Social workers are likely familiar with Prochaska & DiClemente's Transtheoretical Model of Change ( also referred to as the Stages of Change Model, 1983) and its various refinements; (e.g. Prochaska et.al., 1992; Prochaska and Velicer, 1997).
The model posits that individuals who successfully made positive behavioural change go through the change in stages - progressing from a stage of denial of the need to change ( pre-contemplation), to awareness (contemplation), preparation, action, and maintenance of the change. An unofficial sixth stage, relapse, is added to acknowledge the possibility of the individuals slipping back into their old behaviour (or earlier stage) until they are finally able to sustain the change and exit the change cycle.
Figure 1. below summarises the 'Stages of Change Model':
The Stages of Change Model views individual change as a process requiring various interventions to move the individual, progressively through the various stages. Change happens over an unspecified length of time, and may go back and forth as the individual loses or gain motivation toward making the change.
Although the model took shape from behavioural studies ( smoking cessation, Prochaska & DiClemente,1983 ) it has been applied across various bio-psycho-socio problems, like domestic violence ( Alexander & Morris, 2008), adolescent depression ( Lewis et.al. 2009), hoarding disorder ( Ayers et.al.), etc.
Over the years, the model has been subjected to numerous criticisms ( - some challenged the assertion that change is sequential across a range of situations, behaviours, and client groups. Others challenged if change really happened in stages, or instead, as a continuous process ( read Littell & Girvin (2002) review of 87 studies of the model).
Yet, the model still remains widely used by social workers for assessing if their clients are ready to change, and for working on developing interventions to help clients move along the change continuum.
Is the Transtheoretical Model Applicable to Muslims?
Personally, while I find the stages of change model useful for my practice, it feels inadequate to apply the model 'as is' when working with my Muslim clients. Prochaska & DiClemente's model seems to emphasise temporal considerations, built on a premise that change happens through a cognitive process of contemplation, reflection, gaining insight, and a determination to change. The practitioner challenges the client's denial of the need to change through carefully crafted questions and gentle confrontations. This humanistic approach focuses on creating cognitive and emotional dissonance to encourage clients to consider and work towards behaviour change.
Muslims, on the other hand, are also concerned with the transcendent aspect of their decision-making and behavioural change - Is change good for me in this life, and the hereafter? Do I exercise my free will in making this change? Or am I going against what has already been predestined for me? Hence, change for Muslims, could be a matter of faith, taking into consideration their relationship with God, and being accountable to the consequences and repercussions of their decision to change.
The Proposed 'Muslim Stages of Change'
Here, I venture to propose an adapted Transtheoretical Model of Change that social work practitioners could adopt when working with Muslim clients. Figure 2. represents the stages of change that a Muslim goes through. In this model, I have incorporated the transcendent element that influences decision-making and behaviour change for the Muslim individual.
I shall proceed to explain the first stage, Inertia, in this article. I shall identify key areas for social workers to consider when making an assessment at this stage, and propose interventions to move the Muslim client(s) (henceforth, 'clients' ) to the next stage. I shall discuss the other stages in my subsequent blog posts.
The First Stage - Inertia
Prochaska described individuals in the Pre-contemplation stage as people who do not see their behaviour as problematic and therefore do not see the need to change. They are either 'uninformed' ( do not see the problem even though others do) or 'underinformed' (see change as unrealistic or impossible, and not worth pursuing) (Prochaska & Norcross, 2002).
In my view, whether clients are uninformed or underinformed about the problem, the denial or resistance to change offers more significance to social workers when working with the clients. I refer to this as a stage of Inertia.
At this stage, clients hold their position of homeostasis, even when they are living in dysfunctionality. Whether they deny having a problem or refuse to acknowledge that the problem is resulting in negative consequences, the stage of Inertia offers clients familiarity to deal with the day-to-day challenges instead of venturing into the unknown realm of change.
Hence, assessing if clients are in the Inertia stage will inform the social worker to formulate interventions towards creating the clients' awareness of the need to change.
Case Example 1
Ms S, a single lady in her late 40s initially refused to seek medical treatment for her bloated abdomen because she believed this to be the work of evil spirits that she had inherited (saka) from her maternal ancestors. She insisted on getting spiritual healers because she felt that was the only way to cure her – despite going through more than five failed healing sessions with different practitioners. Her sixth healing session resulted in elevating the symptoms which allowed her to walk with assistance. This further entrenched her in the belief that her condition has a spiritual origin. However, the relief was only temporary.
