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  • Dr. Olivia Froehlich

Change 101

Change is hard. This isn’t a ground breaking statement, we all know that change is hard. But it’s important... in fact, it’s crucially important. The ability to change gives us control over how we live our lives. We change from year to year, perhaps even from day to day, and some changes come about more organically while others are deep-rooted, stubborn, frustrating, and can make us feel downright helpless in the face of it. So WHAT makes change hard? And more importantly, how do we still enact change regardless of how tough it is? The goal of this blog is to better understand what makes change difficult, to reframe why we change in order to increase our chance of success, and to know how change progresses so that we can predict and prepare for the hardships.


What is change? And what can we actually change?

Change is taking something and making it different. Authors Freeman and Dolan describe change in their 2001 paper as a “‘shaking up’ process,” and then further characterize it as a “destabilization” effort in one's life1.


What in our lives CAN we make different? I would say this isn’t exactly a trick question, but it actually is kind of tricky and sort of philosophical. There are things about us that are changeable, you may be thinking about hair color, clothes, weight, risk for certain diseases, smoking status, etc. Now, think about what YOU can change when it comes to those things. What stands between your current hair color and an awesome bright pink mohawk? There are steps you have to take first. You have to change your behavior before your hair, all of a sudden, becomes an awesome pink mohawk. Behavior is defined as “anything a person does in response to internal or external events. Actions may be overt (motor or verbal) and directly measurable, or covert (e.g. physiological responses) and only indirectly measurable; behaviors are physical events that occur in the body and are controlled by the brain”2. So, in our awesome pink mohawk example, you probably have to see some awesome pink mohawks in your life or online for you to start thinking about acquiring one yourself. You may download an app on your phone which shows you what it could look like. You have to make an appointment with your hair stylist. You have to drive or walk or bike or take public transportation to get there. THEN you can have an awesome pink mohawk. And that's not even taking into consideration the further behavioral changes required to maintain your new awesome pink mohawk.


We often set the goal of a behavior change to an intended outcome, as opposed to the goal being the behavior itself. This is often incorrect and to our own disadvantage. One-time changes, such as the hair color example, make this distinction hard to recognize because the intended outcome of your (you guessed it) awesome pink mohawk is the sole reason why you engaged in the behaviors to acquire it. However, once we start discussing changes related to how we want to live our lives, or health-related changes, setting the behavior as the goal is critical to our success. For example, the change of hitting 10,000 steps daily to achieve an outcome of lowering your blood pressure puts the value and the expectation on a particular outcome that may or may not happen, rather than placing the value and expectation on the behavior change itself. Another example may be deleting your Twitter account so that you don't feel stressed everyday. The outcome may or may not be achieved, and if it isn't, we may incorrectly assume that the behavior change didn't work or isn't worth upholding. Please hold while I reinstall the little blue bird app.


Why is it important to orient ourselves to changing behaviors and not outcomes? It’s important to define a behavior as the end-point of change, rather than an outcome, because “there are a host of influences that could intervene and [weaken] the link between behavior and outcome”3. Other things out of our direct control, such as our environment, society, genetics, etc. can get in the way of us achieving at outcome. Sure, there’s room for outcomes and goals later down the road as we enact change, but when we first start to change something, it’s important to value the behavior change itself, rather than a specific outcome because that outcome may or may not happen as a result of our behavior. Furthermore, setting the behavior as the goal of the change allows us to “succeed” much quicker than if we set an outcome as the goal. If your change was hitting 10,000 steps daily and you value the behavior change as the end-point, EVERY day you hit 10,000 steps is a win. If your change was hitting 10,000 steps daily and you value lowering your blood pressure as the end-point, you only "win" if that actually happens. What other factors could intervene and prevent you from achieving the outcome? There are a lot! And might you be tempted to quit the behavior change if your outcome isn't achieved? You could then be missing out on other benefits from your behavior change which you might not be aware of.


Why is change hard?

I’m sure we all have some ideas as to why change is hard, but let’s put some words to those ideas. If change is a type of “destabilization” (as Freeman and Dolan offer) in our lives, it’s natural for humans to find that destabilization uncomfortable and to seek relief by going back to how they were before, “even if the existing system does not function optimally or adaptively”1. This discomfort is a sign that we’re moving towards, or are already outside, of where we feel safe and comfortable in our lives, and our self-protection processes might kick in. Freeman and Dolan offer that “the therapeutic goal becomes to move the patient through a series of changes that allow them to begin to expand their safety zone”1. Slow, steady, realistic, and behavior-focused, not outcome-focused is the key to succeeding at difficult behavior changes.


So what if you aren’t ready to change? Or, don’t know what you need to change? These sentiments, and many others, are crucially important to recognize and take into consideration when someone is trying to enact change in their life. Let’s talk about the stages of change.


Stages of change

A large part of the literature surrounding how humans change behavior revolves around the stages of change, which you may or may not be familiar with. There are five original stages proposed by authors Prochaska and DiClemente in 1992, and others have debated and called for inclusion or exclusion of stages since then. I personally like Freeman and Dolan’s revision of the original five stages of change because I believe they more completely capture the realistic process of change. Understanding these stages of change allow you and whoever you’re working with, whether that be a clinician, therapist, or coach, to steadily change behaviors while predicting where things might go… differently… than intended.


