A KISS to Make it Better: A Two Step Model of Behavior Change
Why is it the more educated we become the more complicated we make things?
I was facilitating a Motivational Interviewing [MI] group the other day and during a discussion on the 5A's, the topic of Prochaska and DiClemente's Transtheoretical model [TTM] came up; specifically the stages of change. This got the entire group thinking about the complexities of behavior change and the most prolific model we use to describe it.
Since the 1980s when the TTM debuted, the stages of change have become the most widely used approach to explaining behavior change; thus it is the model most professionals [working on any sort of change process] have become familiar with. The substance abuse and medical worlds have been two sectors that have relied heavily on use of this model. Since its inception the TTM has been heralded as the kissing cousin of Motivational Interviewing [MI]. In all actuality, however, one of the originators of MI, William Miller, clarified in an article dubbed Ten Things that MI is Not , that the stages of change where originally associated with MI only because, they provided a logical way of seeing how MI fits into the clinical process, but in the end, the stages of change model is not MI.
For substance abuse treatment, the TTM allowed for a fresh new look into addiction and allowed us to see how individuals made their way through phases regarding change behavior. One pivotal discovery birthed by this model was that patients needed motivational enhancement towards change more than they needed blame for their existing situation. Look at any substance abuse counseling program curriculum [and even some medical school curricula] and you are bound to find a class that mentions the TTM and its role in behavior modification. The insight that the TTM gave treatment professionals is absolutely extraordinary and subsequently the prevention world has coveted the TTM like a golden calf.
Leanardo Da Vinci has a famous quote that states "simplicity is the ultimate sophistication”. To me the TTM lacks this ultimate sophistication. Some may argue that you could not get a simpler model than one that has managed to reduce the complex nature of behavior change down to a mere five step process. However, I feel that the TTM is in need of one more round of distillation. According to the stages of change, people make their way from a precontemplative state, to contemplative, to preparation, then to action and after that they maintain: Then the cycle repeats [see below].
TTM Stages of Change Model
What this says to me is that what kind of Inaction the patient is in somehow matters more than the inaction itself. We are in constant flux and eternally making our way in and out of readiness regarding any behavior and quite simply it seems unnecessary to complicate the matter anymore than it needs to be. A simpler more therapeutically helpful perspective is that people are either in action or in ambivalence; nothing more.
Maybe it is we the therapist that is assisted most by the stages of change; not in that it teaches us more about the patient, but more about ourselves. Knowing that the patient is contemplative, in preparation or any other phase of the stage of change model may just be a way to help us feel better about the unknown nature of the situation. We resource the stages of change algorithm, place the patient in precontemplation and then [according to one manual] "encourage them to become more mindful of their decision making and more conscious of the multiple benefits of changing an unhealthy behavior”. This is stated like patient behavior is a forecastable action.
What we typically find is that in action is not where we find most of our patients. I’d venture in saying that only about 10% of patients are in action mode; leaving 90% in ambivalence. For this 90% of the population we rely on motivational interviewing to work through the ambivalence, roll with the resistance and navigate a next step that derives from the patients wants and needs at that time. We don’t educate, advise or assist, we just sit there in the ambivalence with them, negotiating this unknown territory as if it were our own journey. We save the rest of the five A’s [Advice, Agree, Assist and Arrange] for the action phase: the other ten percent—a very small portion.
I once read, when people are in ambivalence it is like Linus without his blanket, we have nothing to hold on to. So we ourselves reach for something to grab hold of, to stabilize the spin. I think the complexity of the TTM merely gives providers a blanket to hold on to. It is an ameliorating agent for us; something to ground us as we flounder around looking for a way to help the patient out of their current predicament. What is a bit more difficult to master yet profoundly more therapeutic is to fully embrace that we are only accountable for the interaction with and not the outcome of the situation. In doing so we are able to commit to the patient without any expectation of an outcome and thus we can be more comfortable with their ambivalence. We then know that the best thing we can do is sit in the unknowness with the patient, experiencing the moment with them and not try to fix or right the situation.
