The concept of "stages of change" provided a formal theoretical rationale for the common clinical observation that many patients are not yet ready to talk about change -- a fact that tends to be ignored in many change-focused schools of therapy. The TTM's stage-of-change construct showed how making a change may in fact be the therapist's agenda rather than the client's, and suggested that the therapist might be able to use alternate techniques for dealing with these "difficult" and "unmotivated" clients. If we accept the idea that change happens in stages, we then might start to ask ourselves what the alternative techniques are that can help people in the early stages of change. For Prochaska this was the whole point at first: Knowing a person's stage of change was supposed to allow you to prescribe a particular type of psychotherapeutic intervention that would work well for people in that stage.
These days, most people’s first thought about a method to use in the early stages of change is motivational interviewing (MI), and indeed some people assume that MI and the TTM were directly connected from the very beginning. But MI did not yet exist when Prochaska’s first published the stages of change, and the two ideas only later became entangled with one another. As MI’s star has risen and the TTM’s has fallen, there have been efforts to disentangle the concepts. The third edition of Miller and Rollnick’s Motivational Interviewing text doesn’t use the phrase “stages of change” at all, and in its place the authors conceptualize the process of change using a new concept, the “MI Mountain,” that basically mirrors the stages of change without mentioning the TTM.
Prochaska’s original suggestion for the early stages of change was based on a different TTM component that is only sometimes mentioned in the contemporary literature, called the “processes of change.” The idea of processes came to Prochaska as a graduate student, before he had the idea of stages, and was meant to be an integrative model of what works in psychotherapy.
The 10 (sometimes 8 or 12 in different versions of the model, but originally 10) processes of change were Prochaska's first major contribution to the psychotherapy literature, an attempt to draw usable techniques or change strategies from an eclectic range of psychotherapy methods. It should be remembered that Prochaska's original work was done at a time when the "age of schools" was still alive and well in the training and practice of psychotherapists. Although most psychotherapists now identify themselves as eclectic or integrationist, this is only a recent historical development in the field. At the time of Prochaska's original work, ideas about the integration of psychoanalysis and behavior therapy -- the two leading theoretical models of the day -- were still relatively new, and the currently dominant "cognitive-behavioral" model still saw significant tensions between cognitivists and behaviorists. Prochaska's attempt to cull a list of potentially efficacious therapeutic techniques from theoretically incompatible schools of thought was therefore more than a little revolutionary, and anticipated later efforts to systematize the active ingredients of psychotherapy by task forces of the American Psychological Association's Division 12 (Clinical Psychology) and Division 24 (now a standalone organization, the Society for the Exploration of Psychotherapy Integration).
At this point, some users of the TTM would not relate to Prochaska's list of psychotherapy techniques and might not recognize the terminology "processes of change." Indeed, some colleagues in nursing and related fields have resisted the description of the TTM as a "psychotherapy" model, or even as a model derived from the field of psychotherapy research. These colleagues see the TTM first and foremost as a healthcare model, one that is now widely used in health promotion, patient counseling, and public health activities. These practitioners believe that the term "psychotherapy" relegates the model to the area of mental health only, which they see as only tangential to their primary health care mission.
But the search for an integrative model of psychotherapy was indeed the origin of the popular stages of change concept, and the stages weren't even the original innovation. Instead, the list of psychotherapy techniques was what Prochaska most emphasized in his early writings.
The specific processes identified by Prochaska will come as no surprise to any psychotherapist, including gaining insight, expressing feelings, using situational cues and reminders, and selectively reinforcing behaviors. Many of these are often described as the "common factors" that promote change in all schools of therapy, and have been known since Jerome Frank's early work on psychotherapy integration, Persuasion and Healing, was published in 1961. The greatest innovation introduced by Prochaska in formulating his own list of processes was to theoretically tie specific intervention strategies (processes) to specific patient characteristics (stages) -- one of the first true approaches to tailored messaging in the psychotherapy literature. Matching the right treatment to the right patient at the right time has long been a hope of psychotherapy researchers, but Prochaska's model used a new construct (readiness, which Prochaska operationalized using new measures to classify people by their stage of change) to bring together a wealth of interventions from different theoretical and empirical traditions. The idea of readiness is likely useful in its own right, but when I was in my own graduate program in the mid-1990s, what most captivated me about Prochaska's work was the idea that he might have come up with a rational algorithm for matching specific interventions to particular patients' needs.
