Nutrition

5/STAGES AND PROCEsSES OF HEALTH BEHAVIOR CHANGE 113

intervention should increase the effectiveness, assist the client in progress-ing to the next SOC because of enhanced motivation and readiness, and reduce the likelihood of dropping out of treatment because the intervention was not appropriate.

Stages of Change Change is not viewed as a single event, such as "I will eat less sodium start ing today,

"

but as an unfolding process over time requiring more than one attempt. The model in Table5-1 shows the how, not the why, people change either with counseling or without it on their own. To make changes, people progress through six identified stages. The tasks at each stage vary, and movement through the stages represents personal progress for the client.

Precontemplation

In stage 1, Precontemplation, a person is unaware or underaware that a health problem exists, denies that there is a problem, or has no intention to take action to change. Thus, the individual has no plans, for example, to modify eating practices to lose weight or start exercising in the next 6 months.34 The person may have tried a change previously and failed, such as to lose weight, and may be resistant to the health professional's efforts to suggest possible changes. Perhaps a visit to the doctor initiated a referral to see the nutrition and dietetics counselor for weight loss, even if the patient was not concerned with his or her weight.

Because these clients are unaware, uninformed, or unconcerned about the health problem, the counselor needs to assess the client's views on making a change and address the reasons for not wanting to change rather than providing dietary information. Educating the client about food changes not appropriate at this stage. To identify this stage, the counselor may

asAre you seriously intending to change (name the problem behavior) in the next 6 months?"

1. Precontemplation No intention of changing in the next 6 mno.

2. Contemplation Intending to change, but not soon.

3. Preparation Small changes are made, intending to change in 30 d.

4. Action Changes are made in food choices regularly.

5. Maintenance Behavior changes maintained for 6 mo.

6. Termination

Occurs only if changes are maintained for a year or more.

Tahl

2/COUNSELING FOR HEALTH

BEHAViOR CHANGE

-fat diet ande Cotoa 114

less fat (or more fruits and vegetables) in the near futur2DOUl e

Droblem andi a person with a heart problem may need to know the health benelits

this.

The client needs to "own or acknowledge the health i

For people ignoring the relationship between a high-fat :

ght about eatin heart disease, for example, one may ask: "Have you tho

re" and

At this stag change as well as the risks of not addressing the problem Denef

ofene negative aspects."** These individuals are not ready for act and

idensith interventions. Knowing the person' s SOC helps the counelene

the appropriate type of intervention. Table 5-2 lists sample questions deng interventions at each stage.

Intervention Question for Client Stage

Consciousness raising Precontemplation "What can I do to help?"

Assess knowledge "Do you ever read articles ." about.

Increase self-awareness, gie "What do you know about the relationship between. .. written and oral information

Assess values, beliefs "Does anyone in your family have this problem?"

"Are you aware of the Cognitive restructuring Consequences?"

"How do you feel about making Discuss risks and benefits a change?"

Contemplation "What changes have you been thinking about?" Assess knowledge "What are the pros and cons?" Assess values, beliefs "How do you feel about it?" Assess thoughts, feelings "What would make it easier or Increase pros, decrease

barriers harder?" "What would be the results of the change?"

Self-evaluation "How can I help? Preparation

Cognitive restructurin "Are you intending to act in the next 1-6 mo?" Self-efficacy, commitment "How will you do it?" Decision making "What changes have you made already?" Discuss beliefs about au

billty

"How will your life be imprmin Table 5 2 Stages of Changa l

115 ANGE

"What are you doing Action

differently? Stimulus control "What problems are you having?" Self-reinforcement

"Who can help you?" Social support "How can I help?" Self-management "What do you do instead of Goal setting, group sessions, self-monitoring, relapse prevention

(former behavior)?"

"How do you handle times Maintenance

Coping responses when you slip up?" "What obstacles are you Relapse prevention facing?"