The stages of change are very useful, but only if you use them cautiously. The problem that I have discovered is that they can facilitate an assumptive pattern, pigeonholing people into a mold that which we think they fit. This is done with such subtlety that we ourselves don’t even see it happening. Rechecking the manual I see that the patient is now contemplative so I must "encourage them to reduce their harmful behaviors and look for change within the next six months”. If this were true, my life would be quite boring, but a heck of a lot easier.
In the vein of Keeping It So Simple [KISS] I often think back to a childhood movie when Yoda explained to Luke one fateful day in the swamp. He said: "Do or do not, there is no try”. I think lil’ man Yoda may be on to something.
I Beg to Differ
Wow Pete, please take off your shoes when you address the Trans-Theoretical Model. It is a sacred calf and when you approach it you are standing on holy ground. Your heresy is that by dropping from 5 levels of readiness to 2, you are also dropping the model’s 2 greatest strengths: Hope and Change.
Hope. As astutely posited in your essay and supporting literature, MI is an evidence-based practice, but readiness assessment through the TTM is not. Fair enough, but how do you separate the 2 since they have been co-mingled since birth? How do you separate the science supporting MI from the science of TTM since most clinicians choose their MI interventions on how they gauge their client’s place on the TTM scale?
When you collapse the levels of TTM, you’re left with just 2 levels: abstinent or not. In the process you also take MI from a harm reduction model to an abstinence model. Yes, there is simplicity in this, but there is no hope. Once you carve out contemplation, preparation, and maintenance, clinicians will start turning Okham’s Razor on their own wrists in desperation. We need degrees of change to give us hope. We want morbidity and mortality. Imagine dropping all A1c values except a 7.0 for diabetes. Imagine dropping the quantitative PHQ9 and only keeping the binary PHQ2.
This is especially true with the dreary art of behavior modification. It is often cited that it takes the average person 7 smoking cessation attempts to actually quit the habit for good. Then, you tack on to this the much larger percentage of patients that I see every day who are not ready to attempt smoking cessation. My guess is that, as a result, only about 2-3% of the smokers I see in counseling will actually quit smoking in a given year and that only about 10-15% I see for tobacco specifically will be fully successful. With those difficult odds, if I had a binary approach I would feel quite depressed. If I keep the 5 levels alive then I can at least take comfort in the fact that a smoker moved from precontemplation to contemplation. This allows me to believe that I am the Johnny Appleseed of a tobacco-free world—planting seeds that I won’t harvest. Don’t kill Johnny.
Change. Prochaska and Diclemente’s "Stages of Change” model has brought change to medicine. The model fundamentally change is how clinicians consider their patients. Before 1990 was there a field that hated their clients more than the addictions field? The lingua franca that joined clinicians and clients was all about "drunks, alkies, boozers, winos, and junkies”. In using TTM, we remove the focus from pathologizing a person to describing their desire and readiness. I’d much rather be labeled as a "contemplator” (it’s so zen!) than a drunk. Who wouldn’t prefer to be a "preparer” than a junkie?
And, this is more than mere semantics. This language can saturate a clinical setting and reverse patient hating. It adds a narrative sense to the way clinicians describe their substance using patients. It challenges simple stigma and replaces it with a story of resilience and everyday heroics. It provides an arc with a beginning point (addiction) and an endpoint (harm reduction). It prevents us from viewing patients and the change process in black/white terms. In a circular way, this change instills more hope in both patients and providers and keeps them engaged in the process.
In conclusion, I like Yoda. Compared to other wizened pond frogs, he is incredibly wise. However, one of his axioms seems especially glib: "Size matters not. Look at me. Judge me by my size, do you?” Size does matter. In basketball, bed, and behavior modification a "5” will always be better than a "2”.
||Peter and Randall have been close friends and collaborators since 2006 when Peter was "Data Dude" and Randall was "El Jefe" at the Summit Community Care Clinic in Frisco, CO.|
With CFHA, Peter writes the Re:Activation Blog and Randall writes the CollaboBlog.