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?”
