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How to Change
This intent of this document is to help health care educators with the following:
• A basic understanding of Prochaska’s change theory and how it applies to
lifestyle modification.
• An understanding of how change theory may be integrated into practice to
help facilitate clients’ movement through the stages of change
• An understanding of the defining characteristics of each of the stages of
change so that health care educators can accurately stage clients.
• An opportunity to review the above via sample Case Studies.
Stages of Change
It is important to discuss how change happens before explaining each step to
promote change. James Prochaska, a well known psychologist, discovered that
people go through six stages of change when they try to break unhealthy
habits. Different tasks need to be addressed at each stage in order to progress
to the next stage. It is important for the client to know what stage they are in.
Without knowing this, the client might set goals that are unrealistic. The table
below outlines the six stages of change and the ten steps within them.
Prochaska’s
Stages of Change
Ten Steps to Promote Change
Pre-contemplation
STEP 1
Providing Information on Risk
Contemplation
STEP 2
Outlining Personal Priorities
STEP 3
Listing Possible Lifestyle Goals
STEP 4
Listing Advantages of Change
STEP 5.
Listing Disadvantages of Change
STEP 6
Weighing the Advantages &
Disadvantages of Change
Preparation
STEP 7
Preparing an Action Plan
Action
STEP 8
Taking Action
Maintenance
STEP 9
Maintaining Change
Relapse and
Recycle
STEP 10
Learning from Backsliding
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Pre-contemplation: People in this stage have not even begun to think about
changing unhealthy habits, often because they do not have enough information
about what needs to be changed. In other words, individuals might not be
aware of risk factors for heart disease nor that they have the risk factors. People
in pre-contemplation see no need to change and say they don’t want to change
Contemplation: In the contemplation stage, people begin to think of possible
goals they want to set. It is a time when people begin to weigh the advantages
and disadvantages of change, to identify reasons for unhealthy habits, and to
assess possible obstacles to change. People in the contemplation stage often
say they are thinking of changing in the next six months.
Preparation: Once the client has information on risk factors and have decided
that making the change is worthwhile, they may need to make a plan. People in
this stage are beginning to make a plan for change, including figuring out ways
to make sure goals are achieved. people in the preparation stage often will say
they want to change their bad habits within the next month.
Action: People in this stage are now putting their plan into action. Once people
are in this stage, they need to constantly assess their progress and learn to
troubleshoot if they are having a hard time keeping the plan in action. People in
the action stage have changed their bad habits for less than six months.
Maintenance: People in this stage have been able to put their plan into action
for at least six months. While this accomplishment of six months is wonderful, it
is still easy to fall back into old ways if people stop paying attention to their
progress. In this stage, you want to ask yourself some questions that might help
to stop you from going back to old habits. Questions such as “What is working
and why?” and “How can I keep this up?” can be helpful to keep you on track.
Relapse and Recycle: Sometimes people do fall back into old habits, despite
the best laid plans. For example, research on smoking shows that many people
take six attempts to quit before they are finally successful on a long-term basis.
Even though it can be disappointing to go back to bad habits, it is important to
remember that the client has learned many things about change along the way.
The next time the client tries to make the same change in habit or behavior, it
will be a little easier and they will know more about themselves.
Knowing what stage of change your client is in can be helpful for both you and
your client. It can help you in coaching them to set goals and help them in
being realistic with their expectations.
Remember that the client can move from one stage to the next and back again,
as demands in their life change. For example, in one month, the client might be
in the action stage for increasing exercise, but the next month, they might be
back at the planning stage because they injured their foot. It is natural to go
back and forth and they need to know this.
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The client might also notice that they are in a different state of readiness to
change for each risk factor. For example, the client might already have a plan to
start exercising but they may have not considered changing their diet. The
important point is to keep coaching the client to find ways to make the changes
that they are ready for.
STEP 1
Helping Clients to Assess their Health Risks
The first step for lowering the client’s risk is for them to know the risk factors
and know which factors they have. The client must have accurate information
about the risk factors before they can decide if they need to make changes in
their life.
