Friday, 26 August 2011

Therapy Thursday: The Stages of Change Model

To kick off my Counselling Skills for Better Living series, I chose the well-known Stages of Change model. Why? Because it can be usefully applied to pretty much any change you might want to make, and is a very simple but helpful lens through which to view your process.

The Quick Version
James Prochaska came up with this model back in 1977. He noticed that, whereas many people undergoing all kinds of therapy fail to achieve lasting change, many others get there with no help at all. He studied thousands of cases to see if there was some common pattern or process underlying the success story of those who managed to change. What he found is that almost all of them went through five stages:

Precontemplation: Not ready. Probably in denial.
Contemplation: Ready to admit there's a problem, but not yet ready to change it.
Preparation: Ready to change, and making a plan.
Action: Putting the plan into action.
Maintenance: Working hard to make the change stick.

In practice, these stages can overlap considerably, and people might bounce around between them, periodically falling back to an earlier stage, before they complete the process. If you're making any kind of a change, or think you might need to, it's surprisingly helpful to figure out which stage you are in, and how best to accomplish the work it requires. 

The Detailed Version
If you'd like to know what kind of work is required at each stage, read on. Let's discuss the stages in relation to Bill, a chronic smoker. As we go, I'll give some tips about what you (and Bill) can do at each stage, and what a counsellor might do to help.

Stage 1: Precontemplation (Not Ready)
At this stage, Bill isn't thinking about quitting. In fact, he doesn't think of smoking as a problem at all. Sure it eats up a lot of his money, his wife and kids hate him doing it, he feels like an outcast every time he has to go outside to smoke, he knows his breath smells, he knows how bad it is for his health, and he finds himself gasping for breath every time he walks up a flight of stairs. But hey, he doesn't have a problem! And he certainly doesn't want to live without his ciggies. Deep down he might know it would be a good idea, but it's a deeply buried awareness, and he wants to keep it that way.

Making change is often difficult, painful and scary. It's much easier, at least in the short run, to stick with denial. And denial can serve a purpose. If Bill hates his life and smoking is the only thing that gives him any pleasure, obviously he doesn't want to let it go, and beating himself up about it might just give him one more thing to be unhappy about. In this case, it might be better for Bill to figure out what else he can do to make his life better before he thinks about quitting.

Many people do not get real about their problems until something makes them; like cancer, the threat of divorce, burnout, nervous breakdown, or some other crisis. Emotions are useful flags when something is wrong. If you're feeling unhappy or unfulfilled, the chances are something needs to change. And it might not be the most obvious thing. This is the time to step back and try to look at the situation realistically. There's no need to hurry, though. That just makes us feel more scared and overwhelmed. Acknowledging that something might be a problem is a big enough step to start with.

So what might you need to change? Do you have a hunch in your gut that you're trying to ignore? If so, listen to it without judgement or pressure. Ask people you can trust what they think. What impact is the suspected behaviour having on your life and that of others? What would your life be like without it? Are you living up to your own ideals and values? How do you feel when you think about changing? You're likely to exaggerate the cons and underestimate the pros.

As a counsellor, I would really need to build a relationship with Bill and gain his trust before trying to help him make a change that scares him. I'd help Bill to look at his life clearly and realistically, hopefully finding his blind spots, and eventually clarifying why he needs the crutch of cigarettes so badly. Perhaps smoking isn't the first or most important thing that needs to change. I wouldn't try to push Bill too fast, nor would I challenge his resistance to change head on. Instead, I'd help him explore the gaps between his self-image and values and his behaviour, especially looking for examples where he has crossed his own lines. I'd help Bill to get real about the consequences of his behaviour for himself and others, exploring all of his feelings (not just the obvious ones), and encouraging empathy for the feelings of others. I'd also be looking for leverage, the greatest motivations for change, and the long-term consequences of not changing. Finally, recognizing that change requires energy, I'd look for those things in Bill's life that are working and encourage him to do more of them. I'd also help him to identify other potential sources of strength, joy, support and success that he's not tapping into.

Stage 2: Contemplation (Getting Ready)
Finally it gets through to Bill that quitting would be a good idea. But it's such a hard thing to commit to. Bill loves smoking. It relaxes him, gives him something to do with his hands, makes him feel more confident. It's an absolute must with a coffee, or with a beer, or when he's taking a break at work, or after sex... Most of Bill's friends smoke; would he really be able to remain friends with them if he quit? Most importantly, will life be tolerable without his crutch?

If Bill attempts to quit smoking without being sufficiently motivated to see it through, he is destined to fail. If he neglects to look realistically at all the things he will be losing when he quits, then he'll quickly become overwhelmed by the enormity of his rash decision when reality strikes home, and will reach straight for his cigarettes. If he doesn't keep a thorough inventory of everything he has to gain from quitting at the front of his mind, he will probably not have the strength to see it through.

