Today's podcast is on Prochaska and DiClemente's (1983) Stages of Change Model.

This model describes five

stages that people go through on their way to change: precontemplation, contemplation, preparation,
action, and maintenance.
The model assumes that although the amount of time an individual spends in a specific stage varies,
everyone has to accomplish the same stage-specific tasks in order to move through the change process
(Prochaska & Prochaska, 2009). There is an unofficial sixth stage that is variously called "relapse,"
"recycling," or "slipping" in which an individual reverts to old behaviors. Examples include having a beer after
a period of sobriety, or smoking a cigarette a year after quitting. Slipping is so common that it is considered
normal. Social Workers are encouraged to be honest with clients about the likelihood of backsliding or
reverting to old behaviors once the change process has started, not because we expect our clients to fail,
but because it normalizes the experience and takes away some of sense of failure and shame.

Although the "Stages of Change" model was identified and developed during a study of smoking cessation
(Prochaska & DiClemente, 1983), the model has been applied to and studied with numerous bio-psycho-
social problems, including domestic violence, HIV prevention, and child abuse (Prochaska & Prochaska,
2009). The "stages of change" model is one component of the "Transtheoretical model of behavior change"
(Prochaska & DiClemente, 1983). It is called the "transtheoretical model" because it integrates key
constructs from other theories. The TTM describes stages of change, the Process of Change, and ways to
measure change. In today's podcast, I'm going to focus on the Stages of Change. If you are interested in
learning more about the broader Transtheoretial Model, there are dozens of resources online and in print.
The University of Rhode Island's Cancer Prevention Research Center website has a clear and concise overview
of the TTM: https://web.uri.edu/cprc/detailed-overview/. If you are looking for a social work-specific
application of the TTM, there is an excellent chapter in the second third edition of the Social Workers' Desk
Reference on the TTM and child abuse and neglect (pp. 707 - 715).

The purpose of this podcast is to provide a brief overview of the five stages of change and what intervention
approaches are most appropriate at each stage of change. I drew on a number of resources in the
preparation of this podcast, including a chapter on the stages of change and motivational interviewing by
DiClemente & Velasquez in Miller and Rollnick's second edition of their book, Motivational Interviewing
(Miller & Rollnick, 2002) [note: Miller & Rollnick published a 3rd edition of Motivational Interviewing in
2013, after this episode was recorded. If you'd like to learn more about MI-3, here's a link to the podcast
episode with Mary Velasquez about the changes to the 3rd edition]; A 2002 article by Norcross and
Prochaska (2002) from the Harvard Mental Health Letter called "Using the Stages of Change;" and the chapter
by Prochaska and Prochaska (2009) in the second edition of the Social Workers' Desk Reference that I just
mentioned. All of these references can be found on the podcast website at http://socialworkpodcast.com/.

In today's podcast I'll talk about how to figure out what stage someone is in, and identify a couple of
interventions that are most effective for the person in that stage. I'm not going to go into great detail about
interventions because there is a major treatment approach called Motivational Interviewing that addresses
dozens of intervention techniques. Along the way I'll provide examples of things that social workers can say
to people in different stages of change. I've drawn most of my examples from situations other than
addictions. I've done this because the Stages of Change model was developed out of addictions research and
there are a lot of examples with addictions. Since the Stages of Change is applicable to behaviors other than
addictions, I wanted to focus on some of those examples. I end the podcast with a brief critique of the
model.

Download MP3 [35:29]

