Stages of Change for Health and Wellness

“Only a minority (usually less than 20%) of a population at risk is prepared to take action at any given time. Thus, action-oriented advice mis-serves individuals in the early stages.” -Prochaska and DeClementi

Whether you’re looking to quit smoking, eat better, or make some other lifestyle change, it is important to note that it’s not often a matter of just waking up one day and doing the thing. It’s often a non-linear process which can take months or years, and which can come with periodic relapses. It is indeed a very tiny minority who are able to, say, quit smoking cold turkey and never falling off the wagon (or drinking, or sugar, or anything else).

I’m back in grad school for Integrative Health and Wellness Coaching, in part because I found that while I was having some early success as a Sleep Coach, I felt like I was stuck with some clients. Some people take easily to the method of guided sleep journaling and some other interventions. Others wanted to sleep better but it seemed like they wanted to someone to fix them, without realizing how much effort it may actually take on their part.

This week’s learning in class has been the stages of change, which are noted below (all subsequent quotes are from the citation in the caption). It is important from a coaching perspective because we can better support people by knowing where they are in the process and deploying unique approaches based on this. The applications here are obvious well beyond just behavioral sleep issues.

The Transtheoretical Model (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992)

In the remains of this blog, we’ll look a bit more on each of these stages as they relate to both sleep and other common issues (weight management, substance abuse, etc).

Precontemplation: In this stage, the client/patient probably doesn’t actually want to change. Indeed, they may not think they have a problem. These are the folks who perhaps have family do an intervention, or who have someone else drag them to therapy. In the case of my sleep patients, it is often a bed partner or parent of a child who thinks there is an issue, but the actual patient doesn’t necessarily agree, or doesn’t consider it so problematic they should bother to do anything about it. These engagements rarely yield anything, other than perhaps to lay the groundwork or plant a seed for the patient to consider it vaguely in the future as something to address.

Contemplation: In this phase, people are hopeful about making some changes in the next 6 months or so, but they are also still not totally sold on whether they’ll execute. They know the change will have positive impacts, but they also know they will be missing out on things, and so they’re back and forth with their internal narrative on whether it’s really worth doing, or doing soon. This phase is also known as “chronic contemplation,” and it’s probably where many of us reasonably self-aware people get stuck for long stretches of time.

Preparation: Here, the patient is very close to being ready to take action. Maybe they’re asked their doctor for a prescription to help quit smoking, or perhaps they’ve engaged a counselor or therapist, or bought some self-help books. They’re very nearly ready to make a leap, but hoping to lay all the groundwork to make sure it sticks. This is usually the ideal time for a coach to get involved.

Action: This is what most people think of as the main event. Technically, it involves “making overt modification in their lifestyle within the last six months.” You’re doing something- going to the gym regularly, avoiding substances, counting calories, etc. The consensus in the literature is that you can’t count “cutting back” for this stage – e.g. having a cheat day, only drinking on weekends, low tar cigarettes. This dabbling stuff would be relegated to the preparation stage and only true abstinence would count here.

Maintenance: This is actually the bugger. How many of us have cut carbs for awhile, or done something else with great rigor only to regress? The definition here would be sustaining a change for over six months, for up to 5 years. For smokers in particular, this half decade milestone is important, with only 7% of people relapsing after making it this far. Indeed, some 43% of smokers who have managed to quit for a year still relapse into regular smoking.

Termination: In this final phase, there is no longer any pull for the old substance/behavior. No amount of stress/life events will trigger a return to the negative behavior. They have found long-lasting healthier ways of coping with what life throws at them. Eating well and regular exercise have become subconscious habits. Sorry to be a downer, but not everyone gets to this stage. Some people do sustain healthy weight for life, or full sobriety, but it may only ever be from a maintenance perspective. A study found some 20% of former smokers/alcoholics still had temptation, even if they could continue abstinence. Perhaps in the end either of the last 2 phases are worth celebrating.

I’ve started sharing this concept with sleep patients before we formalize an engagement, asking them where they think they’d fit on the graph. It’s hard to say no to someone coming for help, but it’s helpful to know that they need to be in a specific frame of mind for possible interventions to stick. I’ll look forward to learning more in the coming weeks on the specific tools to use for people in each phase. For now, be well!


Sleep Coaching

Health and Wellness Coaching

Burnout and Stress Management

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