Working with victims of crime: A manual applying research to clinical practice (Second Edition)
5.0 A Model For Client Change: The Stages of Change
Workers often face the problem of how best to 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: precontemplation (no plan to change because they don’t believe they have a problem), contemplation (aware of the problem and 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).
Although little work has been done linking these stages to crime victims, this model may be useful to workers in understanding those requesting services. There is some limited research on female victims of family violence and the process they use to decide whether to remain in the relationship (Cluss et al. 2006; Shurman and Rodriguez 2006). With respect to help-seeking in victims, one study looked at adult survivors of childhood sexual abuse receiving therapy (Koraleski and 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 treatment without being sure if they want to change. Victims may recognize they have a problem resulting from victimization and may seek out therapy to deal with depression or anxiety (action). However, they may refuse to talk about the crime itself, saying that it has nothing to do with the depression (precontemplation). They might then drop out of therapy but still recognize that they needs help (contemplation).
Table 5: The Transtheoretical Model of Change (Prochaska et al. 1992)
These people have no intention of changing. They are often unaware of any problems or deny the extent or severity of the problem. Often, they focus on the negatives of changing and only come in because others have pushed them to seek help.
Workers might meet victims who deny problems or trauma but loved ones describe changes in the victim’s mood, behaviour or overall health. In fact, certain crime victims may deny that there was even a crime (e.g. victims of date rape).
These people are aware of their problem and are seriously considering making a change but are not doing anything to change. They can often spend much time struggling with staying the same versus the amount of effort, energy, and loss it will cost them to overcome the problem.
Workers might have clients who agree they need help but are frozen by shame, fear of telling someone, fear of reactions, or fear that talking about it might make things worse.
People in this stage recognize the problem and plan to do something in a very brief time. In examining habit change, these individuals have often tried to make changes in the past year, but have failed to make lasting changes.
Workers identify this group by noting those who have made some changes on their own and are waiting for an appointment or have tried therapy. This stage is usually very short as the person prepares for change efforts.
People in this stage are actively trying to make changes to improve their situation.
Workers will recognize this as active treatment. Often family and other supports see this as “real” effort and change. Usually this stage is linked to reaching a certain goal. Traditional treatment efforts tends to focus on this stage, ignoring the work the victim must do in deciding to seek help. It also ignores the work that follows treatment in staying healthy.
People in the maintenance stage work to keep the gains made during the action stage. Maintenance is not a static stage, but the process of change.
Workers can help victims by teaching them to talk to supports about stress, watch their own behaviour, thoughts and emotions, and develop skills that might reduce the chances they will be revictimized.
For these reasons, is it important that workers assess where victims are in relation to an issue, and not assume just because they asked for help that they are ready for intensive treatment. In fact, this may overwhelm the victim and cause more distress. If we push too much it may result in victims feeling attacked and increase the likelihood that they will quit and not receive the help they need.
The biggest leap for clients happens as they move from the precontemplation stage to the three stages that follow (Rosen 2000). Further, so-called precontemplators report more distress with treatment, less progress and are more likely to quit treatment early (Smith et al. 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 use resources (both personal and financial) wisely.
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 best to help clients. We train for clients who are in the action stage, 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 precontemplation 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 in the precontemplation 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. Keep in mind that precontemplators often show up in our offices because others have sent them. “Consciousness-raising” activities not only help victims to learn about possible reactions, but these strategies also help them recognize the value of doing something about these negative symptoms or feelings (Prochaska et al. 1994). You must be careful not to pressure the victim and to work with areas of health so that the victim can make a decision that works for him or her (Frasier et al. 2001).
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. Safety planning may be important, depending on the victims’ decisions (Frasier et al. 2001). Keep in mind that most of the change that people undergo happens between precontemplation 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. Making progress and feeling better motivate clients.
These activities may help victims take the big step of deciding they need help, or help them to address particularly painful problems. Further, these interventions can be useful for all clients. Imagine a female 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 keeps going to her therapy group because she doesn’t believe in him. 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! Workers therefore need to understand the victim’s thinking and beliefs about 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 clients have reached their goals, they move into the maintenance stage. In a sense this is what Casarez-Levison (1992) describes as 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 practise those skills effectively. These relapse- prevention strategies will help clients monitor themselves and their world. For example, a man 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 not to 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) notes 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 a client in his or her home life. Victims can also teach their support system about these issues, helping supports understand but also gaining more control and self-efficacy by being able to educate others.
- In trying to change, people cycle through different stages: precontemplation (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 (precontemplation). 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 et al. 1995).
- Most change happens when a person moves from precontemplation 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, etc.). 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 them healthy living skills, educating them about early warning signs of backsliding, and helping them develop self-monitoring skills and other daily activities that are focused on gaining and maintaining control over their life. Allowing time for practising 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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