Action. The person takes specific actions intended to bring about change. This busiest stage of change is characterized by overt modification of behavior and surroundings and requires the greatest time and energy. Support and encouragement are crucial to prevent drop-out and regression in readiness to change.
Maintenance. Goals at this stage are to sustain the changes accomplished by previous action and to prevent relapse. Maintaining new behaviors requires different skills than were needed to initiate change. Gains are consolidated. “Maintenance” is not a static stage; it can last 6 months or up to a lifetime. The patient learns new coping and problem-solving strategies, replaces problem behaviors with a healthier life style, and works through emotional triggers of relapse.
Relapse/recycling can happen but is not inevitable. When setbacks occur, help the patient avoid becoming stuck, discouraged, or demoralized, and help him learn from relapse before committing to a new action cycle. Conduct a comprehensive, multidimensional assessment to explore all reasons for relapse.
Termination is the ultimate goal: to exit the cycle of change without fear of relapse. Certain problems may be terminated or merely kept in remission through maintenance strategies.
Match strategies with stages
Discovery planning. Engaging patients in collaborative care starts with honoring their stages of change and working with them and their families on different tasks for each stage of change.4-6 A patient such as Mr. L, for example—who is at an early stage of change and thinks he has an “unfair boss problem” (not an alcohol problem) or a “nagging wife problem” (not an anger or domestic violence problem)—needs a discovery, drop-out prevention plan.
The cause of the patient’s work or relationship problem may be obvious to you, but a patient in early stages of change resists that information and, if pressed, gets frustrated and leaves treatment. A “discovery” treatment plan embraces the patient’s views and could be focused, for example, on gathering data that would prove to the employer that there is not an alcohol problem.
If random breath alcohol testing, feedback from family, and review of past job losses all prove negative for alcohol problems, the patient would have data to support his or her view that he does not have an alcohol problem. If, however, this exploration reveals an alcohol problem, the patient “discovers” he has more of a problem than he thought. For this plan, the challenge is to keep Mr. L engaged long enough to discover the connection between his alcohol problems and his employment or marital problems.
Recovery planning. On the other hand, a person at the action stage who wants to avoid becoming depressed again or wishes to live a life of sobriety collaborates on a recovery, relapse prevention plan. This patient is committed to developing the knowledge and skills to prevent relapse and open to whatever will promote health and well-being.
The Transtheoretical Model’s 9 processes of change3,4 inform which interventions might be most effective at various stages of change (Table 2). For example, a patient might be proud of the fact that “I can hold my liquor and drink everyone under the table.” Consciousness-raising—such as by explaining that his high alcohol tolerance is a danger signal, not a beneficial ability—can enhance his change process. Even if he is not ready to commit to definitive change, at least exploring whether he has a problem may move him from precontemplation to a contemplation stage of change. Table 3 shows how other processes of change can help motivate patients in later stages of change.4,5
Table 2
Transtheoretical model’s 9 processes of change: What happens at each step
| Process of change | The person… |
|---|---|
| Conscious-raising | becomes aware of a problem from education, advice, self-awareness, or feedback from others |
| Social liberation | begins to think about change because external forces raise awareness (a ban on smoking in restaurants, for example, can heighten awareness that one has a smoking problem) |
| Emotional arousal | becomes more convinced of the need to change when faced with a strong and sudden emotional experience related to the problem (such as death of a loved one) |
| Self-reevaluation | examines his or her values to see whether or not the behavior conflicts with what is important to him or her |
| Commitment | accepts responsibility for changing and affirms to self and others the decision to change |
| Reward | uses self-praise, positive feedback from others, improved well-being or financial security, “natural highs,” and other reinforcing benefits to consolidate change |
| Countering | substitutes other responses to counter unhealthy choices and behavior (such as relaxation techniques to combat angry outbursts or urges to resume smoking) |
| Environmental control | changes surrounding people, places, or things to reduce the risk of continuing or resuming the problem behavior |
| Helping relationships | seeks assistance from trusted friends, professionals, spiritual advisors, or significant others to initiate and sustain the change process |
| Source: Adapted and reprinted with permission from reference 4. | |