The client might hear different information in the newspapers and on TV about
what habits are healthy and unhealthy. If the client is confused, it will be very
difficult for them to feel motivated to make any changes. During this step, it is
very important that the client has all of their questions answered by a reliable,
trusted source.
STEP 2
Helping Clients List their Priorities
The second step to changing or lowering a client’s risk factors is to encourage
the client to spend some time writing out a list their priorities in life and ranking
them. By doing this, they will be able to decide what areas of their life are most
important to them and then what areas in their life they are most likely to
successfully change. Common priorities for people are: spending time with kids,
spending time with spouse, having a meaningful job, financial security,
spending time with friends, travel, and health.
To make it easier for the client to decide what their priorities are, encourage
them to think about their life over the last ten years. In particular, they should
think about their most fulfilling moments and their least fulfilling moments.
Have your clients think about their current priorities. Whatever the client has as
priorities will play a role in whether they make changes and in what areas they
will want to make changes. For example, if the client’s main priority is finding
the money to feed their family, then they are unlikely to want to focus on
increasing their exercise or spending time with friends. The goals the client
makes have to be partly driven by what is going on their life and where their
priorities lie.
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STEP 3
Listing Possible Lifestyle Goals
If the client has been diagnosed with one or more risk factors and they listed
health as a priority in step two, they may want to consider certain lifestyle
changes. Step three involves listing those risk factors that they are ready to
think about changing. Don’t worry about the solutions yet - that will come later.
Please get the client to identify the risk factors that apply to them and indicate
which risk factors they feel ready to think about changing.
Check (3) the appropriate box in the grid below.
Risk factors the client is ready to think about
changing
Risk Factors
Ready
Not Ready
Doe Not
Apply
1. Smoking
2. High Fat Diet
3. Blood Pressure
4. Sedentary Lifestyle
5. Stress
a) Financial Pressures
b) Time Pressures
c) Work Pressures
d) Marital Pressures
e) Family Pressures
f) Legal Pressures
g) Other
6. Other Risk Factors (ex.
diabetes)
Please specify:
_____________________
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STEP 4
Listing the Advantages of Changing a Risk Factor
Remind the client to work on one goal at a time; they may need to pick one goal
and only focus on that one. Also realize that as the client goes through the rest
of the steps in this booklet, they might decide that the goal they picked as an
example is not a goal they want to work towards right now.
We now know that there are 50 benefits to exercising. How many benefits can
the client list for the risk factor they have chosen? While making this list, they
may want to ask someone they trust to help them identify advantages of
changing. Remember to use the brainstorming technique at this point. It is
interesting to note that people can be very well informed and may list numerous
advantages. However, they may not personally appreciate all of the advantages
they have listed. You may wish to ask them to identify those advantages which
they appreciate the most.
Here are some questions which may help the client
make their list:
•
•
•
•
•
•
What makes the client think that their risk factor is a problem?
What kinds of problems does their risk factor cause?
How are others harmed by their risk factor?
How might other people in their life be concerned about their risk factor?
What worries them most about their risk factor?
What can they imagine happening to them as a result of their risk factor?
Now get the client to list all possible advantages that might come their way if
they make changes. At the same time, get them to list all the disadvantage to
continuing their unhealthy habits.
STEP 5
Listing Barriers to Changing a Risk Factor
In order to set realistic goals, it is important to assess the obstacles to change.
For every bad habit or behavior the client wants to change, there are always
obstacles that will make it difficult for them to make that change. Some
obstacles relate to the difficulty in starting new behaviors and others include
becoming aware of rewards the client might get from continuing the old,
unhealthy behaviors. Obstacles to changing may be considered to be
disadvantages to changing. Some obstacles which might affect starting new
behaviors include:
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Too many types and numbers of treatment
Try to keep the client’s treatment plan as simple as possible. If they have a
number of risk factors, focus on changing one at a time.
Not enough time with healthcare professionals
The client needs to have their questions answered. Remind them to not be
afraid to speak up.
