Is your patient ready for change? (YES!!!)
“Is my patient ready for change?” is the question that occupies the mind of most, if not all, health practitioners. But in honesty, it’s the wrong question.
The really important question to ask is “What type of change is my client ready for?”
The Transtheoretical or “Stages of Change”(1,2) model is familiar to most health practitioners who are concerned with any sort of health behaviour change, regardless of whether it relates to smoking, illicit drugs use, alcohol, exercise or junk food. It was built upon the foundations of Bandura’s Self Efficacy Theory (3) and provided a neat way of conceptualizing a person’s readiness for change, ranging from the “precontemplative” (haven’t even really thought seriously about changing) through contemplative, preparation, action and maintenance stages(1). Importantly, it normalizes lapses and relapses and permits a cyclical view of change in which a person may make several attempts at long term change before being “successful”(4).
While very useful, the model does have limitations. For example, although rooted in self efficacy theory, it lacks a “social efficacy” or social context dimension(5). Secondly, the model doesn’t provide useful insight into how much time a person may spend in a stage, nor what is necessary to move from one stage to the next. It is not always easy to determine where in the process of change a particular client or patient currently sits. In this sense it tends to be a descriptive, rather than functional model.
In 1984, the Milwaukee based Family Therapist Steve de Shazer proposed a novel way of understanding more about clients’ processes of change(6) and in some ways this can be seen as an adaptation or variation of the Transtheoretical Model. Rather than viewing clients as “resistant” to change, de Shazer proposed that clients’ actions in completing or not completing homework tasks or not “complying” with treatment goals, is their way of communication their readiness for change.
He proposed a tripartite framework for understanding client motivation in which they were described as “Visitors” (roughly equating to the Pre-contemplative stage), “Complainants” (roughly equating to the Contemplative and Preparatory stages) or “Customers” (roughly equating to the Action and Maintenance stages) (6). De Shazer and his wife and colleague, Insoo Kim Berg, went on to apply these ideas very successfully as a therapeutic approach they named Solution Focussed Brief Therapy(10) and which was applied to several health behaviours such as drinking and drug use (7,8)
The importance of this framework is not simply in the descriptive value, but in the resultant practitioner orientation to the client. He proposed that homework tasks be set according to the client’s level of motivation and the practitioner’s estimation of this. So let’s look first at how to assess motivation in this way and then look at how a health practitioner can usefully intervene.
In short, a Visitor is a client who doesn’t really see any current need for change. This will likely be evident in both their language and the way they discuss the matter at hand (whether it’s smoking, drinking, exercise or any other health behavior) and also the context of their presentation. Have they come to see you voluntarily or are they there at the urging of a concerned spouse or partner, child, work colleague or GP (if you’re an allied health practitioner).
A Complainant will likely acknowledge that there is some sort of problem to be addressed but will also tend to shift responsibility for this change away from themselves. They may talk about making a change when a particular other matter changes (for example: when I’m not so busy at work; when I’ve dealt with a particular family stressor; in the new year, and so on). In other words, they recognize that something needs to change – just not them and not right now.
A Customer is the client we all dream of having – ready, willing and able to start making practical changes, right then and there. They see the need for change, they recognize that they can do this and they set about planning it – health practitioner heaven!!
Of course people can move around these categories – someone can start out being a “visitor” or “complainant” and over time become a customer. The key from a practitioner perspective is to remain alert to small signs of movement and change that indicate this. This enables the practitioner to provide timely and targeted interventions which will really maximize the readiness and motivation the client currently has.
So how best to provide interventions that will match your patient’s level of motivation? Again, we can turn to the work of de Shazer(6,9) to learn ways to do this. In summary, de Shazer proposed three main classes of intervention, each designed to match the client motivation and readiness status. Importantly, none of them pre-supposes that a client is not ready for change – they just may not be ready for the particular change we would like to see them make!
A Visitor should be offered compliments only – this is very easy to do genuinely and in a way that builds rapport which can become a foundation for later interventions. Examples of compliments may be:
“I can see how seriously you take the concerns of your wife/husband/son/daughter in coming to talk with me about your smoking today.”
This acknowledges the efforts of the person and importantly helps the practitioner to remain neutral with respect to change and also with respect to the urging of family voices. If pushing for change too quickly, the practitioner risks becoming “more background noise” for the patient with little change likely. In addition to offering compliments, visitors can also be offered information in a neutral way:
“Here’s some reading you can do for yourself on smoking” (not “Here’s some reading which will show you how dangerous smoking is and that you’ll likely die a slow and painful death if you don’t listen to your family and stop now”).
A Complainant should be given a homework task, but a very particular type – an observation only task. Remember that conceptually, a Complainant sees some need for change, just not them and not now. Giving a task to do something is likely to be left undone by the patient. This can then set up a pattern of guilt, shame and hopelessness in them and a view on your part that they’re “resistant” to change. So what does an observation task look like? It could be a counting exercise:
· “It’s important that you don’t make any changes to your alcohol consumption just at the moment, but I’d like you to keep track of the number of beers you drink each day between now and next Wednesday” or
· “You’ve told me you smoke a packet of cigarettes a day at the moment. I want you to keep track of any days when you smoke less than a packet, even if it’s only one cigarette less, and let me know when we meet next week.”
Interventions of this type are likely to be followed, since they don’t demand any behavioural change from the person currently, but they do keep the person focused on their own behaviour.
A Customer, argued de Shazer, is the only client who should be prescribed any sort of behavioural change task. Tasks which focus on small and incremental change are most likely to be complied with and be successful. Examples could be:
“Between now and next time we meet, I want you to smoke five fewer cigarettes than you usually would every other day”
or
“Between now and next Wednesday, I want you to choose two days on which to walk for 30 minutes and do this”
or
“I want you to add two vegetables to your evening meal every second day between now and our next meeting, starting today”.
For a “Customer” client type, these interventions are useful because they have already demonstrated their readiness to take action.
So, is your patient ready for change? Absolutely yes – but the type of change you expect and prescribe matters. Maintaining a mindset of always viewing your clients and patients as ready for some type of change, whether it’s a change in attitude, what they observe, or what they do, helps you to remain connected to them, to maximize the likelihood of useful change and to avoid the frustration of having clients who seem not to comply or to be “resistant” to change.
1 Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice, 19(3), 276-288
2 Prochaska, J., DiClemente, C. and Norcross, J. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), pp.1102-1114.3 Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-216
5 https://doi.org/10.1017/S0257543400000572
6 de Shazer, S. (1984). The Death of Resistance. Family Process, 23, 79-93
7 Miller, Scott D.; Berg, Insoo Kim (1992): Working with the polysubstance user. A case demonstration of solution-focused brief therapy. Milwaukee, WI: Brief Family Therapy Center
8 Berg, I.K &. Miller S. D. (1992) Working with the problem drinker. New York: Norton
9 de Shazer, S (1982). Patterns of Brief Family Therapy: An Ecosystemic Approach. New York, NY: The Guilford Press
10 https://en.wikipedia.org/wiki/Solution-focused_brief_therapy