Making a Change is a Process

Let’s talk a little bit more about “change”. As you recall, in my last blog I asked if anyone had a desire to change anything in their life. It could be something affecting your quality of life such as your health or a change in career perhaps. Did you think of something? Have you started any action toward the change? If you say no, that is completely understandable so don’t be upset with yourself.

There are several steps to the Change Process. As you know, it just doesn’t happen overnight. So let’s talk a little about the steps involved to achieve a change.

Background: In the late 1970’s, the Stages of Change Model

( sometimes referred to as The Transtheoretical Model -TTM) was developed by Prochaska and DiClemente who were trying to understand the experience of smokers quitting on their own. It was decided that people who quit smoking only if the person was ready to do so. The TTM was created and it focuses on the decision-making of the individual and has become known as a model of intentional change (1). It is an attempt to not only describe your readiness to change a behaviour, but also your emotions and knowledge base. (2) During my years of pharmacy practice, I felt it was so important to tell my patients/clients why they were taking a drug, how it worked in their body and what to expect. Many times people did not realize they were taking a diabetes medication or a blood pressure pill. For me, if I understand how something works, I am more compliant to the regimen.

In the Stages of Change Model there are six stages with are explained below.

#1. Precontemplation: In this stage you have no plans to change anything in the foreseeable future ( ie 6 months). Perhaps you don’t realize that the behaviour is a problem or produces negative consequences. You may not be informed about the consequences of your behaviour. You might have tried to change it before but it didn’t work so now you think it will never happen. You’ve given up on yourself. You act somewhat defensive when anyone brings up the topic of a change and how it could benefit your well being. Rather than placing emphasis on the pros of changing behaviour, you place emphasis on the cons of changing the behaviour.

#2. Contemplation: In this stage, you become more aware of the consequence of this bad habit and you spend time thinking about your problem. You really want to start this healthy behaviour in the near future ( ie within one month) and you consider both the pros and cons of changing. You give equal emphasis to both the pros and cons. For example if a con is added financial stress, then perhaps you will give up eating out by 50% if this is something you currently do. Some authors suggest you are in the teeter-totter stage. Your feelings are mixed about change or not changing. (1). It is possible that you will stay in this stage longer than the above one month suggestion, but that is ok as well.

#3. Preparation/Decision Stage: In this stage you get ready for a change in the near future ( ie within 30 days). You start by taking steps toward the change such as learning more and increasing your knowledge base about how this change can lead to long term benefits and a healthier life. Do not skip this stage by trying to move directly from contemplation into action.

#4. Action: In this stage you take the active steps necessary to make the change in behaviour and you may do this by a variety of techniques. You believe in yourself that you can make this change. You are convinced that the change has improved how you feel about yourself both physically and emotionally. Some might refer to this stage as the Willpower stage. (1)

#5. Maintenance: In this stage you have been able to maintain the behaviour change for at least six months and determined to maintain it as you move forward. You are trying hard not to go back to earlier stages and seriously want to avoid relapse. At this stage, no doubt, you have encountered situations where maintaining this new improved behaviour was difficult. Because of this, you have developed multiple ways to deal with these situations effectively and in advance.

#6. Relapse: In this stage you have returned to your old behaviour. If this happens try to figure out what triggered this relapse. Don’t think you have failed and be discouraged not to start over. You might be able to move through the steps at a faster pace because you now know how well you did before the relapse. Think positive thoughts and create stronger strategies to cope. Discuss how you feel or how your attitude is changing with qualified people. If you exit from the process you can re-enter at any stage.

I have created this example of going through the stages of change involving diabetes management. (fictional)

The patient is 48 year olds and was diagnosed as a Type 2 diabetic 5 years ago. The patient was started with one oral agent and that has grown over the years to 3 oral medications. The patient has some good days and some bad days with diabetes management and rarely tests blood glucose levels even though they do have a meter. The last A1C was 8.5 mmol/L which is above the recommended number.

This patient has an appointment with the doctor today and the doctor is upset with his blood glucose values. The doctor tells the patient that insulin needs to be started at least one injection a day. The patient is upset and refuses to start insulin. The patient knows people on insulin and doesn’t want to go that route. This would be the patient’s precontemplation stage as he is not thinking seriously of ever starting insulin .