TRANSCRIPT

Precontemplation
Characteristics
People in precontemplation do not see their behaviors as a problem and therefore see no need to change.
This is sometimes called the "ignorance is bliss" stage. Clients in the precontemplation stage have
traditionally been thought of as "resistant to change." You might be thinking, "well, if someone doesn't see
their behaviors as a problem and are not interested in changing, then why would I need to know how to work
with them – after all, they are not likely to be in treatment." Although many people in precontemplation
will, by definition, never present for treatment, research has found that between 50 – 60% of clients are in
the stage of Precontemplation, which means they don't see a problem and therefore see no need to change
their behaviors. These include any client who is pressured or coerced into services. Examples might include
the mother whose child has been removed by the state; because it was her partner who abused the child and
not her, she doesn't see how her behaviors would need to change. However the State, and possibly others,
see her parenting as neglectful and not adequate to justify returning the child to her care. Another example
is the child who is brought for services by a parent because of problems in school or at home; the child
might see that everyone else has a problem – the teachers, the other kids, or even the parents. Other
examples include clients who in treatment because they were court-ordered, required by employers, or even
by their partners. In all of these situations, there is someone else who recognizes a problem and has the
power to make the person enter treatment against their will. Norcross and Prochaska (2002) call these
clients "uninformed."

Now, it is possible that these clients tried changing their behaviors in the past but were unsuccessful.
Because the change didn't work or didn't stick in the past, they now see change as unrealistic or impossible
and therefore not worth pursuing. Norcross and Prochaska (2002) call these clients "underinformed."
Examples might include people who have tried to give up smoking or drinking, people who have tried to
leave abusive relationships, youth who have tried and failed to leave gangs, or even have failed to be
successful at school.

So, the group of people who have never seen their behaviors as problems are considered "uninformed," and
the group of people who have seen their behaviors as problematic in the past but are not currently
interested in changing are called "underinformed." Neither group is interested in changing their current
behaviors.

Assessment
Norcross and Prochaska (2002) suggest assessing precontemplation by asking if the person is considering
making a change in the next six months. If they agree to statements like, "I guess I have faults, but there's
nothing that I really need to change" and "As far as I'm concerned, I don't have any problems that need
changing," then they are in precontemplation. Prochaska and Prochaska (2009) note that people in
precontemplation AND maintenance believe that their behaviors do not need changing, but for very different
reasons. So, it is important to find out why. The parent who says, "Yeah, I'm not perfect, but I'm no worse
than anyone else, so why should I change?" is telling you that there is no problem, and therefore no reason
to change. This parent is in Precontemplation. In contrast, the parent who says, "Yeah, I'm not perfect, but
I'm so much better than I used to be and I'm really trying hard not to fall back into my old ways of behaving"
is telling you that he or she changed the problematic behavior and is trying to maintain it. This parent is in
maintenance. If the difference between the two stages is a little confusing, no worries; it will make more
sense by the time I've finished the podcast. Just remember, there are only two stages in which someone
doesn't see a problem: precontemplation and maintenance. In the other stages, contemplation, preparation
and action, the person sees a problem.

Intervention
Clinicians have to tailor their interventions to match the clients stage of change. For people in
precontemplation research has found that it can be helpful to increase awareness about the problem. For a
parent involved in child welfare, the mere presence of protective services can sometimes be enough to
increase awareness (Prochaska & Prochaska, 2009). Another intervention is to move people emotionally. I
ran a group for parents trying to reunify with their children who had been removed by protective services.
One of the first assignments asked parents to write about the abuse or neglect from the child's perspective.
This assignment was often very emotional and for many parents helped to move them from a place of being
defensive about what they had done (or not done) to a place of feeling really sad and remorseful. The
emotional shift was key in getting them to move towards permanent change in their parenting behaviors
because they were able to acknowledge a problem. Prochaska and Prochaska (2009) mention three other
interventions that can be used with precontemplators, including discussing the benefits of changing,
encouraging the individual to look at the consequences of what is happening now, and pointing out
discrepancies between the way the individual would like to be and the way they are.
So, let's say you do all of this and your client starts saying things like, "yeah, I guess that's a problem," or "I'm
sure it would be better if I didn't do that," then they have moved out of Precontemplation and are in stage 2
– contemplation.

