STAGES OF CHANGE MODEL

The Stages of Change Model started off life in the late 1970’s as a model of how behavioural change takes place without the intervention of professional help. James Prochaska and Carlo DiClimente were interested in how change happens naturally so they studied a large selection of smokers who had quit, largely without outside help. They found that on average, smokers had 4 quit attempts before succeeding. Of course the old joke was that with professional help it took at least 6 attempts….

When they analysed their data they found that people passed through 5 specific stages on their way to success (see below). However this didn’t necessarily occur as a linear process. Often people yo-yoed back and forth or stagnated for a period of time. Sometimes they had success for a short spell then had a lapse or relapse which might see them spiral backwards several stages before starting all over again.

One of the key precepts of the model is that each stage demands different types of interventions. You can use your favourite intervention over and over again if you want but if it doesn’t fit the patient’s stage then not a lot may happen. Medical interventions are typical of this. As health professionals we often assume that patients are ready to take action and we prescribe our usual solutions, usually in the form of authoritative directives (stop smoking, drinking, eating too much, etc), then in the light of failure wonder why they didn’t “try” harder. Finding out the stage before we fit the appropriate intervention is paramount.

Another thing we tend to do is to go for too much too soon. We expect our patients to make big leaps and progress through the stages far quicker than they often do. A concept I subscribe to (which I got from NLP trainer John Overdurf) is to find the smallest next step the patient is capable of taking and nudge them towards that instead. Of course, once you match the intervention to the stage, using NLP technology can paradoxically help people make and sustain big gains very rapidly.

The Stages of Change Model has come in for some criticism from research that suggests it is too linear and rational in application and results may be no better than other methodologies. However much of this research is either underpowered or focuses only on one particular stage rather than the whole model. My experience is that when combined with NLP interventions which also incorporate unconscious processes and communication then exceptional results are possible.

One thing I do like about this model is that it is transtheoretical. It doesn’t promote any one particular change model or theory. It looks at the process of change and as such is a form of meta-model; you can use it as a lens through which to look at your favourite methodology and work out where to apply it best. Knowing the model can free you up to be more eclectic in your interventions.

Here are the 5 Stages as I use them:

  • Raising Awareness

This stage is often called pre-contemplation and it is a common stage in general practice presentations. Essentially your patient either doesn’t know they have a problem or they are somehow dissociated from that knowledge; they may be uninformed, avoidant, defensive, in denial, etc, etc.

There are 4 different types of precontemplators, which I go into in more depth in Persuasion in Practice. These are:

  1. Reluctant (fearful of change)
  2. Rebellious (“don’t tell me what to do”)
  3. Resigned (tried and failed before)
  4. Rationaliser (always have an answer)

If you try to get people in this stage to action you are mainly wasting your breath! You want to stir up just enough cognitive dissonance to get them into the next stage. To do that you must get them to become ambivalent, in 2 minds about things – and often the best way is to create a problem for them to move away from.

 

A key question here is: “What is the worst that might happen if you continue on like this?”

(Whilst this is a very common stage in medical practice, most people who elect to go to an NLPer for assistance are usually at the next stage or beyond – but not always)

 

  • Resolving Ambivalence

This stage is usually called contemplation. Your patient knows that a problem exists and is sufficiently connected to it emotionally to create feelings of ambivalence. This is the “will I or won’t I” of change. Or sometimes expressed as “I want to change…and…I don’t want to change”.

Ambivalence is a good thing, as long as you don’t stew in your own juices for too long. Miller and Rollnick, in Motivational Interviewing, state that if you don’t feel this push/pull feeling and really pay attention to what it is telling you then any change you make is much less likely to hold over time. They suggest that it is very important to fully explore the pros and cons of changing and not changing before planning to engage in taking any action. (Behavioural Diaries and Decisional Balance Sheets can be a great help here).

In NLP we call this feeling incongruence and it’s often expressed as a parts conflict…”Part of me wants to X and part of me wants to Y”. NLP has numerous techniques to explore both the conscious and unconscious mechanisms that keep people stuck and negotiate a congruent settlement that allows change to happen. An important perspective is that of unearthing the positive intention behind any so-called “negative” behaviour.

When people seem to be much further on in the process of changing yet still don’t have the result they want the problem usually lies in some hidden ambivalence or obstacle to changing that hasn’t yet been taken into account. So one question to keep in mind is: “What’s the biggest obstacle to you really getting what you want?”

Ambivalence is a very important and normal part of any change process

 

  • Preparing to make changes

Once patients have largely resolved their ambivalence to changing a new state begins to emerge. That is a sense of increasing commitment to make something happen. Like all states, the degree to which it can be felt can come and go, yet it needs to be fostered, developed and pointed in the right direction.

