The Context of Change
Change is a fundamental human experience. Philosophers, wisdom teachers, writers, and scientists have all attested to this pervasive phenomenon in their own way, trying to explain, illustrate, or at least understand how "Everything changes except the fact of change."
Heraclitus believed that the world was in a perpetual state of change, while Gautama Buddha suggested that the universal principle of impermanence is foundational to all existence. The I Ching, arguably one of the most influential expressions of Chinese culture, attempts to describe changes in the universe through a comprehensive system of 64 gua (hexagrams). In the Bible, many books - Exodus, Job, Ecclesiastes, the Gospels, and others - take change for granted, then reveal how it affects human beings.
Both physicians and non-medical psychotherapists are facilitators, catalysts, and promoters of change. With each prescription doctors write, they are fostering change in their patients' state of health; with each diagnostic test they order, they are preparing for possible change in their patients. Psychotherapists might recommend relaxation skills for clients suffering from stress, or communication skills for embattled families.
Whether attempting to treat patients' illnesses or improve clients' wellness, physicians and individual, couple, and family therapists create a milieu within which some form of change can occur. But what drives change? How do people change? What are the factors that facilitate change?
In my own medical practice, I have encountered many individuals who have serious struggles with addictions. All of them have been through treatment programs at least once, if not several times. Some of them are so addicted that they have lost their livelihood and shattered their families. They know that their addictions harm both themselves and their loved ones. Most of them want to change. Some do change; but despite vigorous efforts, many do not.
This dilemma is not new. St. Paul, one of the great shapers of Western culture, certainly never thought of himself as a saint. He confesses, "I do not understand what I do. For what I want to do I do not do, but what I hate I do....For I have the desire to do what is good, but I cannot carry it out. For what I do is not the good I want to do; no, the evil I do not want to do - this I keep on doing....What a wretched man I am!" (Romans 14-23)
Many people are vulnerable to what William Miller calls "The Righting Reflex." By this he means a "built-in desire to set things right." This phenomenon is particularly common for individuals attracted to the healing arts or helping professions. Whenever we meet any resistance from patients or clients, our natural response is to push harder.
Henri Nouwen, one of the most inspiring spiritual writers of our time, cautions us against the potential of violence in the process of teaching and doing therapy. This possibility is especially real if "teaching" (or therapy) is understood to be the mere transfer of knowledge. The script of many therapeutic dramas contains a tug-of-war between the doctor or therapist who prescribes a change and the patient or client who resists change.
How then shall we practice medicine or psychotherapy so that we avoid the pitfalls of the Righting Reflex? What model would facilitate intentional change in an empathic, effective milieu?
The "ABCs" of Changing Problem Behaviours.
A in ABCs stands for activity. It includes the tasks, techniques, and interventions that are part of successful strategies for change.
We need to ask, "Are the therapeutic processes that we suggest to clients realistic for their particular case?" They had better be.
B stands for bond. It refers to the relational bond between physician and patient, or therapist and clients, that evolves during therapy. The question here: "Is the attachment 'good enough'?" If it is not, the chances of success are greatly diminished.
C stands for change stages. It refers to James Prochaska's five stages of change. Change stages are a question of timing: When to do which stage of change to achieve what (goals and objectives)? We need to be mindful of the question: "Is the timing right for the person, couple, or family?"
We have all heard stories of how people may undergo dramatic character alterations after a deeply spiritual experience. Doctors and therapists have been puzzled by the mystery of intentional change. Recent research performed by Prochaska and his colleagues have somewhat penetrated this mystery.
Prochaska began his research on change associated with the difficulties of stopping smoking and overeating. But if there is a universal principle underlying intentional change, Prochaska's model should be applicable to other unwanted behaviours such as cocaine use, unsafe sex, overexposure to the sun, violent rages, and the like. This has subsequently proved to be the case.
In each of the five stages of change, people seem to have a unique set of beliefs about themselves. Moreover, people in each change state seem to have their own sense of timing about readiness to change. Individuals, couples, and families move through these states in different ways and at different speeds.
The Five Change States
Precontemplative Stage: People in this stage do not consider the need to change. They do not perceive themselves as having any problems. If there is a problem, it is external to them. They may say, "I am just fine the way I am. My behaviour is not a problem. If you think it is, that's your problem." This is frequently the stage that one partner is in when a couple comes to therapy.
Contemplative Stage: People in this stage begin to consider the possibility that they might be responsible for their problem behaviour. They may not take any action to change; this stage is more akin to an intellectual acknowledgement of their personal contribution to the problem. They may ask, "I might have a problem with my behaviour, but can I really do anything about it?" Contemplators may intend to take action, but they may not yet have the behaviour-change strategies or emotional commitment that real change requires. Despite their serious intention to take action in the near future, contemplators can sometimes become stuck at this stage for long periods.
Preparation Stage: People in this stage know they have to change. They feel they have to change. They have already taken some proactive steps toward modifying their problem behaviour. They show a combination of rational understanding, emotional commitment, and the beginning of a journey toward change. In this stage, individuals, couples, and families may have a sense of urgency that actions need to be taken in days or weeks. Many couples or families who are locked into destructive anger patterns enter therapy at this stage.
Action Stage: People in this stage have launched full-scale actions both within themselves and within their environment to overcome their problem. This is also the stage where lay persons and professionals alike may erroneously equate action with change. People in this stage believe that "I am actually doing something about my problem right now." In fact, this is a beginning towards effective long-term change.
Maintenance Stage: In this stage, people are fully engaged in preventing recurrence of their problem behaviour. Prochaska emphasizes the importance of recognizing that "maintenance is a continuation of change, not its absence." Some examples of this stage are: Implementing an anger management contract within the family, or attending regular meetings of Alcoholics Anonymous to maintain sobriety.
As a doctor or therapist supports people as they navigate each stage of change, by empathically validating their feelings, helping them interpret events, articulate deep emotions, and resolve the unresolved psychic traumas of life, real change should seem less like an impossibility and less like a resented burden. Instead, intentional change is seen as more like a series of actions that are desirable in themselves, lead to a desirable goal, and often bring healing and restoration to relationships.
Danny S.C. Yeung, M.D., C.C.F.P.
Associate Clinical Director
For Further Reading
Miller, William R., and C'de Baca, Janet. Quantum Change. New York: Guilford Press, 2001.
Norcross, John C. Systems of Psychotherapy: A Transtheoretical Analysis. Pacific Grove: Brooks/Cole Publishing Company, 1999.
Prochaska, James O., et al. Changing for Good. New York: Avon Books, 1994