No matter what their presenting issue, every client comes to therapy wanting change. It's up to you as a therapist to help them achieve it, so understanding the process of change can help you do this as effectively as possible.
The transtheoretical theory of change
According to Prochaska & DiClemente (1983) [1] there are six steps in the cycle of change. These are:
- Precontemplation – essentially before people realise there is a problem, or at least before they realise that they will have to be proactive to change a situation.
- Contemplation – when people know there is a problem and wonder what to do about it.
- Preparation – the decision-making stage where people start making plans for how to bring about change.
- Action – having decided on a plan, people put the plan into action to create the desired change.
- Maintenance – people work towards keeping the changes in place. Hopefully, this will be a long-term change, but they may also move to the next stage.
- Termination or Relapse – if people are successful in maintaining the new behaviours, then the old ones simply don’t appeal to them anymore. If they are unable to maintain the changes they’ve put in place, they will go back to the problem behaviour.
Note that people can drop out of the cycle or return to the beginning at any stage. This is not categorised as a failure, since it can provide helpful information about what doesn’t work for that particular individual. They re-enter the cycle at the beginning and move through the stages again, continuing on an upward spiral until they successfully achieve long-term maintenance (termination). Some people need to move through this several times before successful long-term changes are made but each time, they learn more about what works for them.
DiClemente and Prochaska developed this model whilst working with smokers who wanted to quit, but it has since been applied in many situations, including different kinds of therapy, social work, drug abuse, bullying, and even encouraging sunscreen or condom use. So, let’s go through how you can use this in your therapy room.
Using the change cycle in your therapy
The first thing is to get an idea of where your client is in the cycle.
Precontemplation.
It’s unlikely anyone in this stage will contact you, but you may get calls from worried friends or relatives ‘my partner needs to stop smoking/lose weight/whatever. We’ve all had these calls and it’s best to give information and advice so it’s there when they need it, but not to book an appointment. If the potential client genuinely doesn’t see a problem, or is in denial about there being a problem, it’s unlikely they will be willing to act, and therapy will fail.
Contemplation.
At this point the client is probably toying with the idea of making a change at some point, but they procrastinate. They can see there’s problem, and it’s not going to go away by itself. But either they don’t know what to do about it, or the effort required for change seems overwhelming or not worth the benefits that change will bring. Nagging or pressure, from you or family, is unlikely to move them to the next stage. I had a client once who said his main reason for smoking was that everyone told him not to and he didn’t want to give in. I had some sympathy with this but a quick reframe helped: by insisting on doing the opposite of what everyone told him, he was handing over control just as much as if he did exactly what he was told. Psycho-education - providing information about how you can help, and the benefits of change - can give the client more to consider if it’s done in a way that's personally relevant. You are moving them from an abstract thought that change would be a good thing to a concrete idea of the benefits they will gain from it.
Preparation.
The client is ready to act now or very soon, and this stage generally doesn’t last long. They start to take action and need encouragement and reinforcement. Breaking things down into small steps will make them feel less daunted. Making a therapy appointment might happen in this stage, or at least contacting you to find out the details of what you offer.
Action.
Yay! The client has their appointment booked and turns up, ready and willing for change to happen. They begin to make the changes they have planned. Keep it positive and motivational to support them.
Maintenance.
The change has been made but it’s not yet so entrenched that the new behaviours are fully automatic; it’s still taking conscious effort to stick to them. The maintenance stage can be protracted and may still be happening when therapy ends, so it’s worthwhile discussing strategies for difficult moments or triggers that make it tempting to revert to old behaviours. If you can anticipate these and have a plan in place for dealing with them, they will be easier to resist. Make it clear to the client that if they are struggling, the option to see you again is always there.
Termination...
Clients who have wholeheartedly embraced the change will stick with it and have no desire to return to their old ways. It may take years to move fully from maintenance to this stage and a few people stay in maintenance permanently, with the new behaviours always having to be actively managed. (For example, we all probably know smokers who quit ages ago, but still feel they could smoke if they let themselves do so.)
...OR Relapse.
Some clients will find that a life change or some other factor kicks in and they go back to their original problem. Many feel discouraged that change didn’t last and go right back to pre-contemplation, (why bother? It’s not going to work.) But they can go around the cycle again and should be encouraged to see this as a learning process. Each time they relapse they learn something more about what makes it difficult to make the changes permanent. This information can be used the next time around, so it’s always worth asking clients what they have done before to address their issue, and why they think it wasn’t successful.
This cycle, called the Transtheoretical Model (or TMM), suggests several processes [3] that you can introduce to clients that will help them through the stages, such as:
- Making a commitment – telling people they are making the change,
- Repeatedly replacing unhealthy behaviours with healthy ones (called counter-conditioning),
- Introducing rewards for successfully using the changed habits,
- Avoiding situations that trigger the old behaviours and seeking out situations that encourage the new ones,
- Getting support from family, friends, and therapists.
The TMM has its critics. It’s been suggested that it’s too reductionist and that it’s hard to apply because it can be tricky to identify the exact stage a client is in. Recent research [2] indicates that it may be better applied in situations where people need to change to prevent a problem (like applying sunscreen to prevent skin cancer) rather than to alter a pre-existing habit.
However, it has become very popular in the use of substance abuse, smoking cessation and similar areas and can be useful if you or your clients are struggling with change. TMM can help you and your client move through the process of change together, suggesting approaches that will help your client no matter where they are in that cycle.
References
[1] Yeshiva. (2021). Prochaska and DiClemente’s Stages of Change Model for Social Workers. [online] Available at: https://online.yu.edu/wurzweiler/blog/prochaska-and-diclementes-stages-of-change-model-for-social-workers-2. (Accessed: December 2, 2022).
[2] Hashemzadeh M, Rahimi A, Zare-Farashbandi F, Alavi-Naeini AM, Daei A. Transtheoretical Model of Health Behavioral Change: A Systematic Review. Iran J Nurs Midwifery Res. 2019 Mar-Apr;24(2):83-90. doi: 10.4103/ijnmr.IJNMR_94_17. PMID: 30820217; PMCID: PMC6390443. (Accessed: December 2, 2022).
[3] Moore, L. (2021) Change any behaviour through these stages, Psych Central. Psych Central. Available at: https://psychcentral.com/lib/stages-of-change (Accessed: December 2, 2022).
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Author: Debbie Waller is an experienced hypnotherapist and hypnotherapy trainer. She is the author of The Hypnotherapist's Companion, Their Worlds, Your Words, and The Metaphor Toolbox, all available from Amazon or direct from the author, and a co-writer of the Hypnotherapy Handbook.
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