Stages of Change Model A Transtheoretical Approach February 19, 2009

1. Stages of Change ModelA Transtheoretical ApproachFebruary 19, 2009 Presented by Doris C. Gundersen MD Assistant Clinical Professor University of Colorado Associate Medical Director Colorado Physician Health Program

2. Objectives History of SCM Development Stages of Change The Process of Behavioral Change Clinical Example of SCM Relevance of the SCM

3. History of SCM James Prochaska & Carlo DiClemente Prochaska�s paternal influence Depression Alcoholism Resistance to treatment Research on (successful) tobacco cessation Late 1970s @ University of RI Prochaska and DiClemente were two researches in the 1970s who examined people who were successful tobacco cessation.Prochaska and DiClemente were two researches in the 1970s who examined people who were successful tobacco cessation.

4. History of SCM Discoveries Insight ? change Behavioral Change Occurs Stepwise Behavioral Change is a process ? event Passage through stages of change unique for each individual �You Can�t Push String� (precontemplation) Internal locus of control vs Externally imposed change Applies to a broad range of behaviors Referral to a nutritionist for diabetic control Applied to a broad range of behaviors � weight loss, alcohol and other additions, injury prevention, sexual behavior in risky populations, workaholism You can�t brow beat people into change by scaring them or shaming them Passage may be one session (for the highly motivated/disciplined) to years in one stage of change (usually contemplation) Pushing string can be counterproductive (domestic violence example � lose connection) Sometimes scare tactics work (testicular atrophy with MJ abuse) Referral to a nutritionist for diabetic control Applied to a broad range of behaviors � weight loss, alcohol and other additions, injury prevention, sexual behavior in risky populations, workaholism You can�t brow beat people into change by scaring them or shaming them Passage may be one session (for the highly motivated/disciplined) to years in one stage of change (usually contemplation) Pushing string can be counterproductive (domestic violence example � lose connection) Sometimes scare tactics work (testicular atrophy with MJ abuse)

5. Stages of Change Precontemplation Contemplation Preparation/Determination Action/Will Power Maintenance Relapse Transcendence

6. Stages of Change Precontemplation �before thinking� Problem behavior not yet acknowledged Not thinking seriously about changing Not interested in any kind of help Bad habit(s) currently defended Defensive when pressured to change Denial is strong Ignorance is bliss Emphasize the decision to change is theirs, can educate about risksIgnorance is bliss Emphasize the decision to change is theirs, can educate about risks

7. The Process of Promoting Behavioral Change Precontemplation -Consciousness Raising finding/learning facts -Dramatic Relief Experiencing/expressing negative thoughts or feelngs about the problem -Environmental Reevaluation second hand smoke

8. The Process of Behavioral ChangeClinical Example Precontemplation: Dr. Smith Family/Pastor concerned 25 years in practice �no sick days� 25 years in practice �6150 babies� Have you seen my resume? Entitlement (4 oz/every hour over 8)

9. Stages of Change Contemplation More aware of personal consequence Spend time thinking about the problem Problem acknowleged, commitment to change absent Ambivalence � weighing the pros and cons More open to receiving information, and reflect on thoughts and feelings about the behavior �Just window shopping� Thinking of giving up the positives of their habit along with the negatives They may ask if the long term benefits really outweigh the short term costs. Can stay in this contemplation stage for years Sometimes you can shorten the contemplation stage with some powerful info They may fear failure at this stage, help with pros and cons evaluation.�Just window shopping� Thinking of giving up the positives of their habit along with the negatives They may ask if the long term benefits really outweigh the short term costs. Can stay in this contemplation stage for years Sometimes you can shorten the contemplation stage with some powerful info They may fear failure at this stage, help with pros and cons evaluation.

