Secrets of Therapeutic Change

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How do people really make changes in their lives? The process is more complicated than many people believe.

The Technology of Change

Being a therapist is being in the business of helping people change. Yet in my experience, most people don’t have much of an idea of how change happens. When pushed for an answer on this issue, they may quote Nike and say “just do it.” Others may say “it takes willpower.” With answers like these, I’m not surprised so many people have trouble making changes in their lives. And please don’t hear me to say that any of the people giving such answers are stupid. Often they are quite bright, but they simply don’t know much about the huge body of knowledge about how and when people change their behavior over the long-term.

To begin remedying this situation, I’d like to introduce a relatively simple five-stage model that describes how change works in a bit more depth. The “stages of change” model comes to us from James Prochaska and Carlo DiClemente. Since it was developed in the 1970s and 1980s, the model has been most actively used in addictionology, but can be used in almost any situation where change is needed.

Precontemplation

It’s incredibly hard to solve a problem before you recognize the problem itself. This may seem too obvious at first blush, but many real clients spend a lot of time in precontemplation. We often call this stage by other names: lack of awareness or denial to name two. There is a t-shirt that encapsulates precontemplation for alcoholics: “I don’t have a drinking problem. I drink. I get drunk. I pass out. No problem!”

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Not everyone in precontemplation is so blunt. Sometimes people recognize a problem, but not the severity or the full consequences. Many smokers can talk about what smoking has done or is likely to do to their bodies, but the impact simply isn’t yet great enough, or emotionally “real” enough to push them forward. Still others may be hopeless in the face of their problems. They want change, they know they need change, but don’t believe that anything they do will make a difference. Precontemplation helps therapists and clients alike because it honors the very first steps to change which is to recognize that a problem exists and needs immediate attention.

Contemplation

Once clients have it straight in their heads they have a real problem that needs a solution, they may still not put themselves in motion. Even if the problem is real, clients are apt to believe the cure might be worse than the disease. Therapists can be a big help at this “on the fence” stage because they have ability to listen to and validate the very real ambivalence that clients experience. They also hold the knowledge about what change is really like and can make some well-informed statements on the plusses and minuses of change.

Preparation

It’s no accident that all the prior steps are “in the head.” They are often overlooked but essential. Finally, with Preparation, the client starts getting real. Effective and long-lasting change takes much more than a decision; it takes good strategy. Preparation is the phase where therapists and clients work most actively together to design a battle plan to solve the problem once and for all.

Action

If change was a footrace, Precontemplation, Contemplation, and Preparation would be the training regime. Action fires the starting gun. Commitment and strategy come together to do the “heavy lifting” of change. In this stage, people actually stop smoking, start engaging in social situations they avoided in the past, or hit the gym.

Inevitably, not everything goes to plan in this phase. Experience, being the best teacher, often provides hard lessons on how the plan developed in Preparation must be altered or even rebuilt from scratch. In the action phase, therapists serve as cheerleaders when things go well, comforters when discouragement strikes, and strategic re-planners at all times.

Maintenance

With hard work, the Action stages yields to the Maintenance stage. By this point, the new behaviors are no longer so new and well on their way to becoming ingrained habits. Maintenance is the time when holding on to the change takes less effort and less time than in the action stage. Ideally, maintenance is the terminal state, and the change “sticks” for good.

Therapy in the maintenance stage often takes the form of less frequent sessions. The intent is to “back away” from the client and allow them to do more of the work on their own initiative and timing.

Relapse

Relapse isn’t properly a stage, but rather a possibility at any point in the process of change. While the model is designed to be stepwise in the ideal case, moving from precontemplation to contemplation to preparation to action to maintenance in one continuous upward arc, real-life change rarely happens this way. Relapse simply means falling back to earlier stages. Relapse can strike at any point and push the client back one or more stages.

The therapeutic impact of understanding relapse in this light is that setbacks often aren’t total. A client may move back one or two stages, but that doesn’t erase all the prior progress. Making relapse part of the process of change also helps take the stigma of failure away. Most addicts, even those that are ultimately successful, relapse at some point. Without a good understanding of relapse, clients often take setbacks as indictments of their everlasting inability to change. This “beating yourself up” tendency is so strong with some of my clients that I spend a great deal of time addressing it in session.

Taken together, the stages of change help us understand that change is usually not a quick or simple process. It happens mostly in our heads, and mostly long before we begin taking any physical action. This promotes patience and understanding of the internal demands of change. It also makes setbacks a normal part of the process, reducing the effects of discouragement, shame and resignation.

All clinical material on this site is peer reviewed by one or more clinical psychologists or other qualified mental health professionals. This specific article was originally published by on and was last reviewed or updated by Pat Orner Oliver on .

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