"What are your future plans?" Self-management "What issues have you Commitment, goal setting, solved?"

control environment

Self-management, self-efficacy

Termination

Table 5-2 (continued)

Contemplation In stage 2, Contemplation, a person is aware that the health problem exists

and intends to do better eventually, such as eating differently or exercising more. He or she has no serious thought of or commitment to making a change, however, and keeps putting it off."" The person may be mentally

Sruggling with the amount of time, energy, effort, and cost of overcoming a nealth problem or may be discouraged by previous failures. When the

Cons of changing a behavior are large and the pros are small, the result

dy De ambivalence that keeps people stuck at this stage tor long periods

OT ime, even months or years." The person needs to make a decision.

The counselor may ask, for example:

What have you been thinking about in terms of making a change?"

What are the pros and cons of doing it?

How can you change your environment?

what do you think about eating less fat? What are the barriers or ob

stacles to doing it?"

116 2/COUNSELING FOR HEALTH

BEHAVIOR CHANGE

Preparation

In stage 3, Preparation, a person is more determined to make a

ut 30 days. a chang ant

e or she intends to take initial action soon, perhaps in about 30 davs

may report small changes in addressing the problem behavior, h

reading a few food labels or buying low-lat foods. Clients neod,uch

lop a plan o make

commitment to change, set priorities or goals, and develonMak

action3

The counselor may inquire about possible interest in losimo

becoming more physically active, making healthier choices. and losing weighu records of food intakes. A study of parents of obese children ng weight loss found that about 62% of parents were in the action needing

SOC for child dietary behaviors, but only 41°6 were tor physical activi

child behaviors. Parents who thought their own weight wa

en's problem were less likely to make changes in their overweight chilten

behaviors.

Action

In stage 4, Action, a person takes action to implement a plan and onee come the health problem by actively noditying food choices, behavion environments, and expeticnes 'keep in mind that most clients are mor in the action stage when first teferted for counseling. leople are classified in this stage if they have altered a behavior successtully tor a certain period or up to 6 months, such as purchasing ditlerent groceries or exercising three times a week

Considerable comnmitment of time and energy is required in the action stage when people are trying to change.' The counselor may ask: "What are you doing differently already?" At this stage, clients need knowledg and skills and should know how to respond to a lapse or relapse. New behaviors are not firmly established in a week or a month, and old pa terns may resurtace.

With overweight adults usingTTM with SOC, there was some evide In an intervention that there were improvements in dietary habits d

ne

in physical activity. Ex amples were increased

exercise frequency an duration, increased tr

and vegetable consu tion, and reduced dielu fat intake.

The counselor deveiops

relationship with the cie

5/STAGES AND PROCESSES OF HEALTH BEHAVIOR CHANGE 117

2 CASE ANALYSIS

What SOC is Mr. Howard in?

Maintenance

In stage 5, Maintenance, a person consolidates and integrates new health

behaviors into his or her lifestyle made over several months. With time,

new behaviors need to become automatic. The client has to maintain the

new, healthier habits and work to prevent relapse.7 Maintaining weight loss, for example, takes continuing effort. For some people, this stage

continues for months, years, or a lifetime, or until the behavior becomes a pattern and is incorporated into one's lifestyle. The counselor may ask:

"How do you handle small lapses?" Additional information on counseling about lapses and relapse is found in Chapter 8.

Termination The ultimate goal is the Termination stage, in which changes have been maintained for years. The termination of a behavioral problem occurs if the client reacts automatically, is no longer tempted by the former

behavior, and is no longer lapsing or relapsing. Some people never Teach this stage, but periodically struggle with the health problem. In situations like weight control, a lifetime of maintenance may be the realistic goal.

Recycling Most people do not maintain changes in behaviors successfully on the first attempt. How long do your New Year's Eve resolutions last, or example? Prochaska proposed that most people proceed through the stages in a spiral, rather than a linear fashion. Because lapses and elapse are common problenms, recycling to an earlier stage, such as rom action back to preparation or from preparation back to contem- plation, may be expected several times as people struggle to modify or cease behaviors."

People may avoid high-fat and fried foods, for example, and then start aung them again. Moving back and forth through the stages represents a earning process for the client. Lapse and relapse and the negative emotional eactions (guilt, shame, failure) that may result are discussed along with he skills to recover in Chapter 8. People can learn from their mistakes with the help of the counselor and continue trying