Education That Elevates Psychiatric Care

5 Stages of (Behavioral) Change

Also known as the Stages of Change Theory, there are 5 stages to (behavioral) change. I’ve inserter the word “behavioral” because we’re not talking about social, political, psychological or cognitive changes, to which this theory can just as easily apply. We’re focusing on behavioral change because that is what you are actually going to be tested on, not the theory per se. And the behaviors most often found on the exam are things like weight loss, controlling anger, or nicotine cessation.

Because my own change theory question was, in fact, on the issue of someone quitting smoking, let’s use that example to demonstrate what each stage looks like. 

The first stage is Precontemplation.  This is easy to remember because it literally tells you that the person is pre- (before) contemplation (thinking) about the change.  They see no reason to change their behavior.  They like what they’re doing and either they don’t truly understand that there can be serious consequences to what they are doing…or (more often) they don’t think those consequences will happen to them. 

In this stage, we should be focusing on uncovering what might motivate them to change. This is a good time to use our motivational interviewing skills. Once we have a glimmer of an idea what might motivate them to change, we can educate the patient on the dangers of smoking, the incredibly high likelihood that they will in fact suffer serious consequences unless they stop, and maybe some graphic evidence of what smoking can do to the body. 

The second stage is called Contemplation, and it is exactly what it sounds like—the individual is contemplating changing.  There is no commitment to it yet, but the door has been cracked open just a bit.  Maybe the individual doesn’t have the money for cigarettes anymore.  Maybe they want to move to a place that doesn’t allow smoking or they are dating someone who finds it repelling.  Whatever the reason, they are now open to discussing how they might go about the process of stopping.

These folks are no longer dismissing out of hand the thought of quitting smoking.  They are open to being educated!  How perfect is that?!  (BTW, a great way to start this conversation is by asking them what the advantages are to NOT QUITTING, to continuing to smoke.  This is not only surprising to most patients, but it also gets all the hidden psychological saboteurs out in the open.  Then acknowledge, “Wow, those are some great reasons for smoking.  I can see why you’re still doing it.  What I don’t understand yet is, with all those reasons for smoking, why do you want to quit?” and then let the patient sell himself on the idea of quitting.  I make the patient convince me that it’s gotta happen, and I acknowledge, “You really do have a lot of solid, important reasons to kick the habit.  Any idea as to what your next step would be to do that?”  And if he has no ideas, BINGO, start helping him craft his own personalize, workable plan…which brings us to the stage of…)

Preparation.  The model stipulates that for the person to really be in this stage, they have to be planning the change to start in the next 30 days (which the exam often tests on specifically.) For smokers, these 30 days could include an appointment with a doctor to get a prescription for the nicotine patch or gum, it might include getting through their last pack of cigarettes, maybe having their entire apartment or house cleaned so there are no loose cigarette butts or old packs lying around.  Or maybe those 30 days are used to just get used to the idea of quitting.  Our job here is to help the patient figure out what specific things the patient can do to maximize a successful change and to make it as effortless as possible. 

But, at some point during those 30 days, the individual will take that first step, which places them in the Action stage.  This is when the patient is likely to experience both an elation and sense of empowerment in finally making this important decision and the unpleasant effects of withdrawal.  Remember that a big part of what a smoker goes through when they decide to quit is the social withdrawal, as well as physical.  They will find it incredibly difficult to take “smoke breaks” with their coworkers or family members but not smoke.  So part of the actions the individual has to take must address this change in socialization pattern.  Patients in this stage need a lot of support.

Once they have made it through the Action stage and have stabilized in their new behaviors, they move into the Maintenance stage.  Long time smokers (and everyone else trying to overcome an addiction) often report this stage being the hardest for all kinds of reasons.  Maybe the patient has lost a big part of their social system because of this change, as is so often the case with those who quit drinking.  Maybe the dangers of their previous habit no longer seem all that dangerous.  Or their health has improved so much, they think to themselves, “a cigarette here and there won’t hurt.” 

Maintaining a high level of motivation while fighting off denial and rationalization is tough, and a lot of people relapse several times before the healthier habit finally and completely takes hold of them.  Our role here is to help patients not think in black and white, all-or-nothing terms, because that kind of thinking often leads to a full abandonment of their change. We don’t want them thinking,  “Well, I had three cigarette last night at that party, so my plan to stay entirely smoke free this year is out the window…might as well just admit failure…”  We need to reassure them that initial relapses are pretty common and the important thing to focus on is that they really did start their change, they really can get right back on that path, and they really can make this change successfully.

So those are the 5 Stages of (Behavioral) Change. As always, reach out if you have any questions!