Stages of Change

First, their work says that people progress through a series of stages go make change happen. The stages of change can be thought of as follows: resistant, considering, planning, acting, and maintaining. No big surprise here. However, what is surprising is that the stages seem to be universal across many cultures (including street kids) and across many types of change (including many that are of interest to me working with street youth: housing, employment, drinking, drug addiction, sexual behavior, anger management, and faith).  One can progress from one stage to any other stage, but the finding is that in self-changers and change assisted by therapy, there is a forward progression through the stages in the order listed but with backward steps and subsequent retracing of steps from time to time.

We might define success as seeing people navigate through a change process to the maintenance stage as quickly as possible, with as few backwards steps as possible, and with a long time spent in “maintenance.”

The second part of the work was in looking at what workers can do to participate in change. The most typical thing for a worker to do is to study and develop a message that is relatively effective for some particular change and repeat it. For example, think of DWI awareness raising campains. That’s a single message going out over and over. The researchers measured effectiveness of about a dozen social work tools in progressing people through the stages of change. The result was poor. Nothing really worked much better than anything else. Then something appeared in the research that was startling. The researchers observed that certain approaches were best at moving people from one particular state to another. The same method was not effective in other stages. So, if the worker matches the therapeutic approach to the state of change,  better things can happen. Again, it seems to straight forward, BUT THIS IS NOT NORMALLY PRACTICED! Workers have a few tools and often use them, no matter what the client is experiencing.

When I work with a street youth, I first try to identify one or two areas of change that the youth is interested in or which seem obvious based on the situation.  For example, maybe the youth is self-destructively drinking himself into a hole. Or perhaps it is a problem that the youth has identified. “I want to get a job because I’m tired of not having anything.”
I then assess where they are in the stages of change. I most frequently encounter the resistant stage or the considering stage. I figure this out by shaping my conversation intentionally to discover where they are. The most common response for drinking is: “How are you with alcohol?” “I have no problem with alcohol. I love to drink.” OK… resistant to change. Or, “I know I drink to much, but what can I do. If only I could get into a program that would really help me, but I’ve tried that before.” This is considering change.
Now what do I do? I need to modify my approach to match their stage of change! Tools that work well with resistant stage street youth are: externalization, visualization, and and exploration of the continuum of harm. Externalization includes seeing who or what outside the person is effected negatively by the behavior. For example, “I know you are OK with your binge drinking. How is your girlfriend with it?” “Well… she hates it because I sometimes beat her up.” “Wow. That’s rough.” “Yeah… I guess I shouldn’t do that.” By externalizing, we’ve moved from resistant to considering. It really can be that simple!  Or “My drinking doesn’t hurt anybody.” “What do you think all those ER visits and nights in jail cost?” “Wow! I like to think of myself as not making much of an impact, but I don’t like $1000/ER visit and $1000/night in jail! I guess I really ought to try to avoid those.” Another tool is visualization. We can bring as many senses as possible into play and getting the kid to imagine alternative futures. “If we get into a time machine and go 5 years into the future, what might we see?” We can do group exercises with drama, acting out alternatives. We can do art exercises where make a collage of how you want to be in the future. All these exercises invite the street youth to visualize the future and this can break down resistance. Another great technique is to openly admit that there is a whole range of behavior… from the safest to the most dangerous. Talk about each in terms of pros and cons. Don’t try to argue that drinking heavily doesn’t have pros… party environment, numbing out, forgetting painful things, relaxing. And you can discuss the cons. And consider other outcomes of getting worse and getting better: increase to drug use, increase to liver damage, reduction, occasional drinking, sobriety. It’s a continuum and the street youth can consider where they want to be in it.

In the considering change stage, I think helping with motivation is key. In this stage, I often help look at what’s important to the person. Put things into perspective. “Is your girlfriend or your bottle more important to you?” “Does your drug habit leave any room in your life for the things you enjoy: music, drawing, art, comic books, movies?” “What did you want to do before you starting drinking every day?” These questions help the person to consider their values and commit to planning.

In the planning stage, I believe the two most important things to hear over and over are “These changes are important” and “I believe in you.” And it is crucial to help the person make a realistic plan. When they begin to act, the most important three things are to “Celebrate, celebrate, and celebrate” every step forward. And normalize setbacks. Recovery is almost never a smooth escalator ride up. It’s a bumpy roller coaster with ups and downs.
To follow this model, (1) you assess where the person is with respect to some particular change goal, (2) you adapt your talk and actions to the person being served, and (3) you follow-up as they move through different stages. When they move forward, you move forward. If they go backward, you go back with them. So what if you do all this? Astounding things happen! The researchers showed significantly faster progress through the stages of change when the worker matches the client, perhaps as much as twice as fast! And just as important, there was significantly less going backward and longer  periods of time spent in maintenance stage. That’s something to be happy about!

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