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6.0 A Model for Client Change: The Stages of Change

6.1 How the Stages Work

6.2 Adjusting Your Approach To Fit The Client

6.3 The Basics

Working with Victims of Crime: A Manual Applying Research to Clinical Practice

6.0 A Model for Client Change: The Stages of Change

Workers often face the problem of how to best help clients cope with trauma. Crime victims can be a particular challenge because of the depth of their issues and the fact that, like many clients, progress is often accompanied by periods of no movement and backsliding. Prochaska et al. (1992) developed a model to try to understand how people change, both in treatment and on their own; they called it the Transtheoretical Model of Change (TMC). They found that people cycle through different stages: pre-contemplation (no plan to change because they don’t believe they have a problem), contemplation (aware of the problem and are seriously considering change), preparation (intend to do something soon), action (actively trying to make change) and maintenance (keeping the gains). Although people speak of stages, workers need to understand that a person can exist at all stages at the same time, and shift depending on the specific issue being discussed (Prochaska et al., 1992).

6.1 How the Stages Work

Although very little work has been done linking these stages to crime victims, this model may be useful to workers in understanding those requesting services. One study looked at adult survivors of childhood sexual abuse receiving therapy (Koraleski & Larson, 1997). Out of 83 people in therapy they identified 38 (45.8%) as mostly being in the contemplation stage, 7 (8.4%) as in the preparation stage and 26 (31.3%) as in the action stage. This is often the case - people will enter therapy without being sure if they want to change. A victim may recognize she has a problem resulting from victimization and may seek out therapy to deal with depression or anxiety (action). However, she may refuse to talk about the crime itself, saying that it has nothing to do with the depression (pre-contemplation). She might then drop out of therapy but still recognize that she needs help (contemplation).

For these reasons, is it important that workers assess where the victim is on an issue, and not assume that just because she asked for help that she is ready for intensive treatment. In fact, this may overwhelm the victim and cause more distress. If we push her too much then it may result in the victim feeling attacked and increases the likelihood that she will quit and not receive the help she needs.

The biggest leap for clients happens as they move from the pre-contemplation stage to the following three stages (Rosen, 2000). Further, so-called precontemplators report more distress with treatment, less progress and are more likely to quit treatment early (Smith, Subich & Kalodner, 1995). Workers need to be aware of this group because they inappropriately sit on waiting lists, miss appointments and do not take full advantage of therapy. This is not surprising, given that they are not ready to deal with their problems. Thus it is important to motivate all clients to get the most out of therapy and wisely use resources (both personal and funding).

6.2 Adjusting Your Approach To Fit The Client

How you work with clients is quite individual. It depends on your goals, your training and your own personal style. However, the TMC model has some suggestions regarding how to best help clients. Clients in the action stage are the clients for whom we train. They are ready to make changes, they tend to be motivated and ready to work on their issues. Most workers would want a caseload filled with this group! However, as noted above, not all people who come to your office will be this motivated.

Those people primarily in the pre-contemplation and contemplation stages can also benefit from interventions, but these may be different from what workers normally think about as treatment. Workers can offer those primarily in the pre-contemplation stage reading material such as brochures about common reactions or self-help books. The worker can also spend time with this group to teach them about victimization/trauma and so on. These clients may not recognize that their symptoms are related to the crime or even that they have changed. Recall, often precontemplators show up in our offices because others have sent them. Not only do these “consciousness-raising” activities help victims to learn about possible reactions, but these strategies also help victims link to the value of doing something about these negative symptoms or feelings (Prochaska et al., 1994).

Rosen (2000) noted that precontemplators and contemplators can be motivated to seek help by gathering information (consciousness raising), looking at the effects on themselves (self re-evaluation) and others (environmental re-evaluation), experiencing and expressing emotions (dramatic relief), and monitoring changing social norms (social liberation). Workers can help those in these two stages by helping them to look at the costs of staying the way they are and the benefits of getting help. Recall, most of the change that people undergo happens between pre-contemplation and contemplation (Rosen, 2000). However, any efforts towards helping victims to build and keep motivation can be key in helping them to get the full benefit of treatment. Progress and feeling better motivates clients.

