Ruth Lim is a senior social worker at SPD who counsels and provides social support to people with disabilities at the sheltered workshop. With many years in the social service sector, Ruth has worked with many clients and has seen her charges deal differently with changes happening in their lives. She shares with UPDATES the different stages of change and what a counsellor can do at every stage to help the client cope with these changes.

While change is constant, most people are hesitant to take action when faced with it. For example, when weaning from drug abuse or taking on a job after an extended period of unemployment.

A person would typically move through a series of stages when modifying behaviour, as shown in the Transtheoretical Model of Stages of Change in Diagram 1 (below). The individual must overcome every stage before action occurs. The objective would be to move the person from one stage to the next, and not directly into action as change is a process rather than an event, and it deals with a person’s intentional behaviour.

Diagram 1: The Transtheoretical Model of Stages of Change (Prochaska, DiClemente & Norcross, 1992)

The individual may experience predominant emotions at each stage (refer to Diagram 2 below) such as denial, resistance, anger and understanding. From his perspective, he might feel more comfortable taking lesser risk by not going ahead with the change. Deciding on making any changes would be akin to getting on an emotional roller coaster ride. With such understanding, the counsellor would require stage-specific communication skills and strategies to support the individual.

Diagram 2: Client’s states through the stages of change

Case study
I have a client who is in his 40s. He was a maintenance officer until he had a stroke in 2012. After he was discharged from therapy a year later, he remained at home and refused to get out of the house even though he could move around independently and could take care of his own needs. He continued to stay at home even after his doctor referred him to SPD’s Sheltered Workshop.

Pre-Contemplation Stage – “No Way!”
I could see that the client was in denial – unaware and unwilling to change even after six months. He was not thinking about change but neither has he rejected the notion of change.

The counsellor’s role
Persuasion would not be the most ideal strategy to deploy at this stage as it would most likely be met with outright rejection or resistance. I decided to use active and reflective listening to provide empathy as a form of engagement. I raised doubts in his current behaviour to increase his perception towards the risks and problems of such inactivity, and focused on the advantages of change. Thereafter, I gently pointed out that if he were to attend the sheltered workshop, his wife could take on a job to supplement their household income.

Contemplation Stage – “Perhaps… maybe”
The client might have become bored or had come to the realisation that he was wasting his life away just ‘staring at the four walls of his flat’ every day. He might experience resistance or anger over what he had lost as a result of the stroke. However, when he had finally decided to let go, he would be searching for support. He started to think about trying to make changes in the next six months and discussed with his wife about attending the sheltered workshop at SPD.

The counsellor’s role
As his social worker, I came in to provide him with information so that he could make informed choices. I provided psycho-educational, as well as emotional support after recognising that he could be undergoing a struggle and/or experiencing internal turmoil as he wrestled with his personal dilemma as whether to go ahead with a change or not. I tipped the balance for reasons to change, and highlighted the risks of not changing. The client’s wife was also persuading him gently to enrol into the sheltered workshop programme as a first step towards returning to the workforce, even though it was sheltered employment. I endorsed her statements, and expressed my confidence in his abilities and he would be a suitable candidate for the sheltered workshop.

Preparation Stage – “What’s needed? What must I do?”
At this juncture, the client understood the meaning of change and had started planning on the changes to make so that he could carry on with his life. He was ready to let go of his current lifestyle and to try out new behaviours within the next 30 days.

The counsellor’s role
Problem-solving takes centre stage. I worked with him to determine the best course of action to take and set realistic goals for him. I provided him emotional support, affirmed his actions and enlisted the support of others as he set out to effect these new changes. An occupational therapist was arranged to assess him. His wife also accompanied and trained him to commute to the sheltered workshop using public transport until such time that he could travel independently. He agreed to this course of action and gave me the green light to proceed.

Action Stage – “How am I doing?”
The client gradually moved out of his old ways by taking positive steps and putting his plans into practice for the next six months.

The counsellor’s role
I worked alongside him to cheer him on, constantly reminding him of the need for stimulus control such as keeping a lookout and avoiding any stimulus that might trigger a return to his old ways. Praising his positive behaviours and continuing to provide emotional support reinforced the new changes.

The issue of stimulus control is important. In this client’s case, it could be the fear of being inconvenienced during the morning rush hour, or the fatigue from the working hours at the workshop. As he was used to waking up at 6 am, I suggested that he leave home early to avoid the crowd. There are also regular break times at the workshop where he could rest and re-charge. He agreed to take these steps.

Maintenance Stage – “More of how am I doing?”
By then, the client had achieved positive and concrete developments in his new way of life for about six months. However, changes had to be internalised and consolidated or he might fall back to his old ways.

The counsellor’s role
I continued to provide emotional support and rallied his natural support system to reinforce and maintain his changed behaviours. I discussed with him the need for relapse prevention and we agreed on strategies for stimulus control and relapse prevention.

I checked in on him regularly during work hours and was happy to learn that that he was faring very well with his wife’s support. I continued to praise and encourage him, highlighting what good role model he would make for his children. In not giving up on himself and bouncing back from the setbacks, he was not only a good father but a role model for his children and wife.

Relapse Stage – “I failed, but each slip brings me closer to recovery”
A relapse happens if the client falls back into his old actions and behaviours. Nevertheless, slips or relapses are considered part of recovery rather than failure. Each relapse should be met with new insights and knowledge, leading to lesser frequency in setbacks.

The counsellor’s role
Encouragement and incentives are critical for the client to go. The counsellor would have to encourage the client so that he could pick himself up and continue with the changes that were initiated. Evaluating triggers from any of the five senses and increasing awareness after each relapse can bring the client through the stages of change. I would help the client renew the processes of Preparation and Action without becoming stuck or demoralised due to relapse.

In my client’s case, being around with people with disabilities triggered painful memories of the stroke and was the reason why he hesitated joining the workshop. This could be a possible trigger for relapses and withdrawal from the sheltered workshop. If this had happened, I would have to explore options other than the sheltered workshop to get him out into the community regularly as a start to rebuild his confidence.

Conclusion
The Transtheoretical Model of Stages of Change is useful as it provides a framework for understanding the process of change. It requires the counsellor to identify the stage of change that the client is in before using the appropriate interventions to help the client make progress.

References
Prochaska, J.O. & Norcross, J.C. (2010). Systems of Psychotherapy: A Transtheoretical Analysis, p. 106-119. Belmont, CA: Brooks/Cole.

Segan, C. (1999). An Overview of Prochaska and Diclemente’s Stages of Change Model.