This is the most important stage, and more attempts at change fail by rushing or skipping it than for any other reason. If you're thinking about making a change, you need to make two lists that thoroughly and realistically detail all the pros and cons of change. Having done so, you might decide that you don't want to change after all. Fair enough, as long as you're not kidding yourself, and your decisions really are what's best for you. Perhaps what's needed is a reduction of the behaviour. Or perhaps the behaviour really does offer you more than it takes away, and it is something else that needs to change. If at first the cons of change seem to outweigh the pros, keep thinking about what you can do to reduce the cons and boost the pros until there is no doubt in your mind that you want to change, and are capable of seeing it through. This might involve changing the circumstances around the problem behaviour, or changing the story you tell yourself about it.

As a counsellor, I would help Bill to explore the pros and cons of quitting thoroughly, honestly and realistically. It really helps to have someone act as a reality check in this way. Addictions in particular (and they come in all shapes and sizes) are master manipulators. It helps to keep our eyes on the prize: envisioning a positive future without the problem behaviour, and buying into that vision.

Stage 3: Preparation (Ready)
Bill has worked through the pros and cons, and is ready to quit. Now it is time to make a plan. There are all kinds of possible plans, so Bill has to create one that fits his own unique personality, beliefs and values. Plans that are most likely to succeed progress through small, clear, manageable, and realistic steps. Bill really needs to believe that he can accomplish this. His level of confidence will be the most reliable predictor of success or failure. He would be well advised to seek practical assistance and emotional support from trusted friends and family. They also act as witnesses: the more people who know about his change-plan, the more obliged he will feel to stick with it.

Coming from a behavioural point of view makes a lot of sense at this stage. Bill needs to identify all of the triggers and temptations, the places, people and situations that make him want to smoke (coffee, beer, work breaks, sex, friends who smoke etc). He then needs to figure out how he can either avoid these triggers, or prevent himself from smoking when they cannot be avoided. He'll need to replace old habits with others that are smoke-free. These alternative behaviours will have to be equally or more satisfying. If quitting makes him miserable, he'll obviously fail. In this vein, Bill also needs to analyze the rewards of smoking: cigarettes give him pleasure, help him to relax, help him cope with anxiety and social awkwardness. So he'll have to make it so that they no longer deliver (he could switch to a brand he hates, or make himself use a long cigarette-holder that makes him feel self-conscious) or he'll have to find alternative ways to get the same rewards. Exercise, edible treats, listening to music, taking long baths and doing yoga are obvious choices.

It is important to anticipate and plan for all the things that could go wrong. Forewarned is forearmed. It's also crucial to understand that a small lapse into the old behaviour does not send a person straight back to square one: it is a small blip, not a major disaster. If Bill gives in and bums a cigarette, he does not have to say, oh well, that's that, I failed, I might as well go buy a pack. In fact, such a defeatist attitude is usually a ruse employed by the addiction itself, one of the ways it manipulated people.

If we want to change a behaviour, we need to stop identifying with and defining ourselves by that behaviour. Instead of thinking of himself as a smoker, Bill needs to look on himself as a person who is vulnerable to a nicotine addiction. The problem is thus externalized, put out there, where it can be worked upon. Bill is not the problem, the addiction is the problem, and Bill must fight against it.

Clearly, my job as a counsellor is to help my client prepare a plan of attack that is ideal for them and maximizes their chance of success.

Stage 4: Action
Bill now needs to put all of that preparation into action. He needs to pace himself, taking one day at a time, and rewarding himself for successes. It will really help if he surrounds himself with supportive people. His whole life has been rearranged, so it's important for him to use all the resources at his disposal to keep up his energy and morale.

Stage 5: Maintenance
With addictions, and many other behaviours, there is always a danger of relapse. It is at least 6 months since Bill quit, but he still needs to be vigilant around the dangers, triggers and temptations. Hopefully, he has replaced cigarettes with alternative behaviours that do not co-exist comfortably with smoking, and which are just as rewarding or more so. Sports and other physical exercise are the obvious examples. Bill needs to build up a repertoire of healthy coping strategies, otherwise there's always a good chance that the first piece of bad luck will send him scuttling straight back to his default crutch. He also needs to keep addressing the deeper seated issues, the reasons why he needed a crutch in the first place. Unless they are dealt with, those issues are likely to manifest in new, equally unhealthy ways.

Stage 6: Termination
Sometimes this sixth stage is added to the model. Personally, I don't think it adds a whole lot. But it can be helpful for a person to stop thinking of themselves, for example, as an alcoholic in remission. Such a re-definition of self could be empowering, for sure. But it also hides a potential danger. A certain percentage of alcoholics cannot drink alcohol, ever. If they do, they are likely to relapse and might go right back to square one. In their case, the promise of termination might offer their addiction another subtle snare in which to trap them.
So there you have it. I hope some of you find this useful. Please let me know what you think.