Work pressures and family pressures
If the client feels under pressure at work or at home, they may need to learn
how to handle those stressors before they can make other changes.
Perhaps the client could talk to someone they trust, or they might want to
attend a Stress Management Workshop through the CHR Hypertension &
Cholesterol Centre, Mount Royal College or through the University of
Calgary.
Financial pressures
As has been said before, if the client’s main worry is about making ends
meet each month, then they may need to address this worry before being
able to make other changes. Again, the client should talk to someone they
trust, or see a financial expert who might be able to help them manage
money more effectively.
Physical limitations
Having a physical worry or limitation can make change difficult and can
lower the client’s motivation. For example, having arthritis or chronic pain
may mean they have to be creative in finding ways to increase exercise.
Sometimes speaking to a professional can be helpful in finding ways around
the physical problem.
Psychological concerns
Some people may have psychological concerns, like depression, which can
also lower their motivation and lower their chances of making changes.
Depression and other psychological concerns can be treated. Again, the
client may want to work with a professional (ex. physicians, psychologists,
nurses, social workers) to help them deal with these kinds of problems.
Time pressures
As a result of the many demands that clients may face in their life, many of
which are listed above, the client may find that they have little time to make
changes.
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Rewards of Unhealthy Behavior
Clients might be giving up the enjoyable aspects of the unhealthy behavior.
Most unhealthy habits have some benefits or people would not continue
these habits. The advantages of unhealthy behavior must be identified and
addressed if the client is to change. Some common rewards for unhealthy
behavior are listed below:
• old habits are familiar
• smoking is a way to relax
• drinking is a way to socialize with friends
• fast food is convenient
• fatty foods are cheap
• not exercising means more time to meet work demands
• not exercising allows more time for work to earn more money
Allow clients an opportunity to identify, acknowledge and think about
rewards of continuing the unhealthy behavior they are engaged in.
STEP 6
Weighing Advantages & Disadvantages of Change
After considering the advantages and disadvantages to changing a behavior, it
is often useful for client’s to compare the two. This comparison can help them
decide if they want to start preparing for action. Below is an example of a
decisional grid (using increased exercise).
Pros of exercise
Cons/obstacles of exercise
lose weight
more energy
takes time and commitment
get in shape
gets me out of the
don’t like exercise
lower my BP
house
gym costs too much money
raise my HDL
bad weather makes it hard to exercise
Pros of sedentary lifestyle
Cons of sedentary lifestyle
free
health risk
requires no work
gain weight
more time to make money
feel tired
more time to meet deadlines at work
not enough energy to get everything done
more time to help kids with homework
can’t keep up with my kids (and dog!)
more time to make meals
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Listed in the top left section above are some of the pros of exercise and in the
top right section some of the cons/obstacles to exercise. Listed in the bottom
left section are some of the pros of a sedentary lifestyle, and in the bottom right
section some of the disadvantages of a sedentary lifestyle. Get the client to
think of other pros of exercising and other cons of a sedentary lifestyle.
In the grid below, or on a separate sheet of paper, get the client to list the
advantages and disadvantages they identified in Step 4 and 5 for their goal.
Pros of changing behavior
Cons or Barriers to changing
Pros of not changing behavior
Cons of not changing behavior
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If the client finds they have a similar number of items in each section, it will be
important to weigh how important each item is to them.
For example, lowering their risk of death may be more important than drinking
with their friends. For each of the items above, use a 5-point scale (5 - being
very important and 1 - being not at all important) to help the client in the
weighing process.
During this step, it is very important that the client has a sounding board. If they
believe that the disadvantages outweigh the advantages, the client will not be
able to reach their goal, because they will not be motivated to make any
changes. The client must see a clear benefit in making changes, otherwise they
will not make them.
STEP 7
Preparing a Plan
Once the client has weighed the advantages and disadvantages of changing
their risk factor, they will be in a better position to make a plan. In the previous
steps, the client was asked to identify what the obstacles were. In this current
stage, the client can work towards a plan to address these obstacles.
