1. Health Behavior Change:
Stages of Change Model
AILEEN B. PASCUAL, MD, FPAFP
11 JULY 2013

3. CHANGE INTERVENTION
• Important role of physicians
• Useful in addressing lifestyle modification for
disease prevention, long-term disease
management and addictions.
• Understanding patient’s readiness to make
change and appreciating barriers to change
and helping patients anticipate relapse

4. Transtheoretical Model
•Stages of Change Model
•Prochaska & DiClemente
•Change is a process involving progress
through a series of stages
•Five stages of change

5. GROUP ACTIVITY
• 12 groups
• Each group will be given 1 manila
paper, masking tapes and set of
clipnotes
• There are major categories of the
clipnotes which your group will
match

6. MATCH
STAGES of
CHANGE
GOAL PATIENT PHYSICIAN
? ? ? ?
? ? ? ?
? ? ? ?
ACTION ? ? ?
? ? ? ?

7. 10 minutes

8. Transtheoretical Model
Prochaska&DiClemente
•Stages of Change Model
•Change is a process involving progress
through a series of stages
•Five stages

9. STAGES OF CHANGE
Prochaska&DiClemente
•Pre-Contemplation
•Contemplation
•Preparation
•Action
•Maintenance

11. Pre-Contemplation
•Patient is not even thinking about
changing the behavior.
•They may not see the behavior as
a problem at all.

12. Pre-Contemplation
•Resistance to change can be
summarized in 4 R’s
• Reluctance
• Rebellion
• Resignation
• Rationalization

13. Pre-Contemplation: Reluctance
•Don’t want to consider change
because of lack of knowledge or
inertia
•Approach:
• Provide feedback and information in
a sensitive and empathic manner

14. Pre-Contemplation: Rebellion
• They have a heavy investment in the
problem behavior and in making their own
decisions
• Resistant in being told what to do.
• Approach:
• Offer choices
• Shift some energy used to resist into
contemplating change

15. Pre-Contemplation: Resignation
• Characterized by lack of energy and
investment
• They have given up on the possibility of
change and seem overwhelmed by the
problem.
• Approach:
• Instill hope
• Explore barriers to change

16. Pre-Contemplation: Rationalization
• Many reasons why the problem is not a
problem or is a problem for others but not
for them.
• Session feels a debate
• Approach:
• Empathy and reflective listening

17. Pre-Contemplation
Goal Patient Physician
Patient will begin
to think about
change.
Not thinking about
change
May be resigned
Feeling of no control
Does not believe it
applies to himself
Believes consequences
are not serious
Use relationship
building skills
Personalize risk factors
Give data about
patient’s vitals, labs and
compare with norm.
Express caring concern
rather than scare tactics
Educate in small bits
over time

19. Contemplation
• Person acknowledges that she/he has a
problem and begins to think seriously
about solving it.
• Stage marked by ambivalence
 Giving up an enjoyed behavior causes them
to feel a sense of loss despite the perceived
gain.
• Contemplation does not mean
commitment

20. Contemplation
• APPROACH
• Provide information and incentives to
change
• Deal with the hidden “benefits” of
maintaining the behavior (“decisional
balance technique”)
• Deal equally with the pros and cons of
CHANGING the behavior

21. Contemplation
• APPROACH
• Explore problems with previous
attempts to change.
• Reframe failures into “partial successes”.
• Emphasize the cyclic nature of change in
the stages-of-change model.

22. Contemplation
Goal Patient Physician
Patients will examine
benefits and barriers
to change.
Weighing benefits and
costs of behavior,
proposed change.
Elicit from patient the
reasons to change and the
consequences of not
changing.
Explore ambivalence,
praise the patient for
considering difficulties of
change.
Restate both sides of
ambivalence.
Question possible solutions
for one barrier at a time.

24. Preparation/Determination:
Commitment to Action
• Hallmark: deciding to take appropriate
steps to stop a negative behavior or start a
positive one
• Assess strength and levels of commitment
• Anticipate problems and pitfalls
• Use appropriate techniques.

25. Preparation
Goal Patient Physician
Patient will discover
the elements
necessary for
decisive action.
Experimenting with
small changes
Encourage the
patient’s efforts.
Ask which strategies
the patient has
decided on.
Ask for a change
date

27. Action
•People make drastic lifestyle changes
•Requires greatest commitment of
time and energy

28. Action
APPROACH
• Provide support
• Provide external monitoring of progress
• Focus on successful activity (“Progress, not
perfection.”)
• Reaffirm their decision
• Offer information about successful models
• Usually lasts 3-6 months

29. Action
Goal Patient Physician
Patient will take
decisive action.
Taking a definitive
action to change
Reinforce the decision
Affirm small successes
View problems as
helpful information
Ask what else is
needed for success.

31. Maintenance
• New behavior is becoming firmly established
• Threat of relapse becomes less frequent and
intense
• APPROACH
• Provide feedback about length of time needed
for change
• Help patient become aware of “triggers”
• Help the patient learn from the relapse
• Remind them of the cycle of change

32. Maintenance
Goal Patient Physician
Patient will
incorporate
change into daily
lifestyle
Maintaining new
behavior over time
Continue
reinforcement
Ask what strategies
have been helpful
and what situations
are problematic.

34. Relapse
Goal Patient Physician
Learn from the
temporary
success and re-
engage the
patient in the
change process
Experiencing normal
part of the process of
change
Usually feels
demoralized
Remind the patient
that change is a
process, that most
people “recycle”.
Reframe from failure
to successful for a
while plus new
lessons for continued
success.

35. Termination
•Stage where individuals have zero
temptation and 100% self-efficacy

36. Decisional Balance Technique:
Motivational Counseling
Prochaska and DiClementi

37. How is
Decisional Balance Technique
done?

38. Question 1:
What do you get out of it?

39. Question 2:
What are the
disadvantages?

40. Question 3:
What are your goals in
life?

41. Question 4:
How does the behavior fit
into your goal/s?

42. Question 5:
If you could change, what
would happen?

43. Decisional Balance Technique
5 Questions in series:
1. What do you get out of it?
2. What are the disadvantages?
3. What are your goals in life?
4. How does the behavior fit into your
goal?
5. If you could change, what would
happen?

44. References
Zimmerman GL, Olsen CG, Bosworth MF. A 'stages of change' approach
to helping patients change behavior. Am Fam Physician
2000;61(5):1409-16
Dr. Allan Dionisio
Dr. Cherry Bernardo-Lazaro