Planning ahead for what you want to have happen is very important. NLP has lots of tools for helping patients set useful outcomes, decide which personal resources they need to sustain the change and bring them to bear just when they are needed. (e.g. Results, Reasons, Right Actions). Plus the ability to elicit and amplify any state is a skill you can learn easily. (see Anchoring and Circle of Excellence in the free downloads section)

The emerging field of Positive Psychology points out that paying attention to Signature Strengths, the things that are true of you when you are functioning at your best, is a key determinant of success. Reminding patients of their past successes and achievements builds an inner resilience and fosters a return to an inner locus of control which builds confidence and self-efficacy.

  • Taking Action

This is the stage that many of us mistake our patients being at when they are usually at an earlier point in the process. In this case, pushing for premature change usually leads to failure. However, with the stages negotiated as above, and a plan of action in place, galvanising them to take action in their own behalf becomes paramount.

This is often an outwardly busy stage with much activity generated. However, equally important is the ability to maintain a good state and do something different if the going becomes tough. Developing pattern interrupts, where your patient can identify when they fall into a negative state and get out of it, is very important. So are some simple submodality processes to distance negative imagery and enhance positives – changing focus. Sometimes the ability to take a much needed timeout with a relaxation ritual is needed to reduce stress levels.

One action I often get patients to take is that of an external commitment. I may get them to write to someone in their life who is very important to them, telling them of the result they are committed to achieving. There are numerous other ways, such as tasking, that are equally useful. (A useful read here is Jay Haley’s Ordeal Therapy)

 

  • Staying on Track

Behavioural change literature is full of the key problems of this stage – lapse and relapse. Staying on track is largely about consolidating the gains up until now and preventing stressful situations from derailing the process. There is a need to maintain commitment over time and have some tricks up your sleeve when dire emergencies crop up.

Changing a behaviour can lead to a sense of bereavement and loss, especially when the “problem” behaviours (alcohol, drugs, food, etc) previously led to good feelings. Identifying positive intentions can be useful even though a social transplant away from “well meaning friends” may be required.

In one sense though, a lapse or relapse is actually a sign of success. You can only have them if you have already made a successful change. Many NLPers fail to recognise that many problem behaviours are kept in place by myriads of contextual and specific conditioned responses which can, over a period of time and re-exposure, re-trigger unwanted behaviours. What is really important here however is that after relapses you get a chance to identify the specific triggers that caused them and devise particular strategies to deal with them as they will invariably recur.

You can, paradoxically, prevent a relapse from occurring by prescribing one! Mentally rehearsing a “blip” then getting back with the program can install a useful recovery strategy.

One characteristic that stands out from the Stages of Change Model is the increasing level of commitment to change that is generated as each stage progresses. You cannot persuade anyone to do anything on their behalf if they are not committed. More than anything else you need to pay special attention to eliciting, testing for, monitoring and strengthening this state as the sine qua non of effective change.

So in your next series of consultations, to begin to put these ideas into practice, I suggest you keep in mind the following question:

 “What stage are they at and how can I nudge them one step forwards?”

 

Until next time…

Lewis

5 Responses to “STAGES OF CHANGE MODEL”

  1. Pete D says:

    Hi Lewis

    Your post has raised a number of questions for me, in particular the “Quick Fix” for some conditions, which indeed I have experienced with some clients and not with others. In particular, how much a client can process from one session and maintain a sustained progress through time.

    I do agree with the process of John Overdurf’s “Next smallest step” principle, which in my opinion gives clients small, bite size chunks of success, which when established can be built upon to create a more solid foundation. The reality of change is that people will slip and slide and we as change agents need to pre-frame that possibility when working with them. I believe that they will be better placed to overcome those obstacles if and when they come if they have already “Future paced” such a possibility.

    In relation to your article and in my simple world, would this equate to a five session process, where the client is taken through each phase and given taskings between sessions? This would make sense to the structured part of my personality. I have always avoided and resisted the NLP Breakthrough process, which as you know is the one day fix/change event. I have never been entirely convinced personally that a client can make sustained and long lasting change with such a process. (I am now putting on my hard hat for the flak from the NLP community). Then again I may be totally wrong, but I do like small, progressive improvements.

    Just some thoughts.

    Cheers

    Mr D

  2. admin says:

    Hi Pete

    Some interesting comments….I think the whole range of response is possible from 1 session cures to several interventions spaced over time. Some people (and problems) are suited to a breakthrough session which could last up to several hours…others to incremental change (see Styles of Change, the free chapter download form Persuasion in Clinical Practice)

    People can actually pass through several of the stages in one session. This is particularly so with things like simple phobias, fears, traumatic and post-traumatic stress of reasonably short duration…where the “fix” is essentially a psychological process and a “miracle” can occur.

