Over the last few months, Return to Work Matters has asked work injury case managers about their training needs, as part of a survey on case management practices in Australia. From a list that includes listening skills, influencing the workplace and assessing biopsychosocial factors, case managers have said that the skill they’re most interested in acquiring is the ability to impact workers’ motivation, with more than 40% of respondents saying that they’d like to learn more. To put this in perspective, that’s twice the level of interest seen for the next-most-wanted topic, learning how to better engage health professionals. (If you'd like to have your say, the survey is still open, here.)

We’re listening! In this article, we introduce an evidence-informed approach to motivation and change, described by psychologists James O. Prochaska, John C. Norcross and Carlo C Diclemente in their book, Changing for Good. According to their approach, commonly known as the readiness to change model, change happens in six discrete stages, with most people spiralling up and down through the six stages before achieving lasting change.

The stages are:

1. Pre-contemplation – aka “I don’t need to change anything!”
2. Contemplation – aka “Life might be better if I made a change.”
3. Preparation – aka “Life would be better if I did things differently, and here’s how I might go about it.”
4. Action – aka, “I’m behaving differently.”
5. Maintenance – aka, “I’m still behaving differently, and/or managing relapses as needed.”
6. Termination – aka, “I’m not even tempted to return to my past behaviour.”

You’ll notice that action – the stage where change occurs – is the fourth stage. It’s natural for helping professionals like case managers to want to encourage people to get straight to the change part of change but according to the model developed by Prochaska and colleagues, this can actually have a detrimental impact on outcomes. In other words, case managers wanting to motivate workers to achieve timely recovery and return to work need first to understand the stage of change the current worker is at and match their approach accordingly. Otherwise, well-intentioned efforts to motivate a worker to make positive changes may backfire.

The stages of change model has been particularly helpful in helping people kick destructive habits like smoking, however it is likely to also have some applicability in the context of injury management and RTW. A study led by Chow Lam at the Illinois Institute of Technology assessed readiness to work from the perspective of the change stages listed above and found that there was a predictable link between stage of change and RTW outcome. People in the pre-contemplation stage had the poorest employment outcome, with 25% moving from a work training program to paid employment over the course of the study. People in the contemplation stage did better, with 38% finding work, while people in the action stage did best, with 56% working by the time the study concluded. The study didn’t look at RTW post-injury specifically (the participants were women receiving welfare payments and may not have been injured at all), but does suggest that the change stages provide information about preparedness to RTW.   

Before we dig into the stages of change as delineated by Prochaska, Norcross and Diclemente, we want first to acknowledge that recovery and RTW are not simply about motivation, nor is the injured worker the only party who has influence over outcomes. Amongst many other factors, injury type and psychosocial factors in the workplace and within compensation systems impact trajectories of recovery and RTW. This article, however, focuses on the important issue of worker motivation, as requested by RTW case managers.

Below, we summarise each of the six stages of change, listing the change processes that are helpful in each stage. Some people will find particular change processes more helpful than others. This is fine – there’s no obligation to use all the change processes. However, working through all the stages of change tends to have better results than jumping ahead to the action stage. Think about your own response when you feel external pressure to do something differently. If you don't already believe a change is required, you might be more likely to dig your heels in than work on changing.

 Change Stage 1: Pre-contemplation, aka denial.

“They’re in the pre-contemplation stage of change,” is a polite way of describing a person who has no motivation to change, possibly because they don’t recognise they have a problem in the first place. This might be a worker who is in denial about the finite nature of workers’ compensation benefits; who isn’t aware of the health risks of long term worklessness; or who doesn’t know that the longer they remain off work, the less likely it becomes that they will ever return.  If we home in on a specific condition, a pre-contemplator with chronic back pain might be someone who believes that it’s the doctor’s job to provide treatment that fixes health problems and the patient’s job to be a passive recipient of that treatment. They might genuinely believe that bed rest will help them get better, and that if they feel pain it’s a sign that the activity they’re engaged in is damaging their spine. It’s never occurred to this person that learning how to manage their own pain could be an empowering and therapeutic move, or that they may be able to return to work and life even in the presence of pain. Denial, misinformation and a complete lack of motivation to change their situation are hallmarks of a person in the pre-contemplation stage of change.

