Genuine, determined action is then taken and, over time, attempts to maintain the new behavior occur. The Stages of Change model 4 shows that, for most persons, a change in behavior occurs gradually, with the patient moving from being uninterested, unaware or unwilling to make a change (precontemplation), to considering a change (contemplation), to deciding and preparing to make a change. Understanding this process provides physicians with additional tools to assist patients, who are often as discouraged as their physicians with their lack of change. Physicians can enhance those stages by taking specific action. During the past decade, behavior change has come to be understood as a process of identifiable stages through which patients pass. More often, physicians encounter patients who seem unable or unwilling to change. Physicians sometimes see patients who, after experiencing a medical crisis and being advised to change the contributing behavior, readily comply. Physicians should remember that behavior change is rarely a discrete, single event. 11 – 16 In addition, brief counseling sessions (lasting five to 15 minutes) have been as effective as longer visits. 7 – 10 Simple and effective “stage-based” approaches derived from the Stages of Change model 4 demonstrate widespread utility. The model has been validated and applied to a variety of behaviors that include smoking cessation, exercise behavior, contraceptive use and dietary behavior. 6 The developers of the Stages of Change model used factor and cluster analytic methods in retrospective, prospective and cross-sectional studies of the ways people quit smoking. Current views depict patients as being in a process of change when physicians choose a mode of intervention, “one size doesn't fit all.” 4, 5 Two important developments include the Stages of Change model 4 and motivational interviewing strategies. Research into smoking cessation and alcohol abuse has advanced our understanding of the change process, giving us new directions for health promotion. Lessons Learned from Smoking and Alcohol Cessation.After physicians invest time and energy in promoting change, patients who fail are often labeled “noncompliant” or “unmotivated.” Labeling a patient in this way places responsibility for failure on the patient's character and ignores the complexity of the behavior change process. A feeling of failure, especially when repeated, may cause patients to give up and avoid contact with their physician or avoid treatment altogether. Relapse during any treatment program is sometimes viewed as a failure by the patient and the physician. Patients may view physicians who use a confrontational approach as being critical rather than supportive. Furthermore, promising patients an improved outcome does not guarantee their motivation for long-term change. 1 – 3 Repeatedly educating the patient is not always successful and can become frustrating for the physician and patient. Recommendations for physicians helping patients to change have ranged from the “just do it” approach to suggesting extended office visits, often incorporating behavior modification, record-keeping suggestions and follow-up telephone calls. Much has been written about success and failure rates in helping patients change, about barriers to change and about the role of physicians in improving patient outcomes. Patients easily understand lifestyle modifications (i.e., “I need to reduce the fat in my diet in order to control my weight.”) but consistent, life-long behavior changes are difficult. A change in patient lifestyle is necessary for successful management of long-term illness, and relapse can often be attributed to lapses in healthy behavior by the patient. Exercise programs, stress management techniques and dietary restrictions represent some common interventions that require patient motivation. One role of family physicians is to assist patients in understanding their health and to help them make the changes necessary for health improvement. The Readiness to Change Ruler and the Agenda-Setting Chart are two simple tools that can be used in the office to promote discussion. In this article, we review the Transtheoretical Model of Change, also known as the Stages of Change model, and discuss its application to the family practice setting. Understanding patient readiness to make change, appreciating barriers to change and helping patients anticipate relapse can improve patient satisfaction and lower physician frustration during the change process. The concepts of “patient noncompliance” and motivation often focus on patient failure. Change interventions are especially useful in addressing lifestyle modification for disease prevention, long-term disease management and addictions. Helping patients change behavior is an important role for family physicians.
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