The doctor gives the patient a break and tells him/her/other that if they can over the next three months improve their nutrition and physical activity and lower the A1C by 1.0 mmol/L he will reconsider the need to start insulin. The patient agrees and is more determined than ever to prove the doctor wrong.

Over the next three months the patient works really hard to improve their diabetes management. Checking blood glucose levels has increased by 50%. However, the patient is starting to realize they may not be able to achieve the doctor's goal. The patient begins to think that insulin therapy is needed. This would be the contemplation stage. The patient begins to think of the personal consequences of having poor diabetes management and reads information on diabetes complications. The patient reads stories of others who claimed they felt so much better when insulin was initiated. The patient reads about insulin and talks to the pharmacist about insulin options.

The patient's doctor appointment is approaching and now realizes that something has to change. The patient feels they have tried all they can to improve nutrition and physical activity. The patient has learned enough that longstanding diabetes which is out of control is harmful. They commit to a change (ie start of insulin once a day) when they see the doctor the following week. This would be considered the preparation/determination stage.

The patient is excited to see the doctor and let him know they have tried with extreme effort to manage the blood sugars but now knows that insulin should be started. They have prepared themselves to accept this change. The patient's new gained knowledge on insulin and long term complications of diabetes has lessened their fears of insulin therapy. They have watched videos on administering insulin and have involved their partner who fully supports this decision. This would be the action/willpower stage.

A few months pass and the patient's blood glucose values have drastically improved. They have experienced no significant side effects from the insulin. The use of an insulin pen makes it easy to administer and it is convenient. They have more energy and overall are less stressed about their diabetes management. They want to keep this good control moving forward. This is called the maintenance stage.

Christmas comes and all the food, treats and the busy season brings about some stumbling blocks. The patient really enjoys all the treats and thinks to himself that Christmas only comes once a year so they are going to enjoy it. They will get back on track after Christmas. January arrives and they are having a hard time to get back to the healthier eating and exercise pattern. This is referred to as the relapsed stage. Now is the time for them to evaluate why they relapsed and to feel confident they can be successful once again. A visit to the diabetes clinic or talking to the pharmacist could help them identify why they relapsed and the health professionals can offer encouragement and motivation so they can re-enter the process of change.

These Stages of Change can apply to anything you consider worthy of changing. It isn’t easy. We can only change ourselves.

Did you see yourself or relate to any of the above situations?

The above is just a brief description of the Stages of Change. The list of references will provide a more in depth explanation. Despite the effectiveness of this highly reviewed and well liked Transtheoretical Model (TTM) it does have some limitations such as:

• Even though some of the changes have mentioned time periods, there is no clear sense of how much time or what is a good time for each stage of change. It could be one month for some and 6 months for another. Thus, since we can’t define a specific time frame, we can’t really use time as a success or failure in my opinion.

• The theory assumes that all people aiming to make a change will be logical and well organized when making decisions and this is not always the case.

• When a health professional is involved in encouraging you and helping you to accept and make a change the professionally developed questionnaires at this time are not always standardized or proven.

Thank you for your time and attention today. I hope I have provided some valuable and useful information. I think too many times we beat ourselves up when we want to make a change and expect it to happen too fast. It stands to reason that some things are more difficult to change than others but irregardless we go through the same process even though we may not realize it at the time.

Remember November is Diabetes Awareness Month and November 14th World Diabetes Day. Check out your diabetes association to learn more and discover what is going on in the area of education and research.

I want to refer you to this blog that was published on November 11th, 2022 by a well known and respected blogger, Jeannie Collins Beaudin . Her subject is Insulin Resistance and she provides ideas on how to help overcome the problem of insulin resistance. Though it was not collaborated, the Stages of Change could be applied to the ideas presented on overcoming/helping to decrease the issue of Insulin Resistance.

This blog is for information purposes only. It does not replace information you have been given by your health-care team of professionals.

References:

1) The Transtheoretical Model (Stages of Change) accessed on line November 4th,2022

2) Dr Tan Yew Seng. Behaviour Change accessed on line November 4th,2022

3) Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (2013). Applying the stages of change. In G. P. Koocher, J. C. Norcross, & B. A. Greene (Eds.), Psychologists' desk reference (pp. 176–181). Oxford University Press. https://doi.org/10.1093/med:psych/9780199845491.003.0034