anchors are used to describe the client s substance use behaviour and involvement in treatment, so that reliable and objective ratings can be made (Mueser et al., 2003) The following table compares the stages of change with the SATS-R, the definition and goal of each stage of treatment. Table 3: Overlap between the Stages of Change and the Stages of Treatment Stages of Change Stages of Substance Abuse Treatment Scale -Revised Definition Precontemplation Engagement Client does not have Contemplation Preparation Persuasion contact with clinician Client has regular contact with clinician, and may want to work on reducing substance use Action Active Treatment Client is motivated to reduce substance use, as indicated by reduction for at least 1 month but less than 6 months Goal To establish a working alliance with the client To develop the client s awareness that substance use is a problem, and increase motivation to change To help the client further reduce substance use and, if possible, attain abstinence Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January,

10 Maintenance Relapse Prevention Client has not experienced problems related to substance use for al least 6 months (or is abstinent) (Adapted from Mueser et al. 2003, p ) To maintain awareness that relapse can happen, and to extend recovery to other areas (eg. social relationships, work) Conclusion The Transtheoretical model of Intentional Behavior Change is a model that allows us to view human intentional behavior change (DiClemente, 2007). The Transtheoretical model incorporates elements of various theories of therapy, learning, and behavior change, hence the term Transtheoretical, and looks at what an individual experiences and participates in as they create new behaviors, modify existing behaviors, or stop problematic patterns of behavior (DiClemente). The stages described in the Transtheoretical model include precontemplation, contemplation, preparation, action and maintenance. Within each stage there is a constellation of tasks that create the foundation for movement forward in the process of change as they build upon each other (DiClemente). The path to successful behavior change is to accomplish the tasks well enough to be successful in creating a new pattern of behavior (DiClemente). The journey through the Transtheoretical model is not usually linear but instead can be spiral. Individuals can move forward, backward, and recycle through the stages of change (DiClemente). The stages of change inherent in the Transtheoretical model coincide with the Stages of Substance Abuse Treatment model showing the same goals for the client and motivational strategies for the health care professional. The dynamic framework of the Transtheoretical model makes it imperative that behavior change specialists be aware of the critical tasks and stages, know where clients are in this process of change, and focus efforts on helping them accomplish the parts of the process where they are having difficulty (DiClemente). Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January,

11 References Conners, G. J., Donovan, D. M., DiClemente, C. C. (2001). Substance abuse treatment and the stages of change. New York NY: Guilford Press. DiClemente, C. C. (2007). The transtheoretical model of intentional behavior change. Drugs and Alcohol Today, 7(1), McHugo, G. J., Drake, R. E., Burton, H. L., & Ackerson, T. H. (1995). A scale for assessing the stage of substance abuse treatment in persons with severe mental illness. Journal of Nervous and Mental Disease, 183, Mueser, K. T., Bennett, M., & Kushner, M. G. (1995). Epidemiology of substance abuse among persons with chronic mental disorders. In A. F. Lehman & L. Dixon (Eds.), Double Jeopardy: Chronic Mental Illness and Substance Abuse. (pp. 9-25). New York, NY: Harwood Academic. Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York, NY: The Guildford Press. Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994). Changing for good: A revolutionary six-stage program for overcoming bad habits and moving your life positively forward. New York, NY: Avon Books. Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January,

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