Archive for March, 2010

The wheel of change is an instrument by which the professional helper can assess the point at which the client is at in the cycle of change and thereby offer appropriate intervention. It facilitates the use of the correct therapeutic skills for the stage that the client is at.[i]

Prochaska and DiClemente formulated the Transtheoretical or Cycle of Change Model in 1982.[ii]

It is a multi-dimensional model and the stages of change are the core constructs around which the model is organized. These stages are graphically demonstrated in the wheel of change.[iii]

This model sees change as a cycle and not an all or nothing situation and it is quite possible for an individual to travel around the wheel of change a number of times before breaking the cycle.[iv]

In addition to this, relapse is seen as a normal part of the cycle and not seen as a failure on the part of the individual attempting to change their lives.[v]

Pre-contemplation

This is the first of the stages in the wheel of change and the one to which my individuals return after a relapse. In the pre-contemplation stage the individual is either unaware that there is a problem with their behaviour or they are aware that there is a problem but have given no thought to the possibility of a change of behaviour. Their addiction is “working” for them and the benefits of the addiction, In their own minds, far out weigh and difficulties it may be causing. The individual at this stage has no interest or inclination to change their behaviour patterns.[vi]

Contemplation

This is the second stage in the wheel of change and is where the individual begins to recognise that there may be a problem with their behaviour and they are thinking about that possibility and the possibility of making changes. In Many cases this is a “light bulb” moment, where they are jarred into thought by a specific incident or blatant piece of information regarding the problem behaviour. For example the “hard drinker” being told by their Doctor that lab tests have shown liver damage that will become irreversible if drinking continues. Again, it is often the “individualisation” of information that makes the difference. All smokers know that smoking is bad for them and it is on the television all the time. Indeed it is printed on every cigarette packet. This is generic information and does not affect the smoker. If however a Cardiac specialist sits in front of them and tells them that their heart is damaged by their smoking and they are going to die if they do not stop now, it will have far greater impact on the smoker. Contemplation can arrive and then disappear very quickly and the major challenge for the individual involved is to seize the opportunity when it arises. At this point the individual must weigh the costs versus the benefits of changing the behaviour and the motivational interviewer, if they are involved at this stage, will be looking at ways to “tip the balance” with the client, in favour of modifying  the problem behaviour. Once the balance has been tipped, realistic goals must be set by the individual themselves in conjunction with the councillor or therapist if they are involved.[vii]

Determination

The third of the stages in the wheel of change, determination, is a transitionary period between the balance in favour of change being accepted by the individual and the taking of action. Again, as with contemplation, many people have fleeting feelings of determination that can be harshly knocked back when the “horrors” of the perceived reality of changing behaviour patterns sinks in. These perceptions may well be distorted as a result of the addiction and the mental state of the individual.

Determination will lead directly to action if all aspects of the addictive problem have been considered realistically and the goals that have been set are also realistic and attainable.  Many believe that the only way to change the problem behaviour is to eliminate it completely and undertake an almost complete change in character. Both Alcoholics Anonymous, Minnesota Model treatment centres and the medical professions, espousing the Disease / Medical Models would, insist on total abstinence by the individual, with Minnesota Centres and A.A. also looking for a Spiritual aspect or “Awakening” to take place. M.E.T. would, on the other hand, look more at the acceptance of the individual by the individual, leading themselves to look for a better quality of life. It maybe impossible for the individual to achieve complete abstinence from their problem behaviour, as for example in the case of a chronic over eater. In this case and in the case of some alcoholics, drug abusers and even smokers, harm reduction maybe a realistic goal.[viii]

Action

The decision has been made, now it’s time to do it! The problem behaviour is now stopped or reduced to a less harmful state. This is an incredibly hard time for any individual in the process of change. They have lost their “best friend”. Life is never going to be the same again. Positive reinforcement of the benefits of change and unconditional positive regard, accurate empathy and congruent reality on the part of the professional helper can play a major role in the action stage progressing successfully. The individual needs to have, with the assistance of the therapist or councillor, acquired the necessary knowledge and skills required to continue abstaining or moderating their behaviour. These would include the interventions and skills listed in the processes of change, i.e. Stimulus Control: recognizing “triggers” for the old problem behaviours. Peer Pressure: pressure from old friends who have not changed their behaviours. Lifestyle Enhancement: “filling the gap”. Many who have been in the throes of active addiction have invested large portions of their time in feeding that addiction. Now that that is no longer necessary, they often find that they have a large amount of free time. The individual needs to find something that is pleasurable or interesting to them in order to avoid boredom and the danger of slipping back into the old problem behaviours.[ix]

Maintenance

When in active addiction, the actions carried out by the individual to feed that habit become automatic. The aim in the maintenance stage is for the actions carried out by the individual to maintain the status quo and not to relapse should become automatic. This does not mean that they should not constantly be on guard for high risk situations, “people, places, things” but it means that the initial reaction to a dangerous stimulus is not to immediately “pick up”. In general a person is said to have moved from the action stage to the maintenance stage after a period of six months, though this can vary from individual to individual. It is hoped that this is the stage at which the individual will permanently exit the wheel of change. This is not however always the case and some people will move on, perhaps a number of times, to relapse before breaking the cycle. Some will never break it.[x]

Relapse

Relapse is the name given to when an individual returns to the old problem behaviours. The Transtheoretical Model however, views relapse as a natural part of the cycle of change and this can in-fact go a long way to removing or reducing the shame and self loathing felt by an individual who has relapsed. They are often inclined to view their relapse as a “failure”, by gaining an understanding of the cycle of change they can come to the realisation that it is not an all or nothing situation and they can return to the action stage whenever they want. In a lot of cases however, they will revert to the pre-contemplation stage for an extended period of time before themselves or external circumstances again make them think about making changes and bring them again to the contemplation stage.[xi]

Perceived Strengths and Weaknesses

Whilst generally viewed favourably, there are detractors of the wheel of change and of the Transtheoretical Model as utilized in Motivational Enhancement Therapy.

The strengths of the wheel of change are that it provides an excellent framework for the professional helper, allowing them to provide the appropriate interventions at the appropriate times. It also allows for the client to gain a better understanding of what is happening to them.

Detractors would say that it allows for a “soft” approach, whereby an individual could still be indulging their substance of choice, albeit at a reduced and less harmful level. Thereby claiming a success for the model that others would consider a failure.[xii]

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