People who successfully change their behavior often make use of the following
strategies.
• Breaking down the goal
• Committing
• Replacing Old Behaviors
• Removing the Triggers
• Rewarding
• Helping Relationships
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Breaking down the goal
It is important to remember that long-term goals are always made up of
short-term goals. The client needs to break the big goal down into small
parts, because having goals that are too big makes it difficult for the
client to know where to begin.
Make the goal specific and clear. For example, if the client has decided
to increase exercise, they need to decide what kind of exercise they will
do, when they will exercise, and for how long.
The client’s goals should be realistic and manageable. In other words, if
the client has never exercised before, their goal should not be a 5 km
jog every day. Start slowly at first and build up gradually. Instead of the
daily 5 km jog, they should decide to walk for 10 minutes, 3 times a
week. If they set the goal small at first, they will likely succeed and feel
better about themselves for reaching their small goal. Success builds
confidence and motivation.
Summary of tips for breaking down the goal:
• Break the big goal into smaller bits
• Make the goal clear and specific
• Make the goals realistic and manageable.
• Coach the client to break down their chosen goal and possibly
write it down.
Committing
When trying to make changes, it is important that the client takes
responsibility for making the changes. If they are making changes
because someone else wants them to and not because they want, they
will not be able to follow through on their plans. The client should take
charge of their own life. Make sure that the goal they have picked is one
that matters to them. One way to make a commitment is for the client to
let people know they are planning to change. Once they let people know
they are planning to change, it is harder to back out.
Replacing Old Behaviors
If the client is going to change bad habits, they need to think of new,
healthy habits that can replace the old ones. If they do not do this, they
will be tempted to fall back into old ways. The client should think about
the goal that they have picked as their example and now try to think of
what else they might do instead of the old habit. For example, rather
than working through lunch, the client may go for a walk and use that
time for creative thinking while exercising.
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Removing the Triggers
The client has probably noticed that certain events can trigger old habits.
In what ways can they avoid or remove the events that trigger unhealthy
behavior? Can they remove high fat foods from the fridge? Have they
considered disconnecting cable T.V. service if they want to exercise
more? Once the client knows their triggers, they should get rid of them
or avoid them. Get the client to think about the goal they have picked
and decide what triggers they can remove. How can they go about
removing them?
Rewarding
In what ways can the client reward themselves for doing healthy
behavior? For example, how might they use money saved from quitting
smoking? Could they buy new clothes or put the money towards a
vacation? What kinds of rewards can the client think of that would help
reinforce them?
Helping Relationships
Most people who successfully change their lifestyle do so with the help
of others. Are there exercise, weight reduction or stress management
groups that the client might consider joining for social support?
STEP 8
Taking Action
Now that the client has made a plan, the next step is taking action. If they have
spent time outlining their priorities, becoming aware of obstacles to their goals,
weighing the advantages and disadvantages of change and making a plan
which addresses all of these issues, then putting their plan into action may go
quite smoothly.
Even the best laid plans, however, do not always work the first time. During the
action stage, the client might run into problems or new obstacles that they
hadn’t thought of. If this happens, the client can go through each of the steps
above to see if they can come up with a solution that will help them to continue
to reach their goal. Most people who try to change their bad habits will at some
time fall back into old and more familiar patterns. This is a normal part of the
change process. Encourage the client to learn from these challenges so that
they will be more prepared if a curve ball comes their way.
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STEP 9
Maintaining Change
The ninth step of the change process (also called maintenance) is a time to
strengthen and reinforce the gains that the client has made. It is a time for
reflection, for reviewing what made the habit changes easy or hard for them to
make and it is a time for continued action.
Research shows that new behaviors may take several years to become fullfledged habits. For example, 40% of smokers who stop smoking for one year
may be smoking again after five years. This finding certainly emphasizes the
importance of finding ways to maintain the plan and goals the client has set.
The client may wish to think about the following questions to help keep them on
track.
• What is working and why?
