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Studies of patient adherence to health behavior programs, such as physical exercise, smoking cessation, and diet, have resulted in the formulation and validation of the Transtheoretical Model (TTM) of behavior change. Although widely accepted as a guide for the development of health behavior interventions, this model has not been applied to vocal rehabilitation. Because resolution of vocal difficulties frequently depends on a patient’s ability to make changes in vocal and health behaviors, the TTM may be a useful way to conceptualize voice behavior change processes, including the patient’s readiness for change. The purpose of this paper is to apply the TTM to the voice therapy process to: (1) provide an organizing framework for understanding of behavior change in voice therapy, (2) explain how treatment adherence problems can arise, and (3) provide broad strategies to improve treatment adherence. Given the significant role of treatment adherence in treatment outcome, considering readiness for behavior change should be taken into account when planning treatment. Principles of health behavior change can aid speech pathologists in such understanding and estimating readiness for voice therapy.
Why do some voice patients diligently practice their daily voice exercises, whereas others return only to provide reasons for not doing so? Why do some overcome struggles in changing vocal health behaviors, whereas others give up at the first sign of difficulty? The relationship between learning how to rehabilitate one’s voice, and taking action to do so, appears neither transparent nor direct. As voice therapy is a behavioral intervention that primarily aims to resolve the behavioral component of a voice disorder, it depends inherently on active patient involvement. Any behavioral approach can only be as effective as a patient’s adherence to it. Moreover, there is evidence suggesting that for some voice disorders, patient adherence to treatment, rather than any specific treatment approach, determines outcome, or is suspected to play a substantial role.1–5
Although factors underlying treatment adherence have not been investigated in voice research, they have received considerable attention in other areas of health behavior research. Study of treatment adherence has led to the development of various conceptualizations of health behavior change, including the Transtheoretical Model (TTM),6,7 the Theory of Reasoned Action,8,9 the Health Belief Model,10–12 and health applications of Social Cognitive Theory.13 This current knowledge of intentional health behavior change can inform our understanding of behavior change in voice therapy and therefore our understanding of voice therapy adherence. Given its clinically operational constructs, the TTM appears particularly well suited to the voice clinic, and may explain some of the adherence and behavior challenges we observe in our voice patients.
The purpose of this paper is to apply the TTM to the voice therapy process to: (1) provide an organizing framework for understanding of behavior change in voice therapy, (2) explain how treatment adherence problems can arise, and (3) provide strategies to informally assess patient readiness and facilitate behavior change. Core constructs of the TTM will be discussed first, including stages of change, decisional balance, processes of change, and self-efficacy. Next, treatment adherence problems will be discussed from a TTM perspective of strategy-to-stage mismatch, unresolved ambivalence, and poor self-efficacy. Last, the role of assessing stages, importance, and confidence in clinical voice practice are discussed. Examples and quotations are derived from the authors’ clinical experience.
The TTM has become one of the most widely accepted model of health behavior change.14 The model was developed inductively, through study of the change strategies used by individuals who independently quit tobacco use. Initially describing only smoking cessation, further studies have shaped the model to represent how individuals succeed or fail in changing various health behaviors, including quitting addictive behaviors and initiating new health regimens. For instance, the TTM has been extensively applied across a variety of health behaviors including physical exercise, nutrition and diet, and HIV prevention.14–22
One of the primary contributions of the TTM is the finding that successful self-changers draw upon strategies across psychotherapeutic approaches to achieve their goals.20,23–29 The TTM does not recommend any particular approach, but rather, provides a “Transtheoretical” organizing framework for understanding and facilitating the process of health behavior change.
