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John G Kuna, PsyD and Associates
Applications of Stages of Change Theory
Arguably the core of CBT, and perhaps of all therapeutic counseling, is assisting the patient in
replacing negative behaviors with positive behaviors. The following will present two theoretical
systems for describing and aiding patients in the replacement of dysfunctional behaviors with
healthy ones. The Transtheoretical Stages of Change (SOC) model as originally proposed by
Prochaska and DiClemente (1983), and later revised by Arthur Freeman and Michael Dolan
(2001) will be presented.
Table 1: Prochaska and DiClemente’s Stages of Change Model
Stages of Change Characteristics Techniques
Pre-Contemplation Not currently considering
change: Ignorance is bliss!
Validate lack of readniess
Reinforce personal agency
Explain risks vs. rewards
Contemplation Ambivalent about change: On
the fence. Not considering
change within the next month
Validate lack of readniess
Reinforce personal agency
Encourage evaluation of pros
and cons of change
Identify and promote new
Preparation Some experience with change
Plan to change within one
“Testing the waters”
Identify and assist in
Help identify social support
Verify individual skills for
Encourage small, initial steps
Action Practicing new behavior for 3-
Focus on restructring cues and
Bolster self-efficacy for
dealing with obstacles
Combat feelings of loss and
reiterate long term benefits
Dolan-Freeman Revised Stages of Change
“As practitioners, planning for the change process with clients is the single most important skill
counselors bring to the therapeutic table” (Dolan, 2001).
Table 2: Comparison of the Prochaska/DiClemente and Freeman/Dolan Models
Prochaska /DiClemente Freeman/Dolan
****************** 2. Anti-contemplation
1. Pre-contemplation 3. Pre-contemplation
2. Contemplation 4. Contemplation
3. Preparation 5. Action Planning
4. Action 6. Action
****************** 7. Pre-lapse
****************** 8. Lapse
****************** 9. Relapse
5. Maintenance 10. Maintenance
The Dolan-Freeman model takes into account that some people may be unaware of the
existence of a problem or the need to change (Non-contemplation).
The first two stages offer recognition that some patients are required to enter treatment
In some instances they may oppose violently (Anti-contemplation) the whole therapeutic
process (Dolan, 2004).
Pre-contemplation and Contemplation: are not tied to commitment as described in
Prochaska/DiClemente (1982). Rather, they are understood as cognitive functions of the
For Freeman/ Dolan, the Pre-contemplation stage occurs when the client begins to
consider the consequences, purpose,and the possibility of change.
The Contemplation stage indicates that the client is actively considering and is ready to
The Preparation stage of Prochaska/DiClemente is timed (within the next month) and
requires an unsuccessful attempt at change within the past year.
In the Freeman/Dolan model, Action Planning replaces Prochaska/DiClemente’s
Preparation stage and is designed as an interactive collaborative process between the
counselor and the client.
The Freeman/Dolan Action stage requires a treatment focus that initiates active treatment
planning. The Action stage is the same for both models and is analogous to going from
neutral to drive
The next three stages are completely new and reflect the complex cognitive processes of
upsetting the homeostasis of a person through the change process.
The first of these stages is Pre-lapse, in which the client is evaluating whether the change
made in the Action stage is beneficial or even needed. This is a cognitive process with no
behavioral components. The concept of Pre-lapse is needed to explain that once changes
are made the client initially goes through a rejection process similar to a body going
through the rejection of transplanted parts.
The Lapse stage is the behavioral manifestation of the unsuccessful resolution of the Pre-
lapse stage. This is usually characterized by a single behavioral event, and if therapeutic
redirection occurs, the client returns to the change state. If the resolution of the Pre-lapse
stage is unsuccessful or if redirection is ineffective, then the process will move to Re-
Relapse includes a reemergence of the behavioral problems, and the cognitive patterns
that induce or reinforce the problem behavior.
The lack of these additional stages in the Prochaska/DiClemente model prevents accurate
identification and the interventions necessary for the resolution of problems unique to
The Maintenance stage in both models is conceptually similar; however, the focus in
Freeman/Dolan is to continually assess and fine tune the changes until they become
habitual, and to generalize to other problem areas throughout a person’s life.
The Freeman/Dolan model seeks to provide the counselor with a tool that is more
efficient and clinically relevant.
The model allows the counselor to more accurately determine where his or her client is
on the continuum of change and to factor into the change process any special conditions
or circumstances such as cultural differences.
Empirical basis: In a recent study (Dolan, 2003), the Freeman/Dolan model was found to
offer counselors greater ability to accurately identify the stages their clients were in than
was true of the Prochaska/DiClemente model. In addition, the participants preferred the
Freeman/Dolan model to the original model three to one.
Change and Treatment Planning
Three components of Treatment planning:
(1) Stage or Diagnosis and Assessment;
(2) Level or Problem Identification; and
(3) Treatment or Strategy Implementation.
SLT model refers to a Stage by Level by Treatment interaction of creating change.
The Stage component acknowledges when to change or the current stage of change for
Stage is established using questionnaires, and/or formal and informal counselor
Methodology may include assessments such as psychosocial history, mental status, risk
assessment, presenting problem, and strengths and weaknesses.
Level of the change process refers to what change is required and is determined through
some form of problem list and/or clinical interview. Most theoretical models for
conducting counseling contain the “what” of change within the model.
Included in the Level of change are:
(1) Cognitive or the mental process of knowing;
(2) Affective or raw visceral experiences interpreted as emotions and feelings (cognitive labels);
(3) Behavior or the actions or reactions of persons in response to external or internal; and
(4) Environment or the context for clients’ living.
