In 1983, Prochaska et. al published "Stages and Processes of Self-Change of Smoking: Toward an Integrative Model of Change" in the Journal of Consulting and Clinical Psychology, Volume 51, No. 3, 390-395. Although the paper targeted smoking cessation, this change model has been applied and is appropriate in many clinical situations. The ability to manage diabetes is not a static process. There are periods in the lives of those with diabetes in which management may not be the number one priority. These periods may include major life events (both happy and sad) and, particularly in my diabetes practice, changes in growth and development. As children mature from toddlers through school age and finally adolescence, it is clear that both physical and emotional changes result, thus making diabetes care a continued challenge.
Prochaska defined the following stages in the Process of Change:
The above process has been the basis for much of the psychosocial therapy for those that wish to make behavioral change. The key to understanding this table is that to change behavior, one must move from pre-contemplation to contemplation to action and then maintain the behavior. Movement through the steps is a process and maintenance is often difficult with frequent missteps. A practical illustration of the process is in order.
A 14-year-old teen with a 10-year history of type 1 diabetes presents to the diabetes team for the first time after moving from another city. Her hb A1c is 12 and her downloaded meter indicates one blood glucose check per day. Of course the family and diabetes team know that for the young lady to improve her glycemic status she must increase the frequency of testing and administer the appropriate amount of insulin. The parents cannot make the child do these self-care tasks (often we ask the family to assume more responsibility of the child/teen is unable). Our healthcare team becomes involved to try to move the child/teen from one stage to the next.
Teen: "There is no way I am going to check my blood sugar more than once a day."
Healthcare Team: "Why not?"
Teen: "I have more important things to do in my life then to check blood sugars. Besides, I don't want anyone to know I have diabetes."
Healthcare Team: "So, no point to try to explain why you need to check?"
At this juncture, it is probably not going to be a productive conversation to try to convince the teen of the importance of SBGM. The goal is to try to move them to the next stage "contemplation" wherein the teen is beginning to wonder if checking blood sugars might make them feel better and perhaps improve track times or grades in school. The healthcare team may then begin to start work with the teen to move them towards making changes. Once the teen acts to increase SBGM, the key is to maintain that behavior. This is hard and relapse often occurs.