• What isn’t working and why not?
• Do I have enough support from family, friends and co-workers?
• Have I learned effective stress management skills?
• Do I know what the obstacles are to meeting my goals?
• Have I developed healthy, alternative habits to replace the old ones?
• Can I use all of these newly learned skills when I’m tempted to return
to old habits?
STEP 10
Learning from Backsliding
As mentioned in steps 8 and 9, people sometimes fall back into old and more
familiar patterns when trying to change their unhealthy habits. This is a normal
part of the change process and is called relapse. Returning to old habits does
not mean that they have failed. As stated earlier, research on smoking shows
that many people take six attempts to quite before they are successful on a long
term basis.
Remind the client they have not lost all that they learned while they were
making changes and that relapse provides an opportunity for further learning. If
they are in the relapse stage, consider recycling through the 9 steps above to
get back on track.
Congratulate the client on making their way through this booklet.
If the client has reached this far, they have probably done a lot of work and
have put a lot of energy into trying to make change. They have done good work
and encourage them to keep trying!
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Case Studies
Four short sample case studies follow. They are designed to review the major
stages of change and appropriate educator action for each stage. Keep in mind
that there is not always a direct “right” answer.
Case Study One
Barbara is a single mother who has been smoking a pack of cigarettes
per day for the last fifteen years. Upon meeting with her for the first
time, she makes it very clear that she has not even begun to start
thinking about quitting smoking. She is very concerned at present about
putting food on the table for her family and spends little time thinking
about her health.
Question #1
According to Prochaska’s Stages of Change, which stage do you think
that Barbara is at?
Answer #1
Question #2
What are some of the defining characteristics of clients who are in this
stage?
Answer #2
Question #3
What type of information would you focus on with Barbara at this stage
of change?
Answer #3
Case Study Two
Louisa is a 34 year old client who reports a good knowledge of knowing
why she should quit smoking and yet she reports that she is still
smoking. Louisa is a very bright woman and expresses some frustration
with herself because she just can’t seem to “make it happen.”
Question #4
According to Prochaska’s Stages of Change, Which stage of change do
you think that Louisa is at?
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Answer #4
Question #5
What are some of the defining characteristics of this stage of change?
Answer #5
Question #6
What could you do as a health professional at this stage of change to
facilitate further movement through the stages of Change?
Answer #6
Case Study Three
Bill is a successful businessman and reports to you that he is ready to
quit smoking. Bill also mentions that he has a specific plan he wishes to
use to help him quit smoking. As on of the health care professionals in
Bill’s life you congratulate him about this plan for change.
Question #7
What considerations might you take into account with this stage of
change?
Answer #7
Case Study Four
Ella has been smoke free for 102 days. She is extremely proud of her
success and is continuing to troubleshoot new ways to continue to be
smoke free.
Question #8
What kind of anticipatory guidance would you give Ella regarding the
maintenance stage of change?
Answer #8
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Question #9
What kind of feed back would you give Ella on her success?
Answer #9
Question #10
How would you describe the relapse and recycle stages of change to
Ella?
Answer #10
Answers to Case Studies
Case Study One
Answer #1
Barbara is a single mother who has been smoking a pack of cigarettes
per day for the last fifteen years. Upon meeting with her for the first
time, she makes it very clear that she has not even begun to start
thinking about quitting smoking. She is very concerned at present about
putting food on the table for her family and spends little time thinking
about her health.
According to Prochaska’s Stages of Change, which stage do you think
that Barbara is at?
Answer: Barbara is at the pre-contemplation stage of change
Back up to original Question #1
Answer #2
What are some of the defining characteristics of clients who are in this
stage?
Answer: People in this stage have not even begun to think about
changing unhealthy habits, often because they do not have enough
information about what needs to be changed. In other words,
individuals might not even be aware of risk factors for heart
disease nor that they have the risk factors. People in pre-
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contemplation see no need to change and say they don’t want to
change
Back up to original Question #2
Answer #3
What type of information would you focus on with Barbara at this stage
of change?
