The Optimums Change Model
It is wise to use language people understand in talking about change. Based on experience with the application of the research by Prochaska and DiClemente (1984) I use slightly different language. Change takes place in seven potentially recursive stages.
Change does not happen in a straight line. The pattern is more of a spiral with ups and down being natural, and not exceptional. It does not take place in equal increments or steps. There are often periods of change followed by plateaus or even declines and then great leaps. And finally once one actually achieves a goal like losing 10 pounds or keeping blood sugar below 115 we can relapse. Condemning our efforts because the line does not continue up or down or show exactly the same improvement this week as last is wrong and can result in loss of motivation. Success requires realistic expectations. The stages are:
The Challenge Stage
Our habits serve us well. So it is understandable that we resist making changes until life challenges us to do so. At any point in time, in areas where health is at stake, more than 80% of us do not believe we need to change and have no plans to do so. We avoid thinking about it. Often, we resent those who seek to awaken us. Smokers suck on cigarettes though the hole in their throats created when their cancerous larynx was removed. After quadruple bypass surgery patients resume their sedentary lifestyle and the diet that creates the sludge that clogs their arteries. We shake our heads at those ‘nuts’ out for an early morning run. That is for them. Not for me. The first stage in personal change ends when we face a challenge, and entertain the notion that we may need to change. It is roughly equivalent to the Pre-contemplation stage. That can be because we learn something new by reading an article. It can be because we have an experience that shakes us from complacency. Perhaps we develop a cough. Perhaps an old friend remarks, “…we have sure gained a lot of weight.” Perhaps the stress of work begins to produce headaches. To move beyond this first stage we need only say to ourselves: “Perhaps I really do need to change. I will learn more about what I may need to do.” In short, we need only accept the challenge that life presents.
The Awareness Stage
The second stage of personal change we call the Awareness stage. It is also known as the contemplation stage. We have decided that change is worth thinking about, and we want to learn more about the issues, but we have yet to commit ourselves to changing. We are aware that the things we are doing may not be serving our goals of health and happiness and yet we are full of questions that need answers. Before we begin to change we must know more about what harm we are doing and how making changes will make our lives, and the lives of those we love, better. Perhaps we are waiting for the ‘magic moment’ to change. We need to learn to make our own magic, moment by moment. Perhaps we continue to enfold ourselves in comforting wishful thinking. We need exposure to information that will enable us to create new wishes, for health and happiness, that we make come true. During the awareness stage we must seek new information and think carefully about how that information applies to us. We complete self-evaluations designed by professionals. We talk with our loved ones and actively listen to their point of view. We ask our doctors. We talk with our friends. We gain awareness that will serve us, when we elect to actively change.
Commitment is more a milestone than a stage. Having expanded our awareness we need to make a commitment that we are going to implement some specific changes in our lives and we set a specific date when we will start those changes. In this stage we have yet to conclude how we will change. We are affirming we are going to do so, and we will begin careful preparation to do so. Not only are we willing to say so we are willing to share that information with some person (e.g. spouse, parent, brother, sister, son daughter or close friend). Research has shown that when we “go public” we are more likely to follow through. For the commitment to work it needs to be made to someone we care about and who cares about us.
Few of us would disagree that the key to success in sports is preparation. As we watch the NBA star make each free throw touching only the net, we would agree that practice and preparation led to the success of the moment. As we watch the golfer send the recovery shot from the rough to roll to a stop only two feet from the hole, we know that preparation was the key to the success of the moment. Yet we launch our new exercise program without any planning. We throw away our cigarettes with no planning for how to cope with the effects of nicotine withdrawal. And then we wonder why our programs for change fail. Preparation does not have to be time consuming. Often it can take only a few days. If done wisely a little preparation can be the difference between success and failure. There are two major elements to this stage of change. One is rehearsal and the other is the plan. Most of us have admired the way the astronauts stay calm and keep their focus even during a crisis. They always have a plan and they rehearse sequences. The success of the moment is defined by prior preparation.
The Action Stage
Two thousand years ago all roads led to Rome. Now all roads of change must lead to action. Doing it. The value of awareness and preparation is defined through action. Making changes in ourselves and in our environment to lead to the outcomes we desire in health and happiness is the action stage. We should use every trick in the book. And perhaps invent a few. We may be working on several dimensions of change at once (e.g. aerobic fitness, strength, flexibility) when changes in one dimension serve to facilitate successful changes in others. Sequencing is often the critical element. We must break change down into steps that are within our natural stride. We crawl before we walk. We walk before we run. We run around the block before we run a marathon. This is the stage in which structured programs can be of the greatest help. The plan developed in preparation is implemented in the action stage.
The Maintenance and Celebration Stages
Mark Twain is reputed to have said that stopping smoking was no problem, after all he had done so a hundred times. The patient may have started and abandoned many exercise programs, or weight loss programs, or stress programs. If so, then welcome to the human race! Being human we will have our lapses. Change is a spiral not a line. More often than not the success of a program to change habits related to health and happiness fail when a lapse that could have been a temporary setback becomes a relapse. We may even cycle all the way back to the challenge stage and began to think perhaps it was not worth it at all. Perhaps we find ourselves back at awareness and in need of more information. If we cycle back we must get as soon as possible to preparation and get ready for another run at action. The final stage is called celebration. We reach this stage when we have reached our goals. It is a moment worth a real celebration. We need to reinforce ourselves with a great dinner, a night on the town, a hundred dollar bill we set aside for just that purpose and all the high fives we can get.
No change program is finished until there has been a discussion of what might happen after the patient succeeds in changing the risky behavior pattern. Remembering that change is more of a spiral than a straight line, it is important to patient understand that lapses are the common way that people change and it does not reflect failure. Planning for preventing relapses can be of very positive way to build self-efficacy. Patients who know what they’re going to do if they lapse are much more likely to simply cycle back to an earlier stage and renew the change program. Research in relapse prevention has revealed that there are intrapersonal and interpersonal factors associated with relapse. Negative emotional states like depression increased risks. Negative physical states like a new illness also increase risk. It is extremely common for patients to try and test their new sense of personal control and place themselves into situations that lead to relapse. Finally, patients must monitor themselves for urges and temptations and have a specific plan in advance for handling those. Interpersonal factors that can lead to relapse include conflicts and social pressure particularly in groups where the risk behavior was commonly accepted.