Change is a process.
Change is hard. Helping people to change is hard. This is the challenge we face as clinicians working with those who are engaging in maladaptive or harmful health behaviors knows. People learn powerful habits and coping skills in response to stimuli and life events. One conversation is not sufficient for meaningful change. Change that does occur under the guidance of a clinician is rarely linear or consistent. There is always the temptation to assume that the client “is not ready or not motivated” or that their noncompliance is an indication of a clinical failure, however its not that simple.
The science moves away from a deficit model and towards a process of precontemplation, contemplation, preparation, action, and maintenance. A deficit model puts the responsibility on the flaws of the client, the stages of change model aims to meet a client where they are. Crucially, when working with vulnerable populations, validating and acknowledging external barriers (such as socioeconomic factors) is often required. This supports for rapport and accurate formulation. Notably the research has found that repeated education around the uptake of a health behaviour, leads to poor rapport, disengagement, and feelings of disempowerment. Information does not create behaviour change. In contrast, reviewing points of decision making can enhance the patients innate ability for change. Each stage requires different approaches for long term success. The process of change often includes periods of recycling stages or regression, which does not indicate a failure.
During precontemplation the client is unaware or under evaluates their problems (i.e smoking, problem drinking, avoidance of activity post injury). These clients often present to allied health practitioners (such a physiotherapists or psychologists) due to pressure from loved ones, well meaning doctors or the workplace. These clients may be resigned or report feelings of no control, or experience denial. They often struggle believe any poor outcomes could happen to them. While this can come across argumentative it is crucial to explore the behavior requiring change with open questioning:
- “What would have to happen for you to know that this is a problem?”
- “What warming signs would let you know that this is a problem?”
- “Have you tried to change in the past?”
Fig 1: Less than ideal clinical care.
A client in the contemplation of change stage will experience feelings of ambivalence and will start to assess barriers and benefits of change. There is also an acknowledgment of the future loss when cessation of the behavior does occur (e.g missing the positive factors of smoking like feeling “calmer”). The role of the clinician to explore the benefits and barriers of change equally, while not attempting to sway the client’s decision making, allowing the client to make the choice to change on their own. Open questioning must continue:
- “Why do you want to change at this time?’
- “What were the reasons for not changing?”
More active work occurs during the preparation stage, where both the client and the clinician explore specific behavioral change and engage in experimentation. This may look like a trial of certain feared movement for persistent pain clients, which is feared the least. In those who are attempting to quit smoking, cutting out one or two cigarettes a day. The preparation stage aims to build confidence and some psychological safety for the following action stage
The action stage is where the obvious changes can be seen, a smoker stops smoking and a patient with chronic pain begins an exercise program to regain function. This is the stage all clinicians aim for in the rehabilitation sector. The action stage is where we see change in key performance indicators, such as mobility and lower pain or distress. Going into the action stage without the prior stages can lead to premature recycling backwards. This can happen if the client made the changes abruptly and potentially without their own reasons to do so. Compliance in rehabilitation is rarely built by advice only, more often it comes from the clients own meaning making and values.
Maintenance and relapse prevention focuses in on incorporating the new behavior into the client’s lifestyle. However, relapse awareness crucial to empower people to recycle through steps again. Recycling or regressing through steps is common and normal, building anticipation for this can help facilitate ongoing rehabilitation. Life happens. A key point for clients is that even though they have relapsed, it has taught them something about themselves and what triggers they may need to avoid. The cyclic nature of the stages of change model helps patients to adopt a more flexible cognitive appraisal of their health behaviour. Rather than a black and white approach e.g. smoking or not smoking.
At all stages active listening and empathy is key. The sciences also support a person-centered approach. Studies have found clinician empathy to correlate with a reduction of problem drinking. In contrast confrontational styles have been found to predict ongoing issues. The stages of change model conceptualises change at an active, ongoing and non linear process. Change can be hard, yet crucial in the rehabilitation sector when delivering healthcare.
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