    It’s often a bit different when you are looking for sustained behavioural change (stop drinking, overeating, drug taking, starting regular exercise, etc)…this is where the stages model is very useful especially for staying on track over time. NLP often seems to conjure up the image of “miracle” cure…and whilst that is possible, incremental change is more the norm. If you are seeing a patient/client over a number of sessions then specific tasking for each stage really helps with “buy-in” by increasing the commitment to do what it takes…

    People can vacillate between stages and this is often a signal of a degree of incongruence/obstacle that needs to be addressed…Rather than exhorting “more commitment” at this stage you need to look for the unconscious messages underlying a seeming lack of progress/regression…

    This model fits better with medical practice where consultations are often around 10 minutes…many NLPers can offer far longer sessions and get more done. One issue I have seen over the years in NLP though is often a lack of follow-up…It’s much more impressive if you have a “1 session change” that persists beyond 3-6 months…and often very salutatory to do a 1 year telephone or email follow up to see that changes have taken root.

    Good question Pete, thanks…

    Lewis

  3. Michael says:

    Hey Lewis,

    Thanks for another mind-opening post. I have really like Steve Andreas method of proactively searching for “objections” and then finding solutions to those. I have found changes stick really well with this, and it fits nicely with the Ambivalence stage.

    I’m a little confused about the “Preparing to make changes” stage — isn’t resolving ambivalence a key part of preparing a client to make changes? Or is the “Preparing to make changes” more the actual “installation” of new anchors, beliefs… ie: the chagework… which is then translated into behavioral output in the real world in the next stage? Sorry if I’m trying to put this model into a NLP framework too much… but I’m just trying to imagine how I would use each stage with a client.

    Right now my sequence is more… (1) what results does the client want… are these entirely useful… resolve ambivalence (incongruenty) until congruent about results/outcome… (2) future pace new ways of being/change work (usually easy after congruence is achieved)/learn new skill that would make a difference… (3) client goes into the real world and gets feedback… (4) adjustments made if needed etc.

    Is (2) equivalent of the “Preparing to make changes” stage? Or am I missing something? Sorry if it’s silly question.

    Thanks again,

    Michael

  4. admin says:

    Hi Michael

    The stages model is really an imposition of discrete steps into what is really a more fluid experience. The reality is that people can display aspects of several stages during a session..

    Resolving ambivalence is more often about exploring what stops people from deciding to take action and getting congruent with making the decision to follow through. Many people rate a change as important to make , are confident they have the skills to do so yet don’t because they’re not “ready”…This may because they have several other things going on in their life and can’t yet make a full commitment. This particularly applies to behavioural changes that need to be sustained over a period of time….(the ambivalence is around making a change rather than the incongruities that often arise after setting an outcome)

    Preparing to take action is when they have already made the decision but before jumping in need to get a few things in place….This usually revolves around planning… setting outcomes, eliciting and strengthening commitment, dealing with obstacles that may get in the way, and eliciting various resources and signature strengths that may be key to getting the outcome met…

    Often, in further specifiying the outcome, this may throw up resistences, incongruities and specific obstacles that may not have been apparant…ambivalences that need resolution…(briefly back to the previous stage)…Its often only when you specify clearly what it is you really want that the real obstacles arise…

    If the problem is mainly a psychological issue (we know there is no such thing in reality) then the preparing stage merges with taking action and voila, the outcome is met…(this often happens in many NLP consultations)

    For behavioural changes that need to be sustained over time then there are combinations of mental and physical things that need to be done….adequate planning, thinking through and planning how to deal with consequences etc are the mental side…Physically people may need to rid their house of alcohol, cigarettes, drugs, tempting food etc, etc…(this is more likely in medical consultations)

    I think what you describe as (2) is a combination of Prochaska and DiClimentes Preparation and Taking Action stage…I think this is common in those NLP type consultations that mainly require a psychological shift…

    I certainly don’t want to get too pedantic or nit-picking though…there are some aspects of the model that will suit you better than others…and…if what you are already doing is getting good results I would certainly stick with it and perhaps just notice where one or two of the nuances of this model could be incorporated to good effect…

    In medical consults we do tend to see far more people who are at a much earlier stage than the typical NLPer for whom the client has actively sought them out and is already well committed to doing something different, a confluence of the first 3 stages…

    Lewis

  5. Michael says:

    Thanks Lewis :)