Contemplation
Characteristics
The second stage is called contemplation. In this stage, people recognize a problem and are contemplating a
change, but haven't yet committed to changing. For example, you want to lose weight and have looked into
joining a gym but haven't yet signed up. People in contemplation are sitting on the fence – part of them
wants to change, but an equally compelling part of them wants to stay the same. When you are sitting on
the fence, we say you are ambivalent about change. The contemplation stage is all about ambivalence.
Prochaska and Prochaska (2009) note that people can stay in contemplation for a very long time. Change is
tough. It is hard to take that first step. Chronic contemplators spend lots of time thinking and not much time
doing. This is in part because "contemplators struggle to understand their problem, to see its causes, and to
think about possible solutions" (DiClemente & Velasquez, 2002, p. 208).

Assessment
You can assess for contemplation by listening for statements like, "I know I have a problem, but I'm not
really sure I want to do anything about it." or "I'm not really sure what I can do about it." For example, a
parent in the child welfare system might say something like, "I know I can do better by my kids, but I'm not
really sure how." Once you've established that your client is ambivalent, then you can decide what types of
interventions are most appropriate.

Intervention
The most important thing to remember about intervening with someone in contemplation is that they are
evaluating the pros and cons of change, but haven't yet decided to change. If you start making suggestions
about how to change, the part of your client that wants things to stay the same will bring up all of the
reasons why change is not possible. The last thing you want to do is have your client talk themselves into not
changing their dysfunctional behaviors. Miller and Rollnick (2002) call the social worker's instinct to fix the
situation the "righting reflex." So, how do you talk with your client so that they talk themselves into change?
Prochaska and Prochaska (2009) suggest a number of interventions including: 1) talking with your client
about the pros and cons of changing, also called the Decisional Balance technique; 2) Pointing out the
discrepancy between how your client would like to be and how they are, also known as Developing
Discrepancy; and; 3) Instilling hope.

Pros and cons: For the parent involved with child welfare, you can ask, "What are the benefits of changing
your approach to parenting? What problems do you see with changing?" Your client might respond by saying,
"I will get my kids back and child welfare will be out of my life," and "My kids only respond to spanking. I've
tried time out and it doesn't work, so I'm never going to be able to control my kids without being able to
spank them." You also want to explore the pros and cons of maintaining the status quo, also known as
staying the same. You can ask, "What reasons can you come up with for not changing your parenting style?
What are the downsides of keeping your parenting style the same?"

Developing discrepancy: You can confront clients in this stage and expect to have some impact. But, you
have to focus on the discrepancy between how they would like to be and how they are. For example, you
can say to the parent involved with child welfare, "You say that getting your kids back is your #1 priority, but
you've missed the last two supervised visitations. Since actions speak louder than words, you're telling me
that being with your kids is not your first priority." Now, that might sound harsh, but it points out the
discrepancy between the way the parent wants to be and the way they are. Your client is not likely to be
motivated to change if they don't see a difference between how they would like to be and how they are.
Another way of developing discrepancy is by providing your client with education about how things could be,
such as books or videos that illustrate new behaviors. This kind of information is useless in Precontemplation
because people don't see a problem, but it works well in contemplation because they've partially bought into
the idea that they want to change, but are not sure how.

Instilling hope: This is essential because people in contemplation have a voice inside saying, "change is too
hard, it is not worth it, as bad as things are now it is easier than changing..." When you instill hope that your
client can change, it supports the voice in your client that says, "I don't like how things are going, I want to
change."

Preparation
Characteristics
The third stage is called preparation. In this stage, people have decided to change their dysfunctional
behaviors within a month. People in preparation have taken little steps towards changing their behavior –
they are "testing the waters." Those little steps might have failed, or they might have worked, but they have
not resulted in the kind of behavior change that the client wants. For example, you want to lose weight,
have said no to desert for the last few months and even dusted off a workout tape. But you haven't lost any
weight, don't have a comprehensive plan, and find yourself mostly engaged in the old behaviors, even
though you don't want to.