Change processes that are likely to help at this stage include:

• Consciousness-raising, which involves increasing information about the self and the problem at hand. Consciousness-raising can happen via confrontations (e.g. a spouse or child saying, “I think you have a problem,” or a case manager suggesting that there may be a different way to approach the problem), reading, research and observations of other people’s experiences.
• Social liberation, which involves awareness of the existence of social alternatives to the problem behaviour. In relation to an unmotivated worker, this might come via exposure to a proactive, psychosocially-informed injury management program, via policy interventions that encourage positive behaviours, or via advocates who call for reforms to unhelpful aspects of workers’ compensation and injury management arrangements.

Case managers might help people in the pre-contemplation stage of change by:

• Raising awareness of any relevant programs, support groups or approaches that would help the injured worker realise that there are alternatives to their current unhelpful attitudes / behaviours;
• Ensuring that the worker is aware of any relevant consequences of failing to make a change (e.g. reductions to wage replacement payments); and
• Working with employers to improve the organisational approach to injury management.

Change stage 2: Contemplation, aka thinking about change.

In this stage, the person comes to understand that they have a problem that requires their attention, although they may have no idea how to go about making improvements. This might be a worker who is worried about the financial impacts that work injury may have on his or her family; someone who is desperate to move on from recurring episodes of pain and who is becoming aware that this might not happen if they continue with treatment as usual; or a person who has begun to understand that, no matter how angry they are about the injustice they have experienced, life is only going to get better if they take charge. Contemplation involves self-evaluation and self-reflection, as well as gathering factual information about the problem at hand – for instance, researching the health impacts of smoking or seeking advice about the likely prognosis for recovery from chronic pain if treatment focuses on passive options such as opioids and a weekly massage.

In this stage, consciousness-raising and social liberation may still be helpful, but two new change process may also make a difference, namely:

• Emotional arousal, which involves experiencing and expressing emotions regarding the problem at hand. The idea here is that a person who becomes emotionally aware of the consequences of their problem behaviour may feel more motivated to change it. A person taking opioids for non-specific pain might watch a TV program about the opioid epidemic, for instance, and feel upset to learn that more people in Australia die from prescription opioid overdose than from heroin. Or a person who has lost hope in recovery and RTW might read a story about someone who faced a similar situation but came out the other end with a good result. They might begin to question their own unhelpful habits and wonder if recovery is an option for them too. The point is not to wallow in shame or sadness, but to be open to emotional experiences that provide fuel for action later.
• Self-reevaluation, which requires the individual to make a thoughtful and emotional reappraisal of their problem, and an assessment of the kind of person they may be once they have conquered it. There should be a focus on how the problem behaviour conflicts with the individual’s values, leading them to believe and feel that life would be significantly better without the problem. Depending on the values of the injured worker, relevant motivators might be a desire to provide for their family, to be independent, to live a full and active life, or to show others that they won’t be beaten, despite the injustices life throws their way.     

Case managers could help people in the contemplation stage by:

• Sharing stories about relevant success stories and possibly stories with poor outcomes too, although this should be handled sensitively;
• Referring the individual to appropriate psychological or psychosocial services, if it seems that the injured worker could benefit from professional assistance to help them come to terms with their problem; and
• Helping the injured worker access evidence-based, high quality information about the problem at hand, including information about the pros and cons of change.

Change stage 3: Preparation, aka revving the change engines.

