Friday, September 30, 2016

Stages of Change

In my Health Promotion class I learned the "terminology" behind some of what I have learned experientially through my 7 years as a Certified Health Coach. We were studying the "Trans-Theoretical Model of Behavior Change." 

The goal behind any behavior change is to move THROUGH the stages INTO the healthy behavior you are wanting to bring into your life, so that you can be actively living in and maintaining the DESIRED behavior.

I've been in various stages of ALL of these stages in my own 48-year health journey, I'll describe them and you can see where YOU fit in!

Precontemplation: "I won't/I can't"

Contemplation: "I might"
Preparation: "I will"
Action: "I am"
Maintenance: "I have"
Termination: "It's as if I've never lived any differently than how I'm living now"

The following descriptions were taken from the book Health Behavior Theory, Research, and Practice, 5th Edition, by Karen Glanz, Barbara K Rimer, and K. Viswanath,

Precontemplation is the stage in which people do not intent to take action in the near term, usually measured as the next six months. The outcome interval may vary depending on the behavior. People may be in this stage because they are not informed enough about the consequences of their behavior. Or they may have tried to change a number of times and become demoralized about their abilities to change. Both groups tend to avoid reading, talking, or thinking about their behaviors. They often are characterized as resistant, unmotivated, or not ready for health promotion programs. An alternative explanation is that traditional health promotion programs were not ready for such individuals and were not motivated to match their needs.


People in contemplation intend to change their behaviors in the next six months. They are more aware of the pros of changing than precontemplators and are also acutely aware of the cons. This balance between the costs and benefits of changing can produce profound ambivalence and keep some people stuck in contemplation, a phenomenon characterized as chronic contemplation or behavioral procrastination. These people are not ready for traditional action-oriented programs that expect participants to take immediate action. If contemplators are pushed into such programs, they are not likely to succeed.


In the preparation stage, people intend to take action soon, usually measured as the next month. Typically, they have taken some steps in the past year. They have a plan of action, such as joining a quit smoking health education class, consulting a counselor, talking to their physician, buying a self-help book, or relying on a self-change approach. These are the people who are receptive to and willing to begin an action-oriented program.


People in the action stage have made specific overt modifications in their lifestyles within the past six months. Because action is observable, behavior change has often been equated with action. In the TTM, action is only one of six stages. Typically, not all modifications of behavior count as action in this model. In most applications, people have to attain a criterion that scientists and professionals agree is sufficient to reduce risks for disease. For some behaviors, such as cancer screening, the criterion may be getting an effective cancer screening test (e.g. a mammogram, Pap test, or colonoscopy) that can reduce the risk of dying from cancer. For smoking, there now is consensus that the criterion behavior should be total abstinence, since other changes do not necessarily lead to quitting and do not lower risks to zero.


People in maintenance have made specific, overt modifications in their lifestyles. They are working to prevent relapse, and they do not apply change processes as frequently as people in their changes. Based of self-efficacy data, it has been estimated that maintenance lasts from six months to about five years, depending on the targeted behavior. Longitudinal data from the 1990's surgeon general's report (U.S. Department of Health and Human Services, 1990) supported this temporal estimate. After twelve months of continuous abstinence, 43 percent of individuals returned to regular smoking. It was not until five years of continuous abstinence that risks for relapse dropped to 7 percent. The time frame can very for other health behaviors.


People in termination report having zero temptation and 100 percent self-efficacy. Whether they are depressed, anxious, bored, lonely, angry, or stressed, they are sure they will not return to their old, unhealthy behaviors. It is as if they had never acquired the behavior in the first place, and their new behavior has become automatic. Examples include adults who buckle their seatbelts as soon as they get in their cars or automatically take their antihypertensive medications at the same time and place each day. In a study of former smokers and alcoholics we found that fewer than 20 percent of each group had reached the criterion of zero temptation and total self-efficacy (Snow, Prochaska, & Rossi, 1992). The criterion may be too strict or this stage may be an ideal goal for the majority of people. In other areas, like exercise, consistent condom use, and weight control, the realistic goal may be a lifetime of maintenance, since relapse temptations are so prevalent and strong. Termination has received much less research and practical attention than other stages, because it typically takes so long for individuals to reach this stage."

So my take as someone who struggled with my weight since 4th grade, and someone who desires to continue to live in health, practicing my healthy habits, is that I want to get IN to "maintenance" and remain there. I am happily in ACTION right now, giving myself a "tune-up," and will continue in action even through and back into maintenance. I look forward to the "termination" phase (no not LITERALLY!)! The stage where I have solidified and mastered all my healthy habits, and living and continuing to thrive in my healthy lifestyle will be as routine to me as breathing!  For today, though, I am satisfied living day-to-day and remaining MINDFUL in "action" and "maintenance". Perhaps "termination" is something that can only be observed as having been entered in hindsight.

But there were plenty of years I lived, before finding our wonderful program, in a state of "pre-contemplation". I didn't want to read or hear anything about "how to get healthy" because it always caused me (I thought) to feel terrible about myself. I preferred to live in ignorant bliss, and my health and quality of life suffered tremendously because of it. Oh sure, I had moved into "action" before, but things hadn't worked out the way I had wanted them to and I'd always regress back into the precontemplative state.

Then there were those times I was in a contemplative state, reading about weight loss-programs, and sometimes even trying them (moving into action), but then ultimately failing and regressing back to precontemplation.

I think of the many years I spent in "behavioral procrastination" with regret. I studied Nutrition to try to understand the metabolic processes, and requirements of the human body, in an effort to understand MYSELF and my situation. I became an expert on theory but was inexperienced in ACTION and RESULTS.

Until I found our program, that is. I was so impacted by the stories of the REAL people who had transformed their health through our program I moved directly from pre-contemplation to action, and I have never looked back. Our community is a community of like-minded people who are LIVING the life they always wanted to live, not perfectly, but perfectly IMPERFECTLY and with grace and love, who have MOVED into action and then into maintenance, and who support each other along the way. 

Here's my own takeaway. I am trying to learn how to better identify WHERE people may be in their OWN journey, and how best I can help them move forward from where they are to where they want to be. 

That's my passion, and that's my heart.