These activities may help the victim take the big step of deciding she needs help or it may help her to address particularly painful problems. Further, these interventions can be useful for all clients. Imagine the victim of family violence who is feeling better and whose husband is treating her well (“honeymoon phase”) and promises never to hurt her again. He puts pressure on her saying that she doesn’t believe in him and that’s why she keeps going to group. This victim will need support because she now has to work to believe that there are benefits to staying in therapy---her problem has been solved! Therefore, workers need to understand the victim’s thinking and beliefs related to what makes up “improvement”. Workers can help her explore the cycle of abuse, the possibility of “honeymoon” periods and the long-term benefits of treatment so that she can make the best decision for herself. In a sense, this is allowing your client to have as much information as possible to make a good decision about what she needs to do to improve her life.

Once your client has reached her goals, she moves into the maintenance stage. In a sense this is what Casarez-Levison (1992) talked about when she described the Reorganization/Resolution stage of dealing with victimization. Workers can help victims prepare for this stage by teaching them about healthy living skills. Victims need to learn to watch for warning signs that they are backsliding. Also, workers need to spend some time during treatment teaching their clients specific skills and strategies that allow them to practice those skills effectively. These relapse prevention strategies will help the client monitor himself and his world. For example, the victim who was assaulted in an underground parking garage is forewarned that this may be a challenging place for him. If he decides to park in an underground garage, he can prepare for increased distress or related symptoms. By teaching him skills, the worker helps him to not avoid these situations but, rather, to gain control over his thoughts and feelings so that he can have confidence when facing challenging situations (self-efficacy).

Truly challenging cases are best left to trained clinicians; however, all workers benefit from understanding that change is a process and that the victim is not intentionally trying to be difficult. The TMC basically challenges old concepts of “resistance” by focusing on shifting our clinical approach (Prochaska et al., 1992). Seeking help can be difficult when you feel you are delicately balanced. Mitchell (1993) noted that many clients (not just victims) come into therapy hoping to get help but fearing that the change will be too painful or change their life too much.

One final note, all of these techniques can be used to motivate and teach the victim’s natural support system (family and friends). Thus, a brochure about common reactions to crime victimization left on a coffee table can help the client in his home life. The victim can also teach his support system about these issues, helping his supports understand but also allowing him to gain more control and self-efficacy by being able to educate others.

6.3 The Basics

In trying to change, people cycle through different stages: pre-contemplation (no plan to change because they don’t believe they have a problem), contemplation (aware of the problem and are seriously considering change), preparation (intend to do something soon), action (actively trying to make change) and maintenance (keeping the gains) (Prochaska et al., 1992).

People may be mostly in one stage, but can be in all stages at the same time (Prochaska et al., 1992). For example, a victim may recognize she has a problem resulting from victimization and may seek out therapy to deal with depression or anxiety (action). However, she may refuse to talk about the crime itself, saying that it has nothing to do with the depression (pre-contemplation). She might then drop out of therapy but still recognize that she needs help (contemplation).

People who feel they don’t have a problem (precontemplators) report more distress with treatment, less progress and are more likely to quit treatment early (Smith, Subich & Kalodner, 1995).

Most change happens when the person moves from pre-contemplation into the other three stages (Rosen, 2000).

Workers can decrease their own frustration and improve the effectiveness for victims by assessing where people are in these stages and selecting appropriate interventions.

Precontemplators should be given “consciousness-raising” activities (reading, self-help books, attending information sessions). These efforts help the victim learn about possible reactions and the benefits of getting help (Prochaska et al., 1994).

Other activities that can help motivate victims include: looking at the effects on themselves and others, experiencing and expressing emotions, and paying attention to changing social norms regarding victimization and getting help (Rosen, 2000).

Workers can help victims prepare for leaving active treatment by: teaching healthy living skills, educating about early warning signs of backsliding, developing self-monitoring skills and other daily activities that are focused on gaining and maintaining control over his life. Allowing time for practicing and mastering these skills is time well spent in treatment.

Victims can also benefit by workers developing ways to help educate the victim’s natural supports (family, friends, etc.).

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