At this point, the individual is getting ready to make change within the next month. They might still be doing research, but now the research is more likely to be about ways of changing rather than about the implications of maintaining the status quo. To return to the examples given in the contemplation stage, a worker on long term workers’ compensation benefits might be eager to learn about new approaches to recovery and RTW; a person with recurring back pain might be newly receptive to evidence-based messages about the benefits of self-managing chronic pain conditions, and might change treatment providers in order to get this kind of information; and a smoker might start making plans to quit. Practical planning, including detailing of the steps required to solve the problem, is part of the preparation stage. Self-evaluation still occurs, but now it’s more about imagining a future self who has taken action and overcome the problem than reflecting on the nature of the problem itself.

Emotional arousal and self-reevaluation continue to be important in the preparation stage of change, but now another change process also comes into play, namely:

• Commitment, which involves accepting responsibility for change. Commitment begins with a private, personal choice but tends to work best if there is also some form of public acknowledgement too.

In addition to the suggestions offered in the contemplation stage, case managers may assist people in the preparation stage by:

• Encouraging them to commit to a RTW date, in consultation with their treating professional.
• Reminding workers of commitments they have already made (e.g. to attend relevant appointments), in a supportive and accountable way.

Commitment is central to change and remains an important change process important throughout all the remaining stages.

Change stage 4: Action, aka rolling up your sleeves, getting down and dirty.

Effective action stems from a commitment to change, followed by modifications to a person’s behaviour and environment that allow them to achieve that change in the real world. In this stage of the change process, a worker with chronic back pain might be giving up an opioid prescription and moving to over-the-counter pain medication instead, starting an aerobic exercise and stretching program and / or returning to work. The worker on long term benefits might be engaging with a new rehabilitation provider or seeking psychological treatment for the first time. Support is actively sought, whether it’s via helping relationships (e.g. family members or helping professionals like case managers) or by making changes to the environment that enable personal change.

As well as continuing commitment, action is facilitated by:

• Rewards for desired behaviour, such as self-praise, gifts and accolades from others – noting that rewards are MUCH more effective than punishments:
• Countering, which is the substitution of a healthy response (e.g. exercising when stressed) for an unhealthy response (e.g. drinking when stressed).
• Environment control, which involves restructuring one’s environment to reduce the likelihood of a problem-causing event, for instance signs in an office reminding people to get up and move every hour;
• Helping relationships, i.e. those that offer care, support and other forms of assistance to people attempting to make change.

Case managers wanting to help workers who are actively making change can:

• Offer praise and admiration for progress made;
• Give injured workers the opportunity to talk up their own achievements, for example by writing up a success story for the company newsletter, reminding them that this can really help others in earlier stages of change;
• If possible, brainstorm with the worker, the supervisor and the treating practitioner to identify changes at work and home that might make new, positive behaviours easier to sustain; and
• Connect the worker with champions and helpers, for example others who have made it through a similar RTW journey.

Change stage 5: Maintenance, aka keeping change alive.

In the maintenance stage of change, people focus on preserving their new behaviour and avoiding or promptly dealing with relapses. It’s easy to think that the action stage is the end of the change process, but as most of us know from personal experience, it’s easier to start a new, positive habit than keep at it over time. Most people need multiple attempts before new, preferred behaviours really stick: this is the challenge of the maintenance stage.

The same change process that assist in the action stage are still helpful here in the maintenance stage of change, namely commitment, rewards, countering, environment control and helping relationships.

Change stage 6: Termination, aka a new normal.

Not everyone agrees that terminating undesired habits and behaviours is possible, but Prochaska, Norcross and Diclemente hold that it is possible to change for good – i.e. to stop feeling tempted to return to old, problematic behaviours and have complete confidence that the desired personal transformation has permanently taken hold.

If we consider the patient with chronic pain, who thought that their job was to passively accept treatment, we might now see instead an empowered self-manager, who exercises regularly, understands that pain does not equal damage and behaves accordingly, and knows what actions to take if there is a recurrence of pain. In order to achieve termination, the individual must develop a new self-image, free of the problem behaviour, solid self-efficacy, a healthier lifestyle and not even feel the temptation to return to their old ways. It’s not possible for everyone in every situation, but it’s the ideal endpoint of a change process.