Adapting psychotherapy to the individual patient: Stages of change
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Adapting psychotherapy to the individual patient: Stages of change.

Norcross J.C., Krebs P.M., Prochaska J.O.
Journal of Clinical Psychology: 2011, 67(2), p. 143–154.
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Prochaska and DiClemente's stages of change reliably predict how well psychotherapy patients will do based on their initial stage, but no relevant studies were found on whether matching therapy to the patient's initial stage of change improves outcomes.

Summary The transtheoretical model Often known by its originators' names, Prochaska and DiClemente, or as the cycle of change model. The model conceptualises behaviour change as a process which unfolds over time and involves progression through a series of five stages: precontemplation, contemplation, preparation, action, and maintenance. in general, and the stages of change in particular, have proven useful in adapting or tailoring treatment to the individual. We define the stages and processes of change and then review previous meta-analyses Findings explanation: A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. on their interrelationship. We report an original meta-analysis of 39 studies (Findings: of which it seems 20 concerned substance abuse including alcohol problems) encompassing 8238 psychotherapy patients, to assess the ability of assessments of the patient's stage of change and related readiness measures to predict psychotherapy outcomes.

Clinically significant effect sizes A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. were found for the association between initial stage of change and psychotherapy outcomes, indicating that clients who start treatment at more advanced stages of change reliably tend to make greater progress during treatment. (In particular, this association was found across the relevant 14 studies of addiction outcomes.) We examine potential influences on this relationship including study outcome measures, patient characteristics, treatment features, and diagnosis. For patient characteristics, we found no statistically significant difference in the strength of the stages-of-change/outcomes relationship between adolescent and adult samples or patients of different race/ethnicity. However, this relationship was stronger among samples with higher proportions of women. For treatment features, we found no differences in the strength of the stages-of-change/outcomes relationship between inpatient and outpatient treatment settings, treatments which did or did not follow a manual, and programmes with varying numbers of therapy sessions. However, among studies which made their primary theoretical orientation explicit, the stages-of-change/outcomes relationship was strongest among patients in 12-step programmes as compared to cognitive-behavioural or other orientations.

We also review the large volume of behavioural health research, but scant psychotherapy research, which demonstrates the efficacy of matching treatment to the patient's stage of change. Unfortunately, the aim to assess outcomes from psychotherapy studies which matched treatment to specific stages of change could not be carried out, because no controlled group studies were found which met the review's criteria and matched psychotherapy to the clients' stage or readiness.

Limitations of the extant research are noted, and several practice recommendations are advanced. Probably the most obvious and direct implication is to assess the stage of a client's readiness for change and to tailor treatment accordingly, and in particular to be beware of treating all patients as though they are in the action stage.

Findings logo commentary This article was in a special issue of the Journal of Clinical Psychology devoted to adapting psychotherapy to the individual patient. For other Findings entries from this issue see:
What works for whom: tailoring psychotherapy to the person
Adapting psychotherapy to the individual patient: Preferences
Adapting psychotherapy to the individual patient: Culture
Adapting psychotherapy to the individual patient: Coping style
Adapting psychotherapy to the individual patient: Expectations
Adapting psychotherapy to the individual patient: Attachment style
Adapting psychotherapy to the individual patient: Resistance/reactance level
Adapting psychotherapy to the individual patient: Religion and spirituality

A Findings analysis has specifically analysed the theory and evidence related to whether assessments of the stage of change of addiction patients can be used to improve treatment outcomes.

Last revised 09 March 2011

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