For those who are familiar with the older edition of the stages of change, here’s how Prochaska and DiClemente’s original stages compare with Freeman and Dolan’s:

Now, to the stages, all of which including the key statements, have been taken from Freeman and Dolan’s paper1.

Noncontemplation

This is the stage of change in which the person is NOT considering or even THINKING about changing anything. They may not even be aware that something needs to change.

Key statements:

“I don’t think that I need to change”

“I was not aware that change was necessary”


Anticontemplation

This is “the process of becoming reactive and violently opposed to the notion of needing to change”1. Clients know of the behavior that perhaps others want them to change, but they are staunchly opposed and resistant to this change.

Key statements:

“I don’t need to change”

“I don’t want to be here, you can’t make me change, I think that I’m fine just the way that I am”

“I refuse to change. Others need to change, not me”


Precontemplation

This is the stage when the “person begins to consider the consequences, purpose, and the possibility of change”1. They may even just be thinking about thinking about changing. While they’re not actively pursuing change, they’re not opposed to it like in the anticontemplation stage.

Key statements:

“I guess it might be worthwhile to consider change”

“I was not aware that change was necessary, but now that I do, I need to do something”


Contemplation

This is the stage during which the person is directly and actively thinking about and considering changing something.

Key statements:

“I think that I need to change”

“Change is necessary”


Action planning

This is when the rubber meets the road as the person (and maybe anyone who is helping them) is developing a plan to enact change.

Key statements:

“I plan to change”

“I think that I need to change and need to figure out a way to do it”

“I was not aware that change was necessary, but now that I am, what do I do?” (Notice that this key statement may be coming from someone who is going from noncontemplation directly to action planning. Skipping some stages of change happens!)


Action

This stage includes behavioral progress towards change.

Key statements:

“Change is hard, but I have to do it and I am doing it”

“What do I have to do next?”


Prelapse

This stage is characterized by current and “often overwhelming cognitions related to the reversal of the changed behavior”2. There has not YET been an active reversal back to the original state, the intended behavior change is still in effect, but the mind is wandering and perhaps craving the past.

Key statements:

“Is this worth it?"

“The old times weren’t that bad”


Lapse

This is the stage where the intended behavior change starts to wane and the actions needed to maintain change begin to decrease or become completely ignored. Relapse is very possible at this point.

Key statements:

“Is my change real or even beneficial to continue?”

“I don’t know why I am slipping back”

“Therapy doesn’t work. I’m considering doing what I once did”


Relapse

This is the stage of change where there is a return to the status quo behavior which was originally changed in the action stage. Note that relapse is an expected and incorporated stage in change. Avoiding relapse is great, but it’s the exception, not the rule. By predicting relapse as a part of all behavior change, we can potentially avoid it and put into place redirection back towards the intended change. Redirection will also happen during prelapse and lapse.

Key statements:

“I was not aware that change was so easily taken from me and that continued work is going to be necessary”


Maintenance

This is the final stage of change… but really it’s just a continuation of the behavior change. Maintenance isn’t stagnant, it takes work! “The goals are to (a) fine-tune and adjust changes, (b) support growth, (c) encourage stability, and (d) help the patient be his or her own therapist”1.

Key statements:

“I need to always keep my eye on the need to change”

“I must be aware that change is necessary”


What can YOU do?

I’m not expecting this blog to give you all of the tools to enact every change in your life that you wish to achieve. Change is still hard. The first sentence of this blog will continue to be true… forever. However, understanding that the end-point of behavior change is the behavior and not an outcome might reframe how you approach change in your life. Furthermore, learning about the stages of change can normalize the ups-and-downs that necessarily accompany difficult shifts in our lives.


So what should you do now? I want you to think of one or two difficult behavior changes you’ve made in your life. What stages of change do you remember moving through? All of them? Some of them? Did you skip some? How did you do it? What worked? What didn’t? And if you have things that you want to change in the future and foresee yourself needing help, consider reaching out to a coach or doctor (ahem) who will be with you every step (or stage) of the way!


Written by Dr. Olivia Froehlich

References:

1. Freeman, Arthur, and Michael Dolan. 2001. “Revisiting Prochaska and DiClemente’s Stages of Change Theory: An Expansion and Specification to Aid in Treatment Planning and Outcome Evaluation.” Cognitive and Behavioral Practice 8 (3): 224–34. https://doi.org/https://doi.org/10.1016/S1077-7229(01)80057-2.


2. Hobbs, L., Campbell, R., Hildon, Z., & Michie, S. (2011). Behaviour change theories across psychology, sociology, anthropology and economics: A systematic review. Psychology & Health, 26(Suppl 1), 31.


3. Susan Michie & Marie Johnston. (2012). Theories and techniques of behaviour change: Developing a cumulative science of behaviour change, Health Psychology Review, 6:1,1-6, DOI: 10.1080/17437199.2012.654964


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