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Award-winning
psychologist describes model of behavior change
(February
2008 Issue)
When it comes to making major changes, it's best to take it one
step at a time. This is the basis of the groundbreaking stage model
of behavior change first developed nearly 20 years ago by James
O. Prochaska, Ph.D. The director of the Cancer Prevention Research
Center and a professor of clinical health and psychology at the
University of Rhode Island, Prochaska is most widely known for the
introduction of the Transtheoretical Model of Change, a model that
has been adopted around the world for use in substance abuse treatment
and prevention programs as well as other behavioral interventions.
Based on this model of change and funded in large part by the National
Cancer Institute, Prochaska has conducted more than $60 million
in research on smoking cessation, cancer prevention and other chronic
diseases. He has received numerous awards for his work, including
the Top Five Most Cited Authors in Psychology from the American
Psychology Society and an Innovator's Award from the Robert Wood
Johnson Foundation. He was also the first psychologist to win a
Medal of Honor for Clinical Research from the American Cancer Society.
Prochaska spoke with New England Psychologist's Catherine
Robertson Souter about his work with stage models of behavior change
and the new challenges for the world of psychology in behavioral
treatment.
Q: How did the stage models of behavior change come about?
A: Back in the 70s, psychotherapy was fragmenting into hundreds
of different approaches. Our original idea was to see what was common
across different treatments and how we could integrate the best
of different therapies. We identified some common processes of change
across the theories. When we went to study people who were struggling
to change on their own with an addiction behavior, they taught us
about the stages.
The stages were described 20 years ago by me and Carlo DiClemente,
Ph.D., a professor at University of Maryland at Baltimore, who was
a student of mine at the time. We followed 1,000 people who were
struggling to quit smoking for two years. With the discovery of
these stages, we immediately recognized that was the missing link
that allowed us to integrate things.
Q: What are the stages of change as you outlined them?
A: The first one is 'precontemplation,' where people are
not intending to take action in the foreseeable future. Historically,
these people were called unmotivated, noncompliant, resistant,
and not ready for therapy. We now know that it was us not ready
for them.
The next stage is 'contemplation,' folks who are intending to take
action in the next six months. One thing that characterizes them
is that their evaluation of the pros and cons of changing are equal
so they have a lot of ambivalence.
In 'preparation,' folks are ready to take action. The next stage
is 'action,' where they have now made the overt kind of change that
in most cases you can see. We generally put a timeframe on this
of about six months and then they progress into 'maintenance.' Our
ideal goal from there would be 'termination,' where the problem
is over and they have total confidence and zero temptation no matter
if they are angry, lonely, bored.
Q: These stages have altered the way that behavioral problems
are viewed and treated.
A: Prior to that, the dominant model was an action one,
where change equals taking action: when you quit drinking, when
you start to exercise, when you take your medication. But change
is a process that unfolds over time and 'action' is just one of
those stages. It is when the change is most observable so that's
why behavior change got equated with it. You can see that someone
has quit drinking, you can see them start to exercise but you can't
necessarily see the progress in the other earlier stages but [we
have discovered that] you can assess it, you can measure it and
you can influence it.
This is not only helpful on an individual patient basis but it
allows us to provide programs for entire populations. For example,
smoking cessation clinical guidelines only had evidence-based programs
for smokers who were in the preparation stage: they called them
'motivated.' But that's less than 20 percent of all smokers in the
U.S. If we are limited to 20 percent, even with good programs, the
impact is not going to be as great as if we can target everybody.
When we talk about evidence-based treatments, we look at just efficacy,
what percentage of people has recovered at long-term followup.
Well, with smoking, for example you don't want to look at just efficacy
if you are only reaching less than 20 percent of people with the
problem. You want to look at the participation rate times the efficacy
rate and then times the number of behaviors that are changed or
problems that are solved. In many of our studies we typically get
80% of a population participating and we are now showing in one
trial after another that we can change multiple behaviors as effectively
as if we target just a single one so that means we can have a much
greater impact than when we are dealing with less than 20% of people
with one behavior.
If we are going to go to universal health care, we are going to
need programs that are more inclusive. Psychology doesn't recognize
that it too often has been exclusive. For example, there were more
than 6,000 studies in the year 2000 on smokers but there were no
evidence-based treatments for smokers with mental illness even though
almost 50 percent of all cigarettes are bought by smokers with
mental illness. Well, you can't have that kind of science that excludes
people because they have mental illness, just like we excluded people
who were not motivated.
Q: How much has this stage model of behavior change been integrated
into the standard practice of psychology today?
A: The stages are on the national licensing test - so
they have to know that at least. I would say that in practice, more
often people would be learning motivational interviewing for early
stages and cognitive behavior therapy for later stages. But, those
don't have same kind of tailoring that our kinds of treatment would
add to it. The clinician doesn't have to rely on clinical judgment
but can do an assessment and tailor their interaction.
Q: What is the future?
A: I think psychology is in an incredibly exciting time.
There are demands for behavior change. The need has been there for
a long time and now the demands are starting to catch up. It is
economically driven. We say that pharmaceuticals account for 15
percent of health care costs, but behaviors account for 60 percent.
If you look at all health care costs due to tobacco, alcohol, obesity,
non-compliance with medications, one behavior after another, you
are talking about a huge financial impact.
The demand for health behavior care is starting to move toward
the need - that's providing an unprecedented opportunity for psychology
and psychologists, but we have to change to meet the opportunity.
We need to combine the best of the past, which is more like a medical
model, individual clients in clinics with clinicians and combine
that with a public health model, which is population-based. We have
to expand our boundaries from clinics to homes to worksites; from
clinicians to computers to other kinds of technologies.
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