Motivation to improve yourself.

Text taken from: CAVALCANTI, A. M.; OLIVEIRA, A. C. L. (Eds.). Supported Self-Care: A Manual for Health Professionals. Curitiba: Municipal Health Department, 2012. pp. 09-15.

“Motivation is a state of readiness for change or eagerness to change, which can fluctuate from time to time or from one situation to another. This is also a state that can be influenced.” William R. Miller

According to common sense, people either want to change or they don’t, as if motivation for change were a definitive and immutable state. However, Prochaska and DiClemente (1982) developed a transtheoretical model that describes change as a process experienced through different stages of motivation and readiness. Being a process, it is dynamic, shifting over time and across various circumstances. Therefore, motivation is an internal state of readiness for change and is influenced by external factors.

Health team interventions are more effective when the stage of change in which the person finds themselves is taken into account. Recognizing this stage is important for selecting the most appropriate action strategies—those that facilitate movement from one stage to another or support the maintenance of changes already achieved.

STAGES OF MOTIVATION FOR CHANGE

In 1982, Prochaska and DiClemente described five different motivational stages for behavior change: precontemplation, contemplation, preparation, action, and maintenance. Their characteristics are presented below.

PRECONTEMPLATION

In this stage, the person is not systematically thinking about change and is not ready to change. Their behavior is not seen as a problem or a risk, even when others perceive it as such. Often, the individual seeks healthcare services due to a family member’s insistence or for other reasons.

Regarding the behavior that needs to be modified, the person may appear hostile (unwilling to invest in change or talk about the subject), resigned (having given up on the possibility of change and seeming overwhelmed by the problem), or rationalizing (arguing about personal risks or justifying why the problem is not a problem).

At this stage, the role of the health professional is to explore the person’s views about their current behavior, any concerns regarding the risks they are taking, and any occasional thoughts about the possibility of change. As the individual increases their doubts and concerns about this behavior, the likelihood of progressing to the next stage grows. The goal is for them to consider change more intensely and frequently.

In the change process, the approach used by the healthcare team should be based on Motivational Interviewing, especially at this stage, where attitudes such as trying to convince, persuade, or confront tend to increase resistance and decrease the likelihood that the person will decide to change.

CONTEMPLATION: THINKING ABOUT CHANGE

This is a highly paradoxical stage, characterized mainly by ambivalence. While there is an awareness of the risks and problems stemming from the behavior, there is also a desire to change—but not at this moment. Due to this ambivalence, the person may become a “chronic contemplator,” that is, someone who systematically thinks about the importance of changing but does not take action to make it happen. In this phase, there is openness to the possibility of change, and the individual finds reasons both to change and to justify that now is not the right time.

It is up to the professional to offer relevant information and feedback, make observations, and emphasize the positive aspects of behavior change. The more specific and personal the reasons, the more effective the decision-making process toward adopting healthier behavior. Motivational approaches can help facilitate the transition from contemplation to decision-making, since contemplating does not mean committing.

Techniques such as the decisional balance, which weighs the pros and cons of the problematic behavior and the pros and cons of change, are the most recommended.

PREPARATION: GETTING READY TO CHANGE

In the preparation stage, ambivalence decreases, and both the desire to change and the behavior to achieve it are present. The individual appears ready to commit to action, but this does not mean that all ambivalence has been resolved. The decision-making process continues throughout this stage.

It is advisable for the healthcare team to assess the individual’s strength and levels of commitment. Additionally, it is necessary to develop a specific action plan with collaboratively defined goals. At this stage, it is important to encourage the person to think about potential pitfalls and anticipate problems. Commitment without the necessary skills to cope with everyday challenges and remove barriers can result in a weak action plan.

ACTION: MAKING THE CHANGE

Action is the stage where the person engages in behavior change and takes specific steps to achieve it. This process is often recognized by family and friends. The professional should help the individual direct their change efforts, offer information about various successful models (options), and increase their self-efficacy (a sense of self-worth, adequacy, effectiveness, and competence in dealing with problems). Therefore, it is important to value successful activities and continually reaffirm their decisions.

High self-efficacy is related to greater perseverance and motivation when facing obstacles, which directly influences people’s choices.

In the precontemplation and contemplation stages, the five “R’s” technique guides the healthcare team’s intervention, increasing the likelihood that the person will consider change and progress to the next stages.

THE FIVE “R’s” TECHNIQUE

MAINTENANCE: INTEGRATING THE CHANGE INTO LIFESTYLE

Six months after adopting the new behavior, the person can be considered to be in the maintenance stage. The challenge at this phase is to persist with the new behavior and to avoid or learn how to manage occasional slips or relapses. The skills and strategies required now are different from those used in the preparation and action stages.

The role of the health professional is to help the person consolidate the process, identify and manage slips and relapses, and employ strategies to prevent them. It may be frustrating for the healthcare team to realize that, often, the person stops seeking their assistance because they feel they are making the changes independently. However, it is important to emphasize that this is one of the main goals of the team’s work: to respect the person’s autonomy and to strengthen their self-confidence in dealing with daily life. This will increase their self-efficacy and independence.

SLIPS AND RELAPSES

Slips (lapses) and relapses are expected events when a person seeks to change any long-standing behavior pattern, and are also considered by some authors as one of the stages of change. Slips are characterized by the automatic resumption of the problematic behavior, indicating a failure in self-control, but not leading to a full return to the previous behavior pattern. Relapses, on the other hand, are returns to the initial behavior pattern and most often occur gradually, after an initial slip.

When a slip or relapse occurs, self-efficacy is weakened, and feelings of guilt, failure, or helplessness may gain strength. The person may feel ashamed and give up on persisting with the change process. The healthcare team may also experience similar thoughts and feelings when faced with the person’s slips or relapses. Thoughts such as “we failed,” “we didn’t know how to intervene,” “they don’t really want to change,” or “it’s stronger than they are” may arise and need to be reconsidered. Dialogue among team members allows these thoughts to be questioned and reworked, and the participation of a psychologist at this moment is recommended.

Everyone needs to understand that slips and relapses are part of the process; they are normal and frequent. They are learning opportunities for recognizing problem situations and practicing the development of new, more effective action plans. The role of the team is to help the person who experienced the slip or relapse avoid discouragement and demoralization, as well as to restart movement through the change continuum—contemplating it, renewing their determination, resuming action, and maintaining their efforts.

This restart does not necessarily occur from the first stage, moving sequentially to the second and so on. The process is not linear and may involve multiple progressions or regressions. Someone who was in maintenance and relapsed may restart from the action stage, and after another relapse, may regress to precontemplation. Therefore, until more lasting changes are achieved, the person generally goes through the various stages several times, as if the process were a spiral (Prochaska, DiClemente, and Norcross; 1992).

TERMINATION

When the person has fully integrated the change into their lifestyle, feels very confident in maintaining the process, does not experience frequent slips, and when slips occur, naturally resumes the process, it can be considered that the current behavior is lasting and that the change process has ended. The new behavior becomes the norm, and several other changes are adopted to preserve it. This experience can be used as an example to illustrate the process, celebrate the achievement, and motivate the adoption of other behaviors not yet assumed.

BEHAVIOR CHANGE PROCESS

• Precontemplation / Prethinking: Not ready to change and not thinking about it
• Contemplation / Thinking: Thinking both about changing and maintaining the current behavior
• Preparation / Determination: Preparing to change
• Action: Actively making the change
• Maintenance: Integrating the change into their lifestyle
• Slips and Relapses: Changed but temporarily or permanently returned to the previous behavior

The following table summarizes the main strategies the health team can use to support the change process according to the stages of motivation.