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Medicial Mistakes?
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| | Stages of Change and Readiness for Change: An Interview with James Prochaska, Ph.D. | |
Summary: The pioneering work of James Prochaska, PhD in "stages of change" and "readiness for change" is known to many in the integrative practice community. Changing behaviors is the heart of the best of integrative care. Employers are drawn to Prochaska's work because moving an employee toward change can eventually be monetized. Is this a place for an employer-integrative practice link? I think so. Prochaska will be a featured presenter and workshop leader at the October 15-17, 2008 conference of the Institute for Health and Productivity Management (IHPM), an Integrator sponsor. I look forward to the opportunity to introduce him to Richard Nahin, PhD, MD, senior adviser and acting director of extramural research for NIH NCCAM who will be a keynoter at the meeting. This interview explores Prochaska's work, potential clinical applications in complementary, alternative and integrative medicine research and practice, and the way the reductive research paradigm has hindered application of beneficial change strategies.
 James Prochaska, PhD
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Prochaska's Transtheoretical Model for Stages of Change
An integrative model of behavior change that incorporates
process oriented variable to explain and predict how and
when individuals change behaviors
Stage of Change
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Characteristics
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Precontemplation (PC)
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Not intending to take action in the foreseeable future
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Contemplation (C)
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Seriously intending to make a change in the next
six months but have not made a commitment to do so.
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Preparation (PR)
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Intend to change in the next 30 days and have taken
some small behavioral steps toward action.
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Action (A)
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Have successfully changed for less than 6 months.
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Maintenance (M)
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Made a behavioral change for more than 6 months.
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From: Transtheoretical Model Intervention for Adherence
to Lipid-Lowering Drugs (Disease Management 2006;9:102-114)
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 Institute for Health and Productivity Management - exploring the employer and integrative medicine connection
My intrigue was all the higher as I knew that an award-winning employee wellness program reported here had used Prochaska's work as an outcome measure. (See the bottom chart at Analysis of Noe's Award-Winning Worksite Wellness Program -- Making the CAM-IM Employer Connection, June 13, 2006.) Amidst a reductive research environment malformed for capturing the whole person outcomes of integrative practice, employer interest in measuring shifts in "readiness from change" offers fresh potential. The case statement goes something like this:
If major employers care about it (which they do) and integrative practitioners are concerned with payment and access (which they are), why have integrative clinicians not used such tools and constructs to advance how well they are doing on something they claim to do very well?
 Janice Prochaska, PhD, ProChange Behavior Systems CEO
Background on Prochaska's original thinking
Integrator: How did you get started in developing the stages of change idea?
Prochaska: Our goal was to integrate how people change across a broad range of approaches to change. We followed 1000 ordinary people as they tried to get free of bad habits. The work is based on what these people told us. They taught us about the stages of change. This idea of stages wasn't in the 300 theories of behavior change we'd reviewed. This was this missing link.
Integrator: So you have the theory. What did you do with it?
Prochaska: "Stages" was
a population construct [looking at large groups of people, such as a set
of employees] as well as an individual construct. We knew many doctors and other clinicians used to write off certain patients as
non-compliant, non-motivated or resistant. We also knew patients wouldn't go to clinics for behavior change. They knew they wouldn't get that from their doctors. We knew most health care is at home. We wanted to develop
applications to be useful to as big a population as possible and to guide people so they wouldn't have to go through trial and error. We saw this as developing home-based behavior change just as taking drugs at home is home-based biological change.
Integrator: So what are the tools then for supporting people at home?
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Prochaska:
The majority of behavioral change
falls in
self-change. Professionals
resist this, as it seems to diminish
them.
But think about it in medicine:
Where would physicians be without
the
self-healing?
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Prochaska: The
Change Companies have developed interactive journals using our change processes. Research has shown journaling can improve overall health and wellbeing. [The Change Companies is a "national
publishing, consulting and training company that works with leading industry
experts to develop effective evidence-based materials that assist individuals in making
positive life
change." Prochaska is affiliated as a senior adviser.]
Integrator: It's interesting to me that about the time you were beginning this work, back in the late 1970s, work which reacted in part to a short-coming of typical clinical care, the holistic and complementary healthcare professions were taking root as another was to connect with patients that conventional medicine was giving up on or writing off their potential for change. I have always felt that the best of these integrative practices use home tools like diet diaries, and journaling of various types. These tools are under-utilized though.
Prochaska: In a way, behavioral change is to psychology or behavioral therapy like natural healing is to medicine. The majority of behavioral change falls in self-change. Professionals resist this, as it seems to diminish them. But think about it in medicine: Where would physicians be without the self-healing?
Integrator: So, key tools are interactive journals and stage-based manuals?
Prochaska: The Change Companies from the beginning took the stages of change model and used processes of changes, pathways for individuals to allow a change process to be understood, activated and reinforced.
