Stages of Change Theory

Review of Theory

In the 1980s, James Prochaska and Carlo DiClemente developed a model to explain change processes specific to those battling substance use. Based on their examination of “self-changers,” the Stages of Change (SOC) model formed part of a broader conceptual framework known as the Transtheoretical Model (Prochaska & DiClemente, 1982, 1986; Prochaska, DiClemente, & Norcross, 1992). The SOC model recognizes that individuals are in different stages of readiness for change. We cannot assume that someone is ready (or not) for an important health behavior change. Instead, we can specifically assess individuals’ readiness for change and tailor interventions to meet them where they are. There are five stages of change: precontemplation, contemplation, preparation, action, and maintenance (Prochaska & DiClemente, 1982, 1986). Although a discussion of each stage is beyond the scope of this chapter, they are fairly straightforward for both clinicians and others to understand.

Relapse is another important concept within SOC. During change processes, most people will experience relapse. Relapses are important for learning and helping people solidify their resolve to change. On the other hand, relapses can weaken the will to change and even trigger giving up if someone is frustrated or tired. The stages of change noted above are not necessarily linear (Prochaska & DiClemente, 1982; 1986). There has been evidence for cross-cultural application of SOC theory, with studies in diverse U.S. populations (Fleary, Tagorda, Kim, Rathke, & Nigg, 2018) and Brazilian populations (da Silva et al., 2015) supporting the validity of the model.

Discussions of applied SOC theory typically include motivational interviewing (MI). MI is defined as collaborative, goal-oriented interviewing and communication with a special emphasis on the language of change. MI is designed to enhance motivation and dedication to a goal by exploring the person’s own readiness and reasons for change within a warm, accepting, and compassionate context (Miller & Rollnick, 1991, 2013). Using four processes—engaging, focusing, evoking, and planning—the practitioner facilitates autonomous and personalized change planning by the client/patient.

Evidence in Youth

Given the higher level cognitive processing and self-awareness required for SOC application, the majority of studies have focused on adults, with some adolescent populations also included (Armstrong et al., 2011; Borrello, Pietrabissa, Ceccarini, Manzoni, & Castelnuovo, 2015). Although the scope of MI applications is beyond this chapter, Borrello et al. (2015) recently published a review of SOC and motivational interviewing applications in childhood obesity treatment.

Physical Activity

Pediatrician-led motivational interviewing strategies rooted in SOC have been shown to increase physical activity in overweight children (Davoli et al., 2013). One recent paper noted the importance of both leisure time physical activity and the integration of devices/technology (Nemet, 2017). Although not an explicit SOC focus. White et al. (2018) alluded to the importance of autonomous motivation with regard to promoting increased leisure time physical activity.

Screen Time

Very little work specific to SOC or MI has been conducted with regard to changing screen time and improving the weight status of young children and adolescents. This may be a function of parental control, or lack of control, over screens, and the normalization of technology/screen time in children’s daily lives. Imagine a child or adolescent being asked about his or her “readiness” to change or reduce screen time. Although conjectural, given the lack of evidence, it is likely that most children and adolescents would be in precontemplation, at best. Motivating parents to want to change or reduce screen time is where we must focus our future efforts (Epstein, Paluch, Gordy, & Dorn, 2000). Wright et al. (2015) recently validated the parental SOC model with regard to support for healthy eating and physical activity. They did find that parents’ SOC level directly affected their ability to limit child and adolescent television to less than two hours daily. Wright’s model, with its emphasis on parental inclusion and involvement, has much promise.

Dietary Outcomes

Similar to screen time, it is complicated to assess child and adolescent SOC and its relevance with regard to dietary changes and healthy weight outcomes. The study noted above (Wright et al., 2015) also found that parent SOC level predicted their willingness and ability to provide five servings of fresh fruits and vegetables daily, limit sugary drinks to one serving weekly, and limit fruit juice to no more than six ounces daily. Construct validity for parent SOC and potential usefulness for obesity prevention efforts were supported by this work.

Substance Use

SOC theory has been applied to interventions for substance use in a variety of ways. The main way that this theory has been applied is through MI. A metaanalysis of MI with adolescents finds a small but significant effect for reducing substance use and that these effects remain over time (Jensen et al., 2011). Further, MI has been delivered successfully by school-based mental health personnel

(Winters, Fahnhorst, Botzet, Lee, & Lalone, 2012), and has been incorporated into a number of effective interventions including Teen Intervene (Winters & Leitten, 2007) and Screening, Brief Intervention and Referral to Treatment (SBIRT; Curtis, McLellan, & Gabellini, 2014).

Another approach based on the SOC theory is Motivational Enhancement Therapy (MET). The goal of MET is to facilitate rapid internal motivational change (NIDA, 2020c). MET has been implemented in schools (Walker, Roff-man, Stephens, Wakana, & Berghuis, 2006), and findings have been promising regarding its ability to reduce adolescent substance use. A comprehensive review of MET interventions by Tevyaw and Monti (2004) finds that these interventions reduce substance use, decrease substance-related negative consequences and problems, and increase treatment engagement. These findings were stronger for youth with higher levels of substance use and less motivation to change.

Risky Sexual Behavior

Several studies have found that the SOC theory can be applied successfully to the study of adolescent risky sexual behavior for health promotion skills such as condom use (Grimley, Riley, Bellis, & Prochaska, 1993). The effectiveness of MI on reducing risky sexual behavior, particularly among female adolescents is supported with a plethora of research (Downs et al., 2004; Gold et al., 2016). For example, Shrier et al. (2001) conducted a randomized control trial using an intervention focused on increasing motivation to engage in safer sex practices with 123 female adolescents with cervicitis or pelvic inflammatory disease. Results indicated that the intervention led to improved condom use and decreased number of sexual partners at 6-month and 12-month follow-up. Motivational interventions have also been implemented with teenage mothers in an attempt to reduce rapid subsequent births of additional children. A randomized control trial using a computer-assisted motivational intervention (САМІ) with pregnant mothers (n = 235) found that participating in two or more САМІ sessions reduced the risk of rapid subsequent births (Barnet et al., 2009). Overall, motivational interventions appear to be an effective way to reduce adolescent risky sexual behavior for adolescent females. Additional research is needed on motivational interventions with male youth.

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