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In our first article describing the Transtheoretical Model of Change, we focused on the various stages of change that are thought to occur when people change a problematic behaviour, such as drug or alcohol misuse.
In this article, we consider the Processes of Change, the cognitive and behavioural activities that facilitate change. The extent to which each of these processes is used depends on what state of change the person who has a problematic behaviour has reached.
These processes occur in people who change their problem behaviour without professional assistance (self-changers) and in people who work with counsellors or other forms of practitioner.
The following is a summary of the ten processes of change suggested by James Prochaska and colleagues in the book “Changing for Good” (see below) and other publications.
Consciousness Raising involves increasing the awareness of a person about the causes, consequences, forms of help and cures for a particular substance use problem. By increasing the amount of information available, we increase the likelihood of sensible decisions being made.
Interventions that increase awareness include education, media campaigns, information about key resources, and feedback.
Social Liberation involves new opportunities or alternatives that the external environment provides for a person to begin or continue their efforts to change.
Examples of social liberation are no-smoking areas and easy access to clean syringes and needles. Advocacy organisations and empowerment procedures provide opportunities for people trying to change.
Emotional arousal is a significant, often sudden, emotional experience related to the problem at hand. It parallels consciousness-raising but works at a deeper psychological level. For example, a person with a drinking problem may be deeply affected by learning of a drinking buddy’s serious motor accident under the influence.
Psychodrama, role playing, grieving and personal stories can move people emotionally.
Self re-evaluation requires a thoughtful and emotional reappraisal of a person’s problem, and an assessment of the person they would be if they overcame it.
Self re-evaluation allows the person to see how and when their substance use problem conflicts with their personal values. As a result, they can come to really believe that life would be better without their problem.
Commitment (or self-liberation) is both the belief that one can change and the commitment and recommitment to act on that belief.
The first step of commitment is private, telling oneself that I am choosing to change. The second step is going private, announcing to others that a firm decision to change has been made. Public commitments are more powerful that private ones.
Countering (or counter conditioning) involves the learning of new healthier behaviours to replace the problem behaviours. These healthier behaviours replace the problem substance use itself, as well the factors that lead to the substance use.
Examples of countering include going for a jog when the urge to get high occurs, using relaxation to counter stress, or doing something with a friend rather than drinking alone at home. People need to find the countering activities that best suit them.
Environmental (or stimulus) control involves restructuring one’s environment so that the problem of a problem-causing event is reduced. Cues for unhealthy behaviours are removed and prompts for healthier alternatives are added.
Environmental control techniques can be as simple as removing alcohol or cigarettes from the home, or objects that have been frequently associated with the use of drugs, e.g. needles and syringes. No-smoking signs may be placed around the house.
Environmental Re-evaluation combines both affective and cognitive assessments of how the presence or absence of a personal behavioural problem affects one’s social environment.
This includes considering the effect of one’s smoking on others, i.e. the impact of passive smoking. A heroin user may become concerned about how the acquisitive crime used to support their habit is impacting on the victims of this crime.
Environmental evaluation also includes the awareness that one can serve as a positive or negative role model for others.
Rewards (or reinforcement management) provide(s) consequences for taking steps in the right direction. This may involve punishing problem behaviours or rewarding desirable behaviours.
However, punishment is rarely used by people who change themselves or by therapists, since it neither leads to lasting change nor is ethical. Rewards are often used successfully to change behaviour.
Self-praise or praise from family and friends, buying a present with money one would otherwise used on drugs, and group recognition are examples of rewards that can facilitate change.
Helping relationships take a variety of forms, including help from family members or friends, peer support groups, and professionals (either specialist or generalist workers).
It is important that these helping relationships combine empathy, trust, openness and acceptance, as well as support for the healthy behaviour change.
It is important not to make the mistake of confusing these processes with techniques of change. Each of the outlined processes involves a broad strategy that may employ any number of techniques.
For example, countering can involve the techniques of relaxation, desensitisation, assertion or positive self-statements.
In the next article, we will look at how people use different processes of change at different stages of change.
Recommended reading:
James O. Prochaska, John C. Norcross and Carlo DiClemente (1994) Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad habits and Moving Your Life Positively Forward. Harper Collins.
