Despite advances in medical technology and evidence-based guidelines, most efforts to improve health require some change in behavior on the part of patients. These changes in behavior might involve reduction or elimination of destructive behaviors (e.g., smoking and alcohol dependence), promotion of healthier lifestyles (e.g., regular exercise, safer sex), and adherence to medical regimens intended to treat acute or chronic illness (e.g., taking medications, dietary restrictions checking blood glucose). Most clinicians, however, feel more confident in their diagnostic and treatment skills than they do in their ability to ensure that patients will make necessary lifestyle changes or closely adhere to medical regimens.
In this chapter, I will describe and integrate three of the most researched approaches to behavior change: the Stages of Change Model of James Prochaska and Carlo DiClemente, the Motivational Interviewing Model of William Miller and Stephen Rollnick, and the Self-efficacy Model of Albert Bandura. My goal is to outline a practical approach to influencing patients that respects the complexity of human behavior while breaking clinician interventions into manageable steps.
The Stages of Change Model introduced the idea that people move through a succession of six relatively distinguishable stages in making changes in behavior.
Precontemplation stage: There is little thought about the problem or its solution.
Contemplation stage: The problem and the potential methods, costs, and benefits involved in trying to address it are explored and evaluated.
Preparation/Determination stage: Choosing and committing to a specific course of action and timetable around which to commit energies to change.
Action stage: New behaviors are initiated and problem behaviors are replaced (e.g., following a diet and exercise program on a consistent basis).
Maintenance stage: Successful changers begin to incorporate Action stage behaviors into a "new normal" way of living.
Relapse stage: There is a return to an earlier stage after an initial period of successful change.
The change process starts in the Precontemplation stage during which people have a problem but are not thinking much about the problem or its solution. Problem awareness typically begins in response to some "bad news" that can arise in myriad forms, for example, physical symptoms, clothes that don't fit, workplace prohibition on smoking, doctor reports problem with routine blood pressure or lab test. The disturbing data prompt entry into the Contemplation stage where they begin to think more about the problem and begin weighing the pros and cons of trying to address it. They may make halfhearted efforts of change, but lack the commitment needed to sustain them. In the Preparation/Determination stage they become more committed to a specific plan as they prepare to take action. In the Action stage people are "doing it"; engaging in changed behavior on a regular basis (e.g., walking a mile five times a week, closely following a diet plan). The daily effort of behavior change is hard to sustain. Changers learn that ...