Welcome to the archived web site of
Will Joel Friedman, Ph.D. Psychologist (1950-2013)
California License No. PSY 10092
Specializing in Presence-Centered Therapy
balancing mind and heart, body and spirit

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The Structure of Healthy Change—Prochaska and Küblar-Ross

Compiled by Will Joel Friedman, Ph.D.

Outside the realms of life transformation and therapeutic change processes, there is little appreciation for readiness to change. Yet, this single factor is critical in understanding change and working to produce successful behavior change. In his book Working With Emotional Intelligence (1998, pages 327-328), Daniel Goleman reported that psychologist James Prochaska has proposed levels of readiness that individuals move through in any effective behavior change based on comprehensive research involving more than thirty thousand people. Here is Dr. Prochaska's six stage formulation. Which stage are you in right now? What's the next stage you can move to?

  1. PRE-CONTEMPLATION: This initial stage is one of being completely unready within the next 6 months, often in denial of problems and resistance to any attempt to support the person changing. The individual tends to be uninformed or under-informed of the consequences of their actions as well as overestimating the costs and underestimating the benefits of changing.
  2. CONTEMPLATION: At this stage people are aware there actually is a problem to address and are intending to change in the next 6 months. Here people are quite aware of the costs of change and chronically ambivalent. In this stage people wait to take some action until some right moment, substituting thinking for actions. They are not ready for taking needed actions.
  3. PREPARATION: Here people intend to take actions in the near future, that is, the next month. Typically, they have taken a significant action in the past 12 months. Now they are in preparation for one or more interventions for beginning to tackle their problems. Aware of the problem and ways to solve it, people on just on the verge of developing a plan of action. Sometimes people come to this sensitized stage through a dramatic event that rivets their attention, such as receiving a DUI (that is, driving under the influence of alcohol), having a stroke or heart attack, being terminated from their job, a natural disaster or other personal crisis. This is typically a time for developing a specific, concrete and detailed action plan. These people are ready to use a brief action-oriented treatment program.
  4. ACTION: All the preceding stages have set the groundwork for actual behavior change that now commences. Here there are visible, concrete steps taken in working differently with their emotions, thoughts and behaviors. Recovery from difficulties, resolution of the problem and real behavioral improvement are the best criteria for knowing action is occurring.
  5. MAINTENANCE: Preventing relapse is the main activity during this stage. There is increasing confidence about continuing their positive changes with lessening temptation to relapse. This stage generally lasts from 6 months to approximately 5 years. If relapse does occur, it is often due to not being well-prepared for the prolonged effort necessary to attain maintenance. Preparing to cope successfully with psychological distress and pain without reverting to unhealthy behaviors is a key for being in the maintenance stage.
  6. TERMINATION: At this stage the person experiences a very high level of self-control—100% self-efficacy—and a very low level of urges or thoughts to destructively act out old problems—0% temptation. The individual experiences a genuine confidence that they will not return to the old unhealthy pattern of behavior. Many people never arrive at the sixth stage and continue in long-term maintenance.

George Demont Otis     Marin Farms

Dr. Prochaska found that people typically did not have the inherent motivation or drive to progress from one stage to the next. However he found two major natural occurring forces that could help people's progression: (1) developmental events, such as turning a specific age that triggers a reevaluation; and (2) environmental events, such as the death of a pet. He also mentioned a third option of a planned intervention as being a catalyst for change. (James O. Prochaska, "How Do People Change, and How Can We Change to Help Many More People." In Mark A. Hubble, Barry L. Duncan, et al, eds.), The Heart and Soul of Change: What Works in Therapy (Washington, DC, USA: American Psychological Association, 1999), pages 227-255.)

One strategy in working on your readiness for dealing with change is to carefully allocate your precious resources of time, money, commitment and energy. This would translate into spending almost none of your personal resources in the Oblivious stage, limited resources in the Contemplation stage, moderate resources in the stage of Preparation, and maximum resources in the Action stage. Clearly the first stage is a psychological black hole, while the other three ever more powerfully direct your precious energies into changing.

Scientist, author and educator Elisabeth Kübler-Ross pioneered the five stages of the Grief Cycle-shock/denial, anger, bargaining, depression and acceptance-in her seminal work in the area of death and dying. Many people also add a sixth stage of true hope. While these stages are thought to be universal ones for anyone going through a loss of a close loved one, they also broadly apply to all change processes and losses of all kinds. Different people may go through these stages in a variety of orders and even be in several stages at the same time. Each stage is another way to not face the change that has occurred and to make the change go away, until the person comes to acceptance/true hope.