For employers/employees - computer based, tailored interventions
Integrator: When did you start working directly with employers?
Prochaska: The most intense work has been in the last 5-6 years. The need has been there all along, but there's not been enough demand to match it. Now the demand is there. Pro-Change started 11 years ago. Early on we got an SBIR [Small Business Innovation Research] grants to research strategies for stress management, medication adherence and depression reduction. The grants and our mission are both research and dissemination. We wanted to bring what we were learning to as many people as possible. We're using computer-based, tailored interventions. It's an expert system.
Integrator: Any sample outcomes?
Prochaska: The foundation of our programs is our research on over 120,000 individuals though over $70-million in grants. We've a stress management study with 1000 individuals who weren't managing their stress effectively. At the end, after just 3 electronic interventions, 60% of the people were able to manage their stress and then hold their ability for 12 months.
Working with clinics and clinicians
Integrator: I could see where it would be threatening to a practitioner. Still it seems like a great add-on to a practice, this home-study and computer-aided support for change. Do you have programs or research looking directly at clinicians using these tools, or these outcomes?
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Prochaska:
A reason employers are funding
our behavioral change work is that
they can't count on their employees
getting it from their physicians.
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Prochaska: It's not as systematically used in part because our tools have not been as readily available to them. All too many providers don't want to deal with behavior a lot, whereas employers have been more eager. A reason employers are funding it is that they can't count on their employees getting it from their physicians.
Integrator: I think this is a real difference between integrative practitioners and conventional providers. At least what one hears is this interest in working with patients, the desire and interest to get in there and assist them to make changes. If they practice what they preach, I would think they would find these very useful.
(Janice) Prochaska: I was at a community health center earlier this week where we have an SBIR pilot for pregnant women. We have a lap top brought in. They do the intervention for healthy eating, stress management and smoking cessation during the office visit. They're trying to get the data linked into their electronic medical record.
Integrator: Do you see where there might be an uptake of your tools into integrative medicine?
Prochaska: What will happen is these tools will become more available to allow this to help patients work on change between clinical visits, like medicines work between visits. Other tools like journals can be useful. The Change Companies can do more with clinics and providers. The most widely available tool is "Changing for Good." But because we were working more to reach entire populations, our tools were first made more readily available to employers.
Integrator: Providers don't know an entire industry has grown up around these ideas.
Making multiple behavior changes
Prochaska: The lifestyle part of clinical care happens with talking, usually. But bringing these kinds of tools and technologies can extend the provider. We're actually showing that you can change multiple behaviors simultaneously just as you can change single behaviors. It used to be a belief that you could only do one change at a time.
Integrator: This potential for multiple changes simultaneously is quite aligned with thinking and approaches in holistic practices. If you treat the whole, the person shifts in various ways.
Prochaska: Most behavioral change programs don't have multiple change options. In the stages paradigm, its not overwhelming because we don't ask them to tak action at once for all behaviors.
The hindrance to behavior change from reductive research
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Prochaska:
There is no question that the
belief about making only
one change
at a time comes from reductive research.
Science comes in
and says you can
only do one thing ... This is part of
the problem
with obesity. It;s
a multiple behavior problem.
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Integrator: I wonder if this is linked to one of my pet peeve's - the limits of reductive research. It's a huge problem in understanding the potential value of integrative practice. The reductive paradigm forces researchers to look at a single agent or intervention. The story goes out that you can only do one thing at a time clinically because that's all one is typically allowed to research.
Prochaska: There is no question that the belief about making only one change at a time comes from reductive research. Science comes in and says you can only do one thing - whether its adherence, or exercise or diet or weight or another single issue. This is part of the problem with obesity. It's a multiple behavior problem. It's not all about diet. Our program includes emotional eating, eating comfort foods and junk foods.
Educating providers, linking with NIH NCCAM
Integrator: So how do you get practitioners to understand the power of these tools and how to integrate them?
Prochaska: I think what we need to do is teach them about change, about the principles and processes that help people. We've seen integration of these principles across 48 separate behaviors. [Hall & Rossi, 2008] The same principles hold.
Integrator: Well, these dialogues are a starting place for our fields to connect. I would love to put you in touch with Richard Nahin [PhD, MPH] a researcher - the leading health services and extramural guy - from the NIH National Center for Complementary and Alternative Medicine. I learned in a March meeting with [Nahin and Josephine Briggs, MD, NCAM director] that they have some interest in exploring the employer link. Nahin will also be at the IHPM conference.
Prochaska: I would welcome it.
Integrator: Well, I look forward to being a fly on the wall when you and [Nahin] have a chance to talk. I do think that these integrative practitioners may be exceptional partners for prescribing your home tools. Thank you for your time. i look forward to meeting both of you in Phoenix.
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[email protected]
for inclusion in a future Your Comments Forum.
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