At this time, the TTM provides the foundation for health intervention programs and research guided by the Centers for Disease Control & Prevention, including the study of HIV prevention,30 and cancer prevention (www.cancer.gov) and is applied internationally.31,32
The TTM postulates that behavior change is accomplished through a series of stages, rather than a single or sudden event. These five stages of change are precontemplation, contemplation, action, preparation, and maintenance. Time spent in each stage can vary, and “recycling” through a prior stage can occur. The first three stages describe the development of intention to take action, whereas the last two stages describe the process of fully actualizing the intent to change. Thus the initial stages concern introspective cognitions about change, whereas the latter stages are characterized by observable behavior change.6,22 Different experiences and self-regulatory strategies (termed “processes of change”) aid the individual in moving from one stage to the next.33 Self-efficacy influences the entire course of changing.
In the stage of precontemplation, individuals are not seriously considering behavioral change. Two distinct groups of precontemplators exist: those who are not aware that behavior change is possible or beneficial and those who are aware but choose not to pursue it. In the voice clinic, examples of the former group may include individuals with hyper-functional voice disorders who, on initial examination, are not aware of the behavioral component of their dysphonia. When these individuals, after examination and education, do not accept the diagnosis of a functional component or etiology, they remain in this unaware type of precontemplation. The latter (aware) group consists of individuals who, for a variety of reasons, are not interested in changing vocal- or voice-related behaviors. Some examples include patients who are “happy as long as it isn’t cancer”; have other more pressing priorities than vocal (re)habilitation, and those who are retaining their dysphonia for financial or psychosocial reward.
When speaking with a precontemplative patient, strong antichange statements may be observed, such as “Smoking is my best friend,” “I’ve talked this way all my life: that can’t be the cause,” or “My husband makes me yell!” Such antichange statements suggest these patients are not yet considering change, and thus residing in the stage of precontemplation.
In this stage, individuals actively consider making a change in behavior, weighing the advantages and disadvantages, or “pros and cons” of changing. Ambivalence, defined as feeling two ways about change, is the primary characteristic of contemplation.34 This ambivalence must be resolved before any action-oriented therapy can successfully commence.
Ambivalent patients voice opinions both for and against change, such as “I love going to the bar with my friends even though it really makes my throat hurt. I do miss singing.” For those who enroll in voice therapy at the urging of the voice team, as distinct from their own desire to enroll, ambivalence during sessions and poor adherence outside of therapy are likely (“I tried to do my homework but my in-laws were in from out of town”). Other signs of contemplation include the need for repeated discussion of possible causes of the problem rather than the solution (“Do you think this all started when the horse bit my ear?”35), continued requests for evidence supporting the efficacy of voice therapy when this information has already been provided, and requests to explain voice exercises/mechanics when this material has been covered repeatedly. Prochaska et al speculate that a subgroup of contemplators may hope that, while contemplating, the problem will resolve without further action, or that contemplation will provide a solution that does not necessitate action.34
As patients become more resolved about pursuing change, and less ambivalent, they enter the stage of preparation. In preparation, the commitment to change is made. Verbal commitment statements (eg, “I want to work on this” or “I have to do this now”; “I’m really excited about learning better technique”) are indicative of the preparation stage. According to the TTM, collaborative goal setting for a treatment plan is now possible, because the patient is ready to take action. Small steps toward change can also be initiated: patients may wish to clear their schedule of vocally demanding activities, identify practice times, or purchase an amplifier.
In this stage, patients are actively engaged in modifying their voice-related behavior. The voice patient in action uses therapy sessions to discuss accomplishments and difficulties of adopting new behaviors and to review relevant voice exercises and techniques. With mastery experiences in and outside the clinic, a patient’s skill and confidence grows (“I noticed my throat getting tense so I started to talk softer. And that’s when people started listening to me.”), but the possibility for failure also exists, putting the patient at risk for recycling to a previous stage of change: “I’m working on staying in my resonant voice but it’s just so hard to do.”
Maintenance is defined as integration of the newly developed behavior. In voice therapy, patients enter this stage when they are effectively and independently maintaining healthy voice use and vocal health-related behaviors on an ongoing basis. This typically signals the end of regular voice therapy sessions. The patient may state that “I think I’m done with therapy,” “I know what to do when I lose my tone-focus,” or “I don’t have to think about it that much anymore.”
