Tailor education plans to the stages of change

Pros for change must outnumber cons

By Joan Greathouse, MEd


Joan Greathouse Consulting Co.


Do you floss every day? Most of us know we should, but we don’t. Why? Because information alone isn’t enough to motivate us to change. The same principle applies to your patients and clients when you try to help them.

In our work as patient educators, we are often charged with helping people change their behavior to improve their health. Why is change so difficult? Why don’t patients just do what’s best for them?

Think about your own experience trying to lose weight, quit smoking, or exercise regularly. Even when you know you should do these things, even when you want to do these things, old habits are hard to break and new habits are difficult to establish and maintain over time.

Ambivalence plays a major role. For example, I first began thinking about starting a regular exercise program 20 years ago. Although I’ve steadily increased the amount of exercise I get since then, only in the past six months has regular exercise become an established part of my life! I’ve been on a seesaw between the pros and the cons of exercising. Finally, the balance has shifted to the pros. I’ve overcome my ambivalence.

Until recently, the cons of regular exercise had a powerful grip. Excuses were easy to make, including:

• It takes up too much time.

• I hate to add one more thing to my busy schedule.

• I’d rather read or make pottery.

• I hate to sweat.

• My hair gets limp.

Finally, I developed an exercise program I really enjoy and do regularly — walking briskly outdoors alone or with a friend. Because I’m a consultant working alone in my home office much of the time, an exercise break in the afternoon is very appealing. Walking invigorates me, and I often get great ideas on the project I’m working on as I walk. Instead of making a lunch date with colleagues, I often invite them to walk with me around Green Lake or through Discovery Park. My husband and I take hikes together most weekends. Now, exercise is an integral part of my life because:

• I feel better physically.

• I am sharper and more creative.

• I am more relaxed.

• I look better.

• Walking gives me a good work break.

• It’s a pleasant way to spend time with people.

• I love being outside and looking at the water, trees, and gardens.

• I can exercise on my own schedule.

Tipping the balance toward the pros

Think of a behavior you are trying to develop. It can be a health-related behavior or anything else you want to change. List the pros and cons. Where are you on the seesaw of ambivalence? What might tip the balance toward the pros? What will motivate you to make the change? How can you give yourself lots of rewards and support?

What can we learn from our own experiences to help us be more effective in our work?

All change is self-change. We can’t make our patients, clients, or anyone else change.

Change is hard work. The challenge is giving up immediate pleasure for potential future gain, not an easy task.

In order to change, people need to overcome their ambivalence; the pros of changing need to be stronger than the cons.

Prochaska’s Stages of Change theory says that change is a process that happens over time.1 So the first step in helping motivate others to change is to understand where they are in the change process and use techniques to help move them one small step along the route.

The chart accompanying this article depicts a simplified way to understand Prochaska’s stages and some techniques to motivate change. (See chart, above right.) You can use this chart as a starting place to develop effective programs by designing specific strategies to motivate people at each stage of readiness to change. Many health education programs only reach people in the action stage. In fact, only about 20% of your target audience is in the action stage at a given time. So the program never has a chance to affect people in the pre-contemplation, contemplation, or preparation stages.

Even if you only have a few minutes with a patient, take advantage of every teachable moment. One to two targeted sentences can have a significant impact, and patients appreciate your interest, advice, and encouragement.

Stages of Change
Pre-contemplation: Not even thinking about change
Contemplation: Starting to think about a change
Preparation: Planning for change, thinking of ways to change
Action: Actually making the change
Maintenance: Continuing new behaviors, recovering from relapse
Ways to Motivate Change
Increase awareness of problem behavior; provide information
Decrease ambivalence by identifying pros and cons of change; give support
Resolve ambivalence; identify rewards; make action plans
Set short-term goals; give support; help solve problems as they arise
Continue support; help solve problems; help recover from lapses


1. Prochaska J, Norcross J, DiClemente C. Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York: Avon Books; 1994.

Related Reading

Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press; 1991.

For more information about creating programs that target each patient’s stage of change or to schedule a workshop on motivating behavior change, contact:

Joan Greathouse, MEd, President, Joan Greathouse Consulting Co., 3853 Williams Ave. W., Seattle, WA 98199-1540. Telephone: (206) 284-3996. Fax: (206) 284-6362. E-mail: Joan@JoanGreathouse.com.