Assessment
When assessing this stage, it is important to find out why clients are in Inertia.
Ms S is in the Inertia stage of seeking medical treatment. What could be holding Ms S back? What brings about the state of reluctance to change? For Ms S, could she be concerned if seeking medical treatment would result in hospitalisation and even invasive intervention? Is she worried about the medical costs, the post-surgical outcomes, her recuperation, a possible loss of independence, or perhaps a confirmation of her own fears about her condition?
To assess Inertia, social workers need to establish if clients are denying the existence of the problem, or if they are resisting the efforts to address the problem.
When working with Muslims, social workers may also need to assess the clients' beliefs about the problem in relation to their understanding of predestination, a core pillar of the Islamic faith. Clients may hold the belief that whatever is happening to them is already predestined and that making any efforts to change is going against what God has ordained for them.
While social workers may explain the client's resistance to a lack of insight, family members may view this differently. While insight implies a deep understanding of the problem through reflection and contemplation, family members may view the client as yet-to-receive 'hidayah' (God's guidance) towards realising the problematic behaviour or situation (I shall explain the concept of 'hidayah' in my next post when I discuss the next stage of change - Awareness).
Thus, social workers will need to be mindful of judging family members' seemingly acceptance of the problematic behaviour as apathy or fatalism.
Intervention
Prochaska et.al. (2009) suggest moving individuals from a stage of pre-contemplation to contemplation by discussing:
(i) the benefits of changing,
(ii) encouraging them to look at the effect of the current state and review the consequences of what is happening, and
(ii) pointing out discrepancies between the state they would like to be in and the state they are in now.
I would like to add that when working with Muslims, social workers should also explore the spiritual significance of their views about their current situation. Social workers could ask the following questions:
(i) How does your current behaviour/ situation resonates with your beliefs?
(ii) What spiritual guidance would tell you that change is necessary?
(iii) How would you know that you are getting the guidance to change?
Social workers could craft questions that allow for a better understanding of how the clients view their current circumstances in relation to their beliefs.
And, social workers will need to practice patience to allow clients to experience 'hidayah'.
<I shall continue the discussion in my subsequent posts.>
References / Readings
Alexander, P.C., Morris, E. (2008) Stages of change in batterers and their response to treatment. Violence Vict ; 23(4):476-92. doi: 10.1891/0886-6708.23.4.476. PMID: 18788339.
Ayers, C.R., Pittman, J.O.E., Davidson, E.J., Dozier, M.E., Mayes, T.L., Almklov, E. (2018). Predictors of treatment outcome and attrition in adults with hoarding disorder. J Obsessive Compuls Relat Disord. 2018 Aug 9;23:10.1016/j.jocrd.2019.100465. doi: 10.1016/j.jocrd.2019.100465. PMID: 32670783; PMCID: PMC7362989.
Brug, J., Conner M., Harré N., Kremers, S., McKellar. S., Whitelaw. S. (2004). The Transtheoretical Model and stages of change: a critique: Observations by five Commentators on the paper by Adams, J. and White, M. (2004) Why don't stage-based activity promotion interventions work?, Health Education Research, Volume 20, Issue 2, April 2005, Pages 244–258, https://doi.org/10.1093/her/cyh005
Lewis, C.C., Simons, A.D., Silva, S.G., Rohde P., Small, D.M., Murakami, J.L., High R.R., March, J.S. (2009). The role of readiness to change in response to treatment of adolescent depression. J Consult Clin Psychol. 2009 Jun;77(3):422-8. doi: 10.1037/a0014154. PMID: 19485584; PMCID: PMC2822468.
Littell, J. H., Girvin, H. (2002) Stages of change: A critique. Behavior Modification. 26(2) (pp. 223-273). Sage Publications.
Prochaska, J.O., DiClemente, C.C. (1983). Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol Jun;51(3):390–5. Archived 2011-06-06 at the Wayback Machine
Prochaska, J. O., Johnson, S., & Lee, P. (2009). The Transtheoretical Model of behavior change. In S. A. Shumaker, J. K. Ockene, & K. A. Riekert (Eds.), The handbook of health behavior change (pp. 59–83). Springer Publishing Company.
Prochaska, J. O., & Norcross, J. C. (2002). Stages of Change. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 303–313). Oxford University Press.