Stages of Change

At Beijing United Family Hospital and Clinics (BJU), we Family Medicine physicians see a lot of patients who need or want to make changes to improve their health. I am sure most of us have some habits we have been wanting to change for a long time. I am also sure that many us have felt stuck or given up trying. It turns out that psychology can help us understand the process of change and some tools to nudge us along.

I recently shared The Stages of Change model with a patient who needs to lose weight. On a personal level, I have found it to be helpful in thinking about my own goals. This diagram illustrates the process of change and its stages. As you read this, think about some things you would like to change, and where you might be in the cycle.

Pre-contemplation. In this stage we are not sure if we want to change. We may have a lot of reasons to keep things as they are. When I encounter a patient who is still at this stage, he or she might be defensive about the reasons why change is a bad idea. “I know cigarettes are bad for me, but I enjoy them too much.”

Contemplation. In this stage, the person starts to accept the fact that change is needed. I often see patients enter this stage after I tell them about an abnormal test result. This stage could last a week or many years. The individual is still weighing the advantages and disadvantages of change. As a working mom (my eldest is nine and youngest is five) and doctor who is out of shape, I confess I was stuck in this stage for years. After listening to myself telling patients to exercise, I started feeling a bit hypocritical. I knew I needed to get fit, but how was I to balance family, work, personal time and sleep?

Preparation (also called Determination). In this stage, the person might start buying books (Believe me. I have bought a lot.), join classes or start seeking medical help. The individual has finally committed to making a change and taking steps to prepare for action. Some people skip this phase and rush into action, but this can then lead to failure because they weren’t prepared to make the necessary changes. I cannot over-emphasize the importance of realistic goal-setting during this stage. To illustrate, I did not start getting fit by signing up for a marathon. I also did not pay a lot of money to join a gym (not that there is anything wrong with that). I set a goal of walking or biking to work every day and always taking the stairs up to the third floor of our clinic. I know these are very small accomplishments (people did ask me if I lost weight), but research shows that success begets more success. Studies of determinants of successful behavioral change show that small, specific, measurable and attainable goals are the key. People learn from their past successes and failures. Recalling what worked or didn’t work the last time you tried to change a habit is very important. Individuals who successfully maintain weight loss also report more attempts at weight loss than those who are still overweight.

Action (also called Willpower). In this stage, the desired behavior begins to change. It is usually the shortest stage of the entire cycle and lasts six months on average but can be as short as one hour. It is good to seek support and advice during this stage. We know that groups such as Weight Watchers and Alcoholics Anonymous are successful in large part because of peer support.

Maintenance. In this stage, the change is sustained and the individual develops a system of rewards for staying on track. They also believe that the changes that they have made are worthwhile and meaningful.

Now comes the important part – RELAPSE. If we don’t recognize this as a natural part of the cycle, we might just give up right here. In this stage, we fall back into our old habits. People typically experience a strong sense of failure and lose their self-confidence. Rather than give up or wallow in shame, I urge people to remember that it is part of the process. It is important to ask: What situations put us at high risk? How can I avoid this in the future?

The final goal and destination is Stable Behavior (also called Transcendence). At this stage, the individual is no longer at risk of falling back into old habits and has reached a point at which the old habit is no longer a part of who they are.

As I explained all this to my patient who needs to lose weight, I saw her shift into contemplation. We set some very achievable and measurable goals, and I will hold her accountable at the next visit. As for myself, I plan to take it up a notch and am discussing a regular tennis schedule with a friend. Set small, specific, measurable and attainable goals for yourself. Give yourself grace when you relapse into old habits, but learn from your failures and successes. Now that both new year’s celebrations are over, feel free to take on those resolutions.

If you would like to read more about the psychology of behavioral change, visit this link:
http://www.psychology.org.au/publications/inpsych/behaviour/

The American Family Physician article has a useful tool called the Readiness to Change Ruler. You can find the questionnaire (Figure 1) at this link: http://www.aafp.org/afp/2000/0301/p1409.html.