Treatment refers to how clients change and is composed of the strategies and techniques
that are most effective for dealing with specific problems at a certain stage and level of
Example: the counselor might use the strategy of refutation for a client’s cognitive
distortions when the client is in the Contemplation stage and is ready to change.
References (and Recommended Readings)
Freeman, A., & Dolan, M. (2001).Revisiting Prochaska and DiClemente’s Stages of
Change theory: An expansion and specification to aid in treatment planning and outcome
evaluation. Cognitive and Behavioral Practice, 8, 224–234.
Kazdin, A. E. (2000). Psychotherapy for children and adolescents: Directions for research
and practice.New York: Oxford University Press.
Kendall, P. C., &Chambless, D. L. (Eds.). (1998).Empirically supported psychological
therapies [Special section]. Journal of Counseling and Clinical Psychology, 66, 3–167
Nathan, P. E., & Gorman, J. M. (Eds.).(1998). Treatments that work. New York: Oxford
Norcross, J. C., Krebs, P. M., &Prochaska, J. O. (2011).Stages of change.Journal Of
Clinical Psychology, 67(2), 143-154. doi:10.1002/jclp.20758
Prochaska, J. O., &DeClemente, C. C. (1982).Transtheoretical therapy: Toward a more
integrative model of change. Psychotherapy: Theory, Research, and Practice, 20, 161–173.
Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. (1992). In search of how people
change: Applications to addictive behaviors. American Psychologist, 47(9), 1102-1114.
Prochaska, J.O., Velicer, W.F., Rossi, J.S., Goldstein, M.G., Marcus, B.H., Rakowski,
W., Fiore, C., Harlow, L.L., Redding, C.A., Rosenbloom, D., & Rossi, S.R. (1994). Stages of
change and decisional balance for twelve problem behaviors.Health Psychology, 13(1), 39-46.
Expansion of Prochaska and DiClemente’s Stages of Change Model
I. Pre-contemplation Stage
"Ignorance is bliss"
"Weight is not a concern for me"
1. Help patient develop a reason for changing
2. Validate the patient’s experience
3. Encourage further self-exploration
4. Leave the door open for future conversations
1. Validate the patient’s experience:
"I can understand why you feel that way"
2. Acknowledge the patient’s control of the decision:
"I don’t want to preach to you; I know that you’re an adult and you will be the one
to decide if and when you are ready to lose weight."
3. Repeat a simple, direct statement about your stand on the medical benefits of weight
loss for this patient:
"I believe, based upon my training and experience, that this extra weight is putting you at serious
risk for heart disease, and that losing 10 pounds is the most important thing you could do for
4. Explore potential concerns:
"Has your weight ever caused you a problem?" "Can you imagine how your weight might cause
problems in the future?"
5. Acknowledge possible feelings of being pressured:
"I know that it might feel as though I’ve been pressuring you, and I want to thank you for talking
with me anyway."
6. Validate that they are not ready:
"I hear you saying that you are nowhere near ready to lose weight right now."
7. Restate your position that it is up to them:
"It’s totally up to you to decide if this is right for you right now."
8. Encourage reframing of current state of change - the potential beginning of a change
rather than a decision never to change:
"Everyone who’s ever lost weight starts right where you are now; they start by seeing the reasons
where they might want to lose weight. And that’s what I’ve been talking to you about."
II. Contemplation Stage
"Sitting on the fence"
"Yes my weight is a concern for me, but I’m not willing or able to begin losing weight within the
1. Validate the patient’s experience
2. Clarify the patient’s perceptions of the pros and cons of attempted weight loss
3. Encourage further self-exploration
4. Leave the door open for moving to preparation
1. Validate the patient’s experience:
"I’m hearing that you are thinking about losing weight but you’re definitely not ready to take
2. Acknowledge patient’s control of the decision:
"I don’t want to preach to you; I know that you’re an adult and you will be the one to decide if
and when you are ready to lose weight."
3. Clarify patient’s perceptions of the pros and cons of attempted weight loss:
"Using this worksheet, what is one benefit of losing weight? What is one drawback of losing
4. Encourage further self-exploration:
"These questions are very important to beginning a successful weight loss program. Would you
be willing to finish this at home and talk to me about it at our next visit?"
5. Restate your position that it is up to them:
"It’s totally up to you to decide if this is right for you right now. Whatever you choose, I’m here
to support you."
6. Leave the door open for moving to preparation:
"After talking about this, and doing the exercise, if you feel you would like to make some
changes, the next step won’t be jumping into action - we can begin with some preparation work."
III. Preparation Stage
"Testing the Waters"
"My weight is a concern for me; I’m clear that the benefits of attempting weight loss outweigh
the drawbacks, and I’m planning to start within the next month."
1. Praise the decision to change behavior
2. Prioritize behavior change opportunities
3. Identify and assist in problem solving re: obstacles
4. Encourage small initial steps
5. Encourage identification of social supports
1. Praise the decision to change behavior:
"It’s great that you feel good about your weight loss decision; you are doing something important
to decrease your risk for heart disease."
2. Prioritize behavior change opportunities:
"Looking at your eating habits, I think the biggest benefits would come from switching from
whole milk dairy products to fat-free dairy products. What do you think?"
3. Identify and assist in problem solving re: obstacles:
"Have you ever attempted weight loss before? What was helpful? What kinds of problems would
you expect in making those changes now? How do you think you could deal with them?"
4. Encourage small, initial steps:
"So, the initial goal is to try nonfat milk instead of whole milk every time you have cereal this
5. Assist patient in identifying social support:
"Which family members or friends could support you as you make this change? How could they
support you? Is there anything else I can do to help?"
Prepared by Phillip J. Kuna for John G. Kuna, PsyD and Associates