Assessment
When you assess for preparation, you want to listen for statements like, "I really want to change because..."
and "I wish I could just figure out how to..." Prochaska and Prochaska (2009) suggest that a parent involved
in the child welfare system might indicate preparation by making statements like, "I have questions for my
caseworker about how to parent differently," and "If I don't change, I'll never be the parent I want to be."
Because your client has already taken small steps towards change, but hasn't been successful, you want to
find out how much support he or she has to make the change, and if he or she has the skills needed to make
the change. For example, your client wants to stop spanking her children but lacks the social support to do
that. Her friends and family all spank and believe it is an appropriate intervention. When mom is not around
they spank her kids. This mom has no support to parent differently. Furthermore, because she has no
examples of how to discipline without spanking, she lacks the skills to follow through. For example, when
you ask how she might discipline her child without spanking, she comes up short.

Intervention
Prochaska and Prochaska (2009) suggest four interventions for people in preparation: Encourage your client's
commitment to change; support self-efficacy; generate a plan and set action goals.
You can encourage your child welfare client by saying something like, "Your decision to change how you
parent tells me that you are dedicated to not only getting your kids back, but also to strengthening your
family to prevent future abuse and neglect."
When you generate a plan and set action goals you want to make sure your setting up your client for success.
If you have identified deficits in supports and skills, an appropriate plan would be to establish these as part
of the goals for change. You don't want to set up your client with unreasonable expectations for finding
friends and family who will support their new behaviors or else they will move away from wanting to change.
The same is true for new skills. You can set up small and attainable behavior goals for your in-office services
so that at the end of every session they feel like they have accomplished something and are one step closer
to their goal. Social workers should be aware, though, that just because a client is preparing to make
change, doesn't mean that they are willing to participate in the program that the social worker has
identified for the client. I might be prepared to join a gym lose weight, but as a man in my late 30s, I won't
join Curves or Lady Fitness. So, it is important not to confuse willingness to change with an automatic buy-in
of existing programs or services.

Action
Characteristics
The fourth stage is called action. In this stage, people have changed their dysfunctional behavior at least
one day and no more than 180 days. People in the action phase have put into practice the plan developed in
the preparation phase. They are consciously choosing new behaviors, being confronted with challenges to
the new behaviors, and consequently gaining new insight and developing new skills. For example, the
mother who no longer uses corporal punishment tells her social worker, "In the last few weeks of not hitting,
I've realized that it is easier to hit than to not hit, and when I am tired and the kids are driving me crazy, it
takes all I got to not hit them. I really appreciate my one friend who doesn't spank – she's so good to be
around." People in the Action stage are enthusiastic and motivated. When social work students and most of
the public think about what it would be like to do therapy, they usually think of working with people in the
action phase. Prochaska and Prochaska (2009) noted that most treatment programs are built around the
action phase, even though only a small percentage of clients are actually in action. (Story about pregnant
woman and how easy it was).

Assessment
Social workers should listen for statements that indicate both an acknowledgement of a prior problem and
new behaviors. Again with the child welfare example, a father might say, "I'm doing something about the
behaviors that got me involved with child welfare in the first place."

Intervention
Intervention in the action stage includes a lot of verbal reinforcement and supporting the person's belief that
he or she can sustain the change. In motivational interviewing this is called "supporting self-efficacy." You
want to identify specific behaviors that your client has changed and connect them with the changes you're
seeing in their life. For example, if a mother has changed her parenting style and you notice that her
children are responding better as a result, you can make encouraging statements that explicitly support the
mother's ability to change her behavior and get the results she wants as a result of the change. For example,
you could say something like, "I notice that during supervised visitation you are using more encouraging
statements with your kids, and are less likely to withdraw when they start fighting. I've also noticed that
ever since you've been doing that your kids have brought up the subject of coming home more often, and are
more excited about the family getting back together. They also seem genuinely happy when you pay them
compliments rather than ignoring them. All of these things suggest that as hard as it is to parent differently,
you're really making a lot of changes and they seem to be making a big difference for your children and your
family."

Maintenance
Characteristics
The fifth stage is called maintenance. In this stage, people have been engaged in the new behavior for at
least six months and are committed to maintaining the new behavior.

Assessment
You know your client is in maintenance when they report there is no problem and are able to describe how
their current behavior is different from their past dysfunctional behavior.