Here is a description of the stage-to-process mapping from Prochaska in 2015: "This integration suggests that,
in early stages, people apply cognitive, affective, and evaluative processes to progress
through stages. In later stages, people rely more on commitments, conditioning, contingencies, environmental controls, and support for progressing toward maintenance
or termination." Prochaska’s suggested 5 processes that could be used with clients who weren’t yet ready for change, shown in the graphic at the top of this page: consciousness-raising, emotional relief, self-reevaluation, environmental reevaluation, and social liberation. Several of these map to the “cognitive” components of cognitive-behavioral therapy (for example, re-evaluating oneself or one’s environment is similar to what cognitive therapists call “challenging cognitive distortions”). Others, like re-evaluating or changing one’s environment, are more closely tied to the behaviorist tradition. One of the processes, dramatic relief, comes directly from the Freudian psychoanalytic tradition, in which the client has therapeutic emotional experiences in the course of working through his or her transference to the psychoanalyst. None of these processes are similar to MI; other than the psychoanalytic interventions that generate “dramatic relief,” these processes for the early stages of change are mainly designed to convince the Narrative mind that making a change is a good idea. Social liberation also might work at the Intuitive level, by changing a client’s environment so that it elicits different behaviors. But modifying the client’s environment is likely to be a behavior-change activity in its own right if it is done voluntarily, and it raises important ethical questions about autonomy and consent if it is not.
At the later stages of change, Prochaska’s recommendations map much more clearly onto behaviorist techniques such as reinforcement, counterconditioning, and stimulus control, all of which involve the selective cueing of different behaviors, followed by selective rewards and punishments to either encourage or extinguish specific behavioral responses. It’s interesting that Prochaska suggests primarily Intuitive-mind interventions here, those that will work outside of consciousness (e.g., they work very well on animals). This is a little ironic because the client at this stage is already motivated for change and presumably can mobilize his or her Narrative-mind resources in the service of this goal. Social support from helping relationships, which is a likely active ingredient of MI in the early stages of change, is also highlighted in Prochaska’s original model as an intervention for the later stages of change but might be particularly effective in early stages because the Intuitive mind is very responsive to social perceptions.
Perhaps one reason that the TTM has struggled to gain empirical support is that the proposed processes for early stages of change rely mainly on arguments and experiences to win the Narrative mind’s support for change. Even if the processes are successful in producing the desired result, they set the client up for an intention-behavior gap. Two Minds Theory might predict that we should use Prochaska's processes of change the opposite order -- first Intuitive-level, then Narrative-level once the engine of change get started. MI, which is the best-known intervention with demonstrated efficacy for people in the early stages of change, has a direct effect on the person’s readiness or willingness, which might be why it seems to be so uniquely useful. Is there any role at all, then, for the Narrative processes that Prochaska suggested we might use in the early stages of change? My guess is that they might be more useful in moving from action to maintenance, because the Narrative mind does have an indirect effect on later behaviors even though it can’t impact behavior in the moment. Convincing someone to adopt a new mindset is not the best way to help them start a new behavior, but it could be very useful in helping them to maintain it.
If I’m right about the misalignment between stages and processes of change in Prochaska’s original model, then the research ought to show no benefit for matching stages to processes. However, it actually shows the opposite — that matching interventions to the client’s stage of change makes them more effective. This is one good example of a tailoring effect, and Prochaska is justifiably proud of this success. But these results have also been critiqued based on the fact that they usually compare a stage-vs-process matched intervention to a standard message that is not customized at all. This type of research design tends to inflate the apparent benefits of tailoring based on what is called a “pseudotailoring” effect. The mere fact of making any customizations to your message tends to make it more impactful, regardless of what the customizations might be. You might also remember this phenomenon from psychology class as a “Hawthorne effect” — the mere effect of noticing that something is different. In fact, it’s possible to achieve some benefits of tailored messages by giving everyone exactly the same message and simply telling them that it was chosen just for them! In one study I gave some participants a tailored message that was deliberately mismatched to their answers on five different dimensions, and yet I still saw improvements in their behavior comparable to those achieved by appropriately matched messages. Findings such as these mean that the mere existence of a matching effect doesn’t mean that the stages and processes are ligned up correctly in the TTM.
On balance, the processes of change are a useful tool that came out of the same zeitgeist as other efforts to systematically catalogue the active ingredients of psychotherapy. But they are probably no more useful than other lists of “common factors” or other grab-bags of eclectic psychotherapy techniques. In particular, the proposed match between stages of change and specific processes has been largely abandoned by everyone except for Prochaska and his colleagues. Instead, most practitioners who are convinced of the diagnostic usefulness of the stages of change will instead reach for MI as their primary process of change with precontemplators, and more traditional methods using education and persuasion once their clients are sufficiently motivated for change.
Comments
Post a Comment