The first stage of shock and denial is a temporary defense when we first begin to take in new information. In this stage it may be a time of protection while we begin to face and understand the change very slowly. People generally feel a heightened awareness of situations and relationships that will no longer be in their life. In this protective stage we do our best to run away from the change, not face the change, pretend it did not happen or will not occur. While in shock and denial, people typically are not very present in their lives.

When running away, denial and pretending the change did not occur, we may feel quite emotional and get upset. In this second stage of anger people may take their emotions out on themselves (by turning it inward) or others (by turning it outward), all to make the change go away. In other words, at this stage of anger people aim to use their emotions of rage and envy to make the change go away and are often frustrated in resisting the change and wanting to ward off feeling hurt and vulnerable. Any one that stands for or symbolizes life, passion, optimism or energy may become the object of projected jealousy and resentment.

When using our emotions to make the change go away doesn't work, and even makes us feel more out of control and not like ourselves, we may engage in the third stage of bargaining. Bargaining is when we use our brains and powers of reason to make deals or promises to once again make the change go away or at least delay or postpone facing the change. If we feel or think we are somehow responsible for the change, we also may aim to figure a way to make amends, deals, threats, promises and agreements to have things go back to the way they were. Oftentimes we are feeling guilt about the change and think we need to figure out a way to make the change go away, even though we might not be responsible for the change in the first place. Most commonly people engage in a negotiation with a Higher Power for life to continue as it was in exchange for reforming their lifestyle in some fashion.

People enter into the stage of depression when it starts to become clear just how certain the change, such as death, in fact is. When we realize that we are simply not able to make the changes go away, we can feel quite helpless, powerless and hopeless. Some people feel and express sadness and depression when they are really feeling angry and resentful inside. Some may spend lots of time crying and grieving, become silent and beg off seeing friends or visitors. This is a key stage to feel and express through the loss in the form of grieving and it often takes disconnecting form activities and people with their love and affection. We often do not feel like doing what we usually enjoy. Cheering up someone in this stage of depression is usually not advised or helpful. While this may be a difficult stage, it usually comes forward just before more positive stages. It is a timeout for our learning and growing through the loss and realizing that it is not possible to make the change go away and before moving forward again.

When we can no longer fight the change in all the various ways of previous stages, we either accept the change itself or accept that the change will not go away. In this fifth stage of acceptance, we begin to do everyday activities again as well as have a more peaceful, calm feeling, like somehow everything will be okay. People in this stage often want to be left alone and the wild roller coaster of feelings and physical/emotional pain may no longer be present. Some describe this stage as the end of the dying or loss struggle.

A sixth stage of true hope is often mentioned in which we again feel energy and we stop thinking so much about the change that has taken place. We become more active in other areas of our life and can once again tap into the ability to plan and look forward to the future. All these six stages take time, often as much as two to five years to cope with a major change, death or loss. Be kind and patient with yourself.

George Demont Otis     Sunny Meadow 1931

To change means to grieve what you are letting go of as much as you accept the new you are taking on. Sophie Otis, Ph.D. has affirmatively adapted Elisabeth Kübler-Ross's six major stages of change and grieving into four stages in "the healing cycle." She uses this with individuals learning to better manage chronic pain and disease processes. Elizabeth Kübler-Ross contributed developing these six stages to help people face major losses, such as death, and to understand the sequenced steps individuals travel in their coping: (1) shock and denial; (2) anger; (3) bargaining; (4) depression; (5) acceptance; and (6) true hope. Dr. Otis proposed four stages from impact to healing (loss—>healing) that are worth knowing and remembering:

  1. Shock—>Awakening: This stage commences with impact of a change occurring that is characterized by letting the world in, basic aliveness, warmth, sensitivity, exploration, breath and asking for help;
  2. Distress—>Feeling: This stage can be described as gaining compassion for wounded self, receptivity to help from others, intimacy, self-soothing, going deeper into specific emotions, occasions of pleasure and joy in quality of experience;
  3. Disorganization—>Surrender: This stage is one of self-awareness, acknowledging losses, mastery of circumstances, new skills, mental clarity, concentrated thought, willingness to change, resurgence of hope and investigating new realities;
  4. Acceptance—>Forgiveness: The concluding stage is notable for a sense of wholeness, unity and intimacy with others, an expanded vision of self, understanding, knowledge, consciousness, creativity, renewal and recommitment.
© Copyright 2013 by Will Joel Friedman, Ph.D.

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