Intervention
Intervention at the maintenance stage looks different than at the previous four stages. You will probably be
meeting less frequently. Your conversations will revolve around how your client is sustaining their
commitment to the new behavior. You will talk about how he or she might cope with a relapse and ways to
avoid relapse. Clients in this stage of change tend to be confident about their ability to maintain the change.
You can help your client to identify when they have become overconfident, and consequently might put
themselves in a position to relapse. As an example, I was working with a gay man in his late 40s who
reported 12 months of sobriety. I knew this client was in maintenance because he described his past
behaviors and distinguished them from his behaviors from the past year. He was confident about his ability
to stay sober, but had decided to go into therapy as he started to get back into the dating scene. He was
looking for a committed relationship that was supportive of his drug and alcohol free lifestyle. In our first
session he said that he could think of three places he could find a partner, and each place presented some
challenge to his sobriety: bars and clubs, the AA meeting he'd been attending, and online. We talked about
how frequent contact with his AA sponsor would be one way of demonstrating commitment to sobriety, as
well as a source of support while stepping out into situations that might trigger a relapse. For example, we
talked about what he would do if he met a man online who suggested they get together for a drink. He was
clear that he wouldn't drink and was confident that he could be around someone who was drinking, but had
concerns about how his sobriety might look to his date. So, we addressed situations that might trigger him to
want to drink, including the desire to take the edge off of meeting someone new, the desire to conform to
social expectations, and the fear of not being able to perform sexually sober. We came up with a plan that
included support by his sponsor, self-affirming statements, and an honest talk with his date. I also had him
describe what his life was like prior to becoming sober, including losing his job and being homeless for a
period. I contrasted that with his current situation and emphasized how easily he could lose it all. Since he
was in maintenance, emphasizing these differences served to reinforce his commitment to sobriety and
added a sense of urgency to the plan.

Relapse
There is an unofficial sixth stage – relapse. This is the "falling off the wagon" stage. A relapse is defined as
resuming the old behaviors. So, you have to engage in new a behavior, which means you are in action or
maintenance, before you can "relapse" into old behaviors. The longer someone is in maintenance, the more
devastating relapse can be to the person and those around him or her. People who relapse often feel
disappointed and frustrated. Watching a client go through relapse can be painful for the provider. But, as I
mentioned before, it shouldn't be unexpected. Relapse is considered the unofficial sixth stage of change for
a reason – it occurs very frequently. So, you shouldn't rest on your laurels and wait for your client to relapse.
But, when it happens, don't over react and make the situation worse.

Intervention
There are a couple of specific areas to address when intervening with someone in the Relapse stage. The
first is to find out what triggered the relapse. Have your client describe the moment he or she engaged in
the old behavior, and then work backward to find out how he or she got to that point. Next, you can review
your client's motivation for engaging in new behaviors and identify what barriers exist that might prevent
your client from "getting back on the wagon." If you have been working with your client for a while, you can
review the motivations identified during work in a prior stage. Listen for new motivators. Sometimes people
in relapse gain insight into why they do what they do and are able to come up with new motivators as well
as barriers. The third area to address is your client's coping strategies. Clearly his or her coping strategies
were insufficient to maintain the change, so you'll want to help him or her identify and implement new
coping strategies. Since your client is likely to be feeling like a failure for relapsing, acknowledge his or her
feelings and then reframe the relapse as an opportunity to learn and become stronger. You can say
something like, "I realize you feel like a failure, and I understand why. But I want to suggest that perhaps
this relapse is a wake-up call to some of the problems with the strategies you've been using and an
opportunity to fix them and improve on them." The client I talked about who presented in maintenance had
a relapse during our treatment. Although our sessions had gone well in the beginning, he had been
unsuccessful finding a partner. One of the people he met online had invited him to go sailing. He ended up
drinking a wine cooler on the boat. Although he stopped after one drink, he felt horrible about himself and
his recovery. He was so ashamed that he had not yet called his sponsor. When we talked about what
happened he said that he had been out on the boat all day without eating, that he was so grateful to have
some company that he threw caution to the wind, and that he was exhausted from being in the sun all day.
He said that he had not taken care of his basic needs and was Hungry, Angry, Lonely and Tired –the four
states that make up the AA acronym, HALT. He even said that he thinks his experience had taught him that
there was a fifth basic need that hadn't been met – that he was horny. He laughed and said that HALT should
be renamed HHALT. Our intervention addressed his new insight into how he could maintain sobriety and
some of the unexpected challenges of improving his romantic life. We came up with a new plan and he
implemented it. Given that he had a relapse, once he engaged in the new plan, what stage was he in? If you
said, Action, you'd be right. So, our sessions changed focus somewhat to address the needs of people in the
Action phase.