10. Decisional BalanceWeighing the Pros and Cons -precontemplators/contemplators cons loom large -action to maintenance pros outweigh cons -Write them down, be specific

11. The Process of Promoting Behavioral Change Contemplation Self Reevaluation: See Yourself as: Nonsmoker Nondrinker Slim and fit Working less

12. The Process of Behavioral ChangeClinical Example Contemplation: Dr. Smith looks in the mirror: Ruddy and pudgy Isolation Burnout Scotch is anesthesia���but it sure tastes good I�m losing my marriage

13. Stages of Change Preparation/Determination Getting ready to change A commitment to change is made �I�ve got to do something about this� Researching what they need to do Learning what it will take to change Call clinics Discuss with friends/doctor Read books, research internet If this state is skipped, usual failure Testing the water � great deal of planning and education, high level of awareness Encourage small steps, support through barriersIf this state is skipped, usual failure Testing the water � great deal of planning and education, high level of awareness Encourage small steps, support through barriers

14. The Process of Behavioral Change Preparation/Determination Self liberation � choosing and committing to act on a belief that change is possible Accepting Responsibility

15. The Process of Behavioral ChangeClinical Example Preparation/Determination: Dr. Smith apologizes to spouse for pain caused Calls his primary MD for PE/labs Reads books, internet postings about Etoh abuse

16. Stages of Change Action/Will Power Belief of ability to change Employing discovered techniques/tools to promote change Enhancement of self esteem Early on, dependent on willpower Therefore risk for relapse Review pressures that may lead to slips Open to receiving help/resources A lot of overt source of support during this time is crucial This can be the briefest stage but busiest stage, requires greatest commitment of time and energy. Receives a lot of recognition so increased self esteem.A lot of overt source of support during this time is crucial This can be the briefest stage but busiest stage, requires greatest commitment of time and energy. Receives a lot of recognition so increased self esteem.

17. The Process of Behavioral Change Action/Willpower -contingency management (increase rewards for + behavior) -helping relationships seek and use supports -counter conditioning substituting alternative behaviors (meditation vs Etoh) -stimulus control (triggers/cues)

18. The Process of Behavioral ChangeClinical Example Action/Willpower: Dr. Smith learns primary MD has been in successful recovery for 15 years Labs: No end organ damage Reads books, internet postings about Etoh abuse Begins attending AA meetings Pink Cloud, �This is a piece of cake�

19. Stages of Change Maintenance (the longest stage) Goal = maintain status quo Maintaining the behavioral change Avoid temptations to return to bad behavior Reformulating rules in one�s life Acquiring new skills to avoid relapse Learning to anticipate triggers Prepare coping strategies in advance Some regression is natural, you can go through several different stages in one day. Maintenance is a long ongoing process so that the behavior ismore thoroughly adopted Important to continue to plan for follow up support, discuss coping and relapse, evaluate triggers, reassess motivatin and barriers, brainstorm alternatives for more effective coping strategies.Some regression is natural, you can go through several different stages in one day. Maintenance is a long ongoing process so that the behavior ismore thoroughly adopted Important to continue to plan for follow up support, discuss coping and relapse, evaluate triggers, reassess motivatin and barriers, brainstorm alternatives for more effective coping strategies.

20. The Process of Behavioral ChangeClinical Example Maintenance: Dr. Smith commits to 90 mtgs in 90 days (even though he�s �got �er done�) Dr. Smith commits to seeing a sponsor -education on common triggers -education on managing stress -retooling social life

21. Stages of Change Relapse (oops) �even monkeys fall from trees� 1 Krispy Cr�me, might as well have 12 Returning to old behaviors Accompanied by feelings of discouragement or failure Relapse is normal/expected � a learning opportunity, not a failure Restart preparation phase (try not to return to precontemplation or contemplation phase Relapse can undermine self confidence, learning high risk situations, control environmental cues, learn how to handle unexpected stressRelapse can undermine self confidence, learning high risk situations, control environmental cues, learn how to handle unexpected stress

22. The Process of Behavioral ChangeClinical Example Relapse Dr. Smith feels shame/embarrassment Sponsor �opportunity in crisis� -detailed chain analysis -identified unanticipated triggers -Dr. Smith is reempowered -Poker game is sacrificed in the service of staying sobers

23. Stages of Change Transcendence The exception Maintain maintenance long enough your bad habit is no longer an integral part of your life but to return to it would seem atypical, abnormal. Threat of relapse no longer a risk �zero temptation and 100% self-efficacy�

24. Relevance of SCM Useful in wide variety of health promotion programs Opportunities to intervene more successully depending on Stage Scarce resources are matched to the right audience (ex telephone survey)

25. Doris C. Gundersen MDContact Information Phone : 303-860-0122 Address: 899 Logan Street Suite 410 Denver CO 80602 Email: doris.gundersen@ucdenver.edu