The process of change: Part 1

Whether we are working as a therapist, coach, teacher or other helping professional, we are all in the business of helping clients make positive changes in their lives. But how does this change happen?

In this article series, I will take you step-by-step through what the process of change looks like. We will use the Transtheoretical Model (TTM), bringing an evidence-based framework to understand the stages of change.

A brief introduction to the Transtheoretical Model

The Transtheoretical Model, also sometimes referred to as the stages of change model, was developed by Prochaska et al. It helps us make sense of a client's readiness and ability to change.

It consists of five steps:

1. Pre-contemplation, "I don't need to change"
2. Contemplation, "Should I change?"
3. Preparation, "How would I do it?"
4. Action, "I'm doing it"
5. Maintenance, "How do I maintain this?"

In this article, we will assume a client is considering change. Although some frameworks tackle pre-contemplation, most people ask for help when they are at contemplation or later. Therefore, we will start at the contemplation stage.

Contemplation

At the contemplation stage, we are asking ourselves whether we should change or not. Let's consider some examples of clients in the contemplation stage:

Charlie has a strong self-critic. He has come to therapy because he makes himself miserable. But he is also successful academically and feels that his self-critic drives him to achieve more and if he were kinder to himself, he would not achieve so much.

Nina has come to coaching because she is unhappy with her job. She is thinking about switching careers but knows that doing so will mean giving up her senior position and income and going back to a relatively junior role. She is not sure how she would adapt to this or whether she wants to make the lifestyle changes necessary to live on a smaller income.

Jesse engages in binge drinking. Their partner has said they are unpleasant to be around when they drink and Jesse is worried that the relationship could end. But Jesse also enjoys drinking and it is the primary way of socialising with their friends. Jesse is worried that if they stop, they will lose these friendships.

In each of these examples, the person has good reasons to change. But they also have good reasons to sustain their current behaviour. In the language of Motivational Interviewing, this is known as ambivalence.

Reasons to stay the same

As discussed above, there are often good reasons for a client to want to stay where they are. Let's review some of these reasons.

We often feel anxious about the unknown. Even though we may be unhappy with our current situation, it may provide us with a level of comfort. Nina may be unhappy with her job, but at least she has plenty of money.

We may also worry that the change will make things worse. Charlie does get good grades. Being kinder to himself is likely to result in equally good grades and improvements to his mood. But there is a possibility that his grades would get worse without the self-criticism.

There may be practical losses, as well. Jesse may well see their friends less if they decide to socialise without alcohol. They will miss out on events. The friendships may survive but they may not.

All of these factors may also influence our identity. Charlie likes to think of himself as clever. Nina likes her senior position. Jesse thinks that fun people drink and boring people are teetotalers. Changing these things may profoundly impact their identity.

Supporting clients at this stage

We may think we know what the client should do. At such times, it can be very tempting to simply tell the client what we think. The problem with this approach is that telling someone what to do rarely works.

This realisation led to the development of Motivational Interviewing. The idea was to normalise ambivalence and avoid trying to push the client to do the "correct" thing as when we get pushed in one direction, we often push back and go in the other.

Using the MI framework, clients make the decisions themselves. We validate their reasons not to change (sustain talk) while amplifying reasons to change (change talk).

Practical tools

Use reflective listening and the OARS model: questions, affirmations, reflections, summaries. Make the client feel heard and understood to create a safe space for them to make the decision.

Pay attention to change talk using the DARN model: desire, ability, reason, need. For example:

• "I could find a way to live on a smaller budget" demonstrates ability.
• "I would love to be more chilled out about my exam results" demonstrates desire.
• "It would help my relationship if I stopped drinking" demonstrates a reason.

Exploring values can be useful here, too. Clients are often living in contradiction with their values. Helping them identify what they think is important and exploring how their current way of behaving aligns or does not align with these values, can be a strong motivator in deciding to change.

Conclusion

The first step to changing is deciding to change. In the Transtheoretical Model, this is known as contemplation. Clients must make this decision for themselves but we can support them in exploring their options and building the case for change.