CONCLUSION
To review, the stages of change model is a way of thinking about how someone goes about changing his or
her behavior. The stages of change model assumes that change takes time, that there are common tasks in
each stage, and that by tailoring your intervention to match the stage of change, you will be more successful
in helping your client to make lasting change. The stages of change model is the key construct of the
broader Transtheoretical Model, which also includes Processes of Change and ways to evaluate change.

There are five official stages and one unofficial stage. The Precontemplation stage is the "ignorance is bliss"
stage. People in this stage don't see a problem and consequently are not interested in changing their
behavior. The second stage is Contemplation. People in this stage are "on the fence:" they acknowledge a
problem, but are not sure it the benefits of change outweigh the benefits of staying the same. The third
stage is Preparation. People in this stage see a problem and "testing the waters;" they taking small steps
towards change. The fourth stage is Action. People in this stage have identified a plan for changing the
behavior and have started to implement it. The fifth stage is maintenance. People in this stage have been
engaging in the new behavior for at least six months. The unofficial sixth stage is relapse. People in this
stage have "fallen off the wagon" and are engaging in the old behaviors.

Critiques of the model

Like all popular models, the Stages of Change model has been subject to numerous criticisms. In 2002 Julia
Littel and colleagues published a review of 87 studies using the Stages of Change model and concluded that
there was no evidence to support assertion that there are consistent stages of change across a range of
situations, problem behaviors, and populations. There is no conclusive evidence that change occurs in
stages, rather than as a continuous process. And finally, there are no known studies that follow the
progression through all five stages. Prochaska and Prochaska (2009) countered these criticisms, stating that
it was misleading to evaluate the stages of change model outside of the broader TTM, which the
acknowledge has been subject to far fewer studies.
In 2004, Adams and White suggested two reasons why the stages of change model may not be applicable to
complex behaviors, such as those commonly presented by social service clients. 1) The model was developed
around changing single behaviors, such as smoking cessation, and does not clearly account for changing
multiple related behaviors, such as changing parenting styles. 2) Identifying the stage of change depends
almost entirely on client self-assessment, rather than standardized measures. How do I know that my client
is in precontemplation? She tells me. If I ask my client if they have changed their parenting behavior, they
might respond "no," placing them in precontemplation, contemplation, or preparation. However, a parenting
skills inventory might suggest that changes have occurred in one area, but not another. Thus the
determination that the client is not in "action" is based on a global assessment of change, rather than
accounting for different levels of change within a more complex set of behaviors. Although the developers of
the model noted that the change process is not linear (Prochaska & DiClemente, 1983), some studies have
found that self-report statements can place people in different stages within a matter of days, and
sometimes multiple stages at once.

A final note about the stages of change model. It is not the only model that has been developed for
explaining how people change behaviors. Conner and colleagues (2004) identified four other proposed
models, including the Health Action Process Approach (Schwarzer, 1992), the Precaution Adoption Process
Model (Weinstein, 1988), Goal Achievement Theory (Bagozzi, 1992) and the Model of Action Phases
(Gollwitzer, 1990; Heckhausen, 1991) that are similar to Prochaska and DiClemente's stages of change
model.

So, the stages of change model, although subject to criticism, remains a widely used model for
understanding how people change, assessing a client's readiness for change, and developing programs and
interventions that target change behaviors.

--End--