Answer: At this stage of change providing information about risk
is very important, however the most important role of the health
care professional is to keep the lines of communication open. By
fostering open communication, when to client is ready for change
they will likely seek turn to a healthcare professional who they feel
they can communicate with.
Back up to original Question #3
Case Study Two
Answer #4
Louisa is a 34 year old client who reports a good knowledge of knowing
why she should quit smoking and yet she reports that she is still
smoking. Louisa is a very bright woman and expresses some frustration
with herself because she just can’t seem to “make it happen.”
According to Prochaska’s Stages of Change, Which stage of change do
you think that Louisa is at?
Answer: Louisa is at the contemplation stage of change.
Back up to original Case Study
Two
Louisa is a 34 year old client who reports a good knowledge of knowing
why she should quit smoking and yet she reports that she is still
smoking. Louisa is a very bright woman and expresses some frustration
with herself because she just can’t seem to “make it happen.”
Question #4
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Answer #5
What are some of the defining characteristics of this stage of change?
Answer: In the contemplation stage, people begin to think of
possible goals they want to set. It is a time when people begin to
weigh the advantages and disadvantages of change, to identify
reasons for unhealthy habits, and to assess possible obstacles to
change. People in the contemplation stage often say they are
thinking of changing in the next six months.
Back up to original Question #5
Answer #6
What could you do as a health professional at this stage of change to
facilitate further movement through the stages of Change?
Answer: Some of the ways that a health care professional can help
a client work through this stage of change would be to help clients
work through activities such as:
• Outlining Personal Priorities
• Listing Possible Lifestyle Goals
• Listing Advantages of Change
• Listing Disadvantages of Change
• Weighing the Advantages and Disadvantages of Change
Back up to original Question #6
Case Study Three
Answer #7
Bill is a successful businessman and reports to you that he is ready to
quit smoking. Bill also mentions that he has a specific plan he wishes to
use to help him quit smoking. As one of the health care professionals in
Bill’s life you congratulate him about this plan for change.
What considerations might you take into account with this stage of
change?
Answer: Planning is often one of the stages of change that is
undervalued. Change is hard! Change requires planning, and
planning should include back up plans for when things do not go
how we anticipate that they should.To be successful with lifestyle
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change it is important to plan for it and to make appropriate
arrangements. This may include setting up personal supports so
that when you feel like you are going to need a smoke you have a
friend that you can call on to talk with and help you get through the
situation.
Back up to original Question #7
Case Study Four
Answer #8
Ella has been smoke free for 102 days. She is extremely proud of her
success and is continuing to troubleshoot new ways to continue to be
smoke free.
What kind of anticipatory guidance would you give Ella regarding the
maintenance stage of change?
Answer: People in this stage have been able to put their plan into
action for at least six months. While this accomplishment of six
months is wonderful, it is still easy to fall back into old ways if
people stop paying attention to their progress. In this stage, you
want to ask yourself some questions that might help to stop you
from going back to old habits. Questions such as “What is working
and why?” and “How can I keep this up?” can be helpful to keep
you on track.
Back up to original Question #8
Answer #9
What kind of feed back would you give Ella on her success?
Answer: Congratulate Ella on her success this far. Ella has
successfully maintained her lifestyle change for 102 days, allowing
her to remain in the Action stage of change.
Back up to original Question #9
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Answer #10
How would you describe the relapse and recycle stages of change to
Ella?
Answer: Sometimes people do fall back into old habits, despite the
best laid plans. For example, research on smoking shows that
many people take six attempts to quit before they are finally
successful on a long-term basis. Even though it can be
disappointing to go back to bad habits, it is important to remember
that the client has learned many things about change along the
way. The next time the client tries to make the same change in
habit or behavior, it will be a little easier and they will know more
about themselves.
Back up to original Question #10
References
Calgary Health Region. (2000). Creative lifestyle changes: How to
change.
Prochaska, J., Norcross, J., & DiClemente, C. (1994). Changing for
good. New York, NY: Avon Books.
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