Part of successful maintenance is mastering the ability to return to healthy voice use in case of relapse/recycling. Therefore, as the patient moves into the maintenance stage, discussion of relapse prevention is important.18,21,36
In the TTM, the process of resolving ambivalence in contemplation is referred to as decisional balance. A significant increase in the perceived pros of change as compared with the perceived cons of change is seen in patients who resolve ambivalence and commit to action.37,38 This shift comes about if the patient finds that the behavior change is vital to an important goal in his or her life. For instance, a patient who sings in church may resolve her ambivalence when realizing that singing is a vital part of worship for her, and that worship is fundamental to her values.
The TTM identifies 10 self-regulation strategies that successful self-changers use to move from stage to stage.7,39 These function as independent variables between the dependent variables of stages.40,41 TTM proposes that these “processes of change” can be elicited or applied in therapeutic interventions. Table 1 describes each process of change and provides voice-related examples. The strategies should be considered broad categories of therapeutic interventions, rather than specific techniques. For example, the process of “consciousness raising” is a broad strategy that can be accomplished through very different techniques from oppositional schools of psychotherapy or counseling.
Although any process can be used at any stage, it has been found that “experiential processes” typically help develop the intent to change, thus increasing readiness for action in the preaction stages (precontemplation, contemplation, and preparation), whereas “behavioral processes” support change in the action and maintenance stages. Experiential processes raise awareness of the importance of change in the individual’s life and help resolve ambivalence about change. Behavioral processes are practical strategies that help reinforce outward behavior change.
It is relevant to note that different psychotherapeutic approaches tend to focus on a subset of processes of change. For instance, Gestalt therapy engages experiential processes to develop awareness and resolve ambivalence, but does not address outward behavior change.42 Conversely, behavior modification43 addresses reinforcement of outward behavior, but omits the cognitive/experiential component. Each psychotherapeutic technique appears to focus on a part of the change continuum, but not on all components, and therefore does not necessarily provide tools to progress through the entire path of change.34
In addition to the 10 processes of change, the construct of self-efficacy is a variable that affects the progressive movement from stage to stage. Self-efficacy refers to an individual’s confidence in his or her ability to accomplish a specific task in a specific situation,44 or their task-specific confidence. Introduced by Bandura as a core component of the Social Cognitive Theory of human behavior,44 self-efficacy has been incorporated into the TTM. Self-efficacy has shown to be a strong predictor of successful outcome in both health behavior change28,45–47 and academic learning.48–51 Self-efficacy determines which goals people choose to consider, how long they will persist in the face of failure experiences, the outcome they expect from their efforts, and the effort they invest.44,52
It has been postulated that an adequate level of self-efficacy must be present for a patient to first consider making changes in health behaviors and subsequently an even higher level is needed for an individual to take action.27 In the voice clinic, patients commonly express a lack of confidence in their abilities, eg, “I’ve talked like this all my life- I’ll never be able to change my voice,” or “I’ve tried before and I’m just too tense to quit cigarettes.” These statements reflect poor self-efficacy for the task at hand. Such beliefs may stop a patient from taking action, and lead to recycling/relapse in a patient who is in the action stage. Therefore, self-efficacy beliefs in voice patients may need to be supported to encourage successful attainment of the behavior change goals.
It is reasonable to assume that self-efficacy for vocal tasks can be developed. In contrast to stable personality traits associated with voice disorders,53–55 self-efficacy beliefs are changeable.56,57 Thus, positive self-efficacy beliefs should support the pursuit of goals in voice therapy, even in individuals whose (unchangeable) personality traits constitute a risk factor for vocal deterioration. For instance, the neurotic extraversion identified in many patients with vocal hyperfunction54 is a stable personality trait. However, active listening skills that can reduce vocal misuse in conversations can be learned regardless of this trait. Social Cognitive Theory proposes and has accrued evidence for four sources of self-efficacy beliefs. In order of importance these include: mastery experience, vicarious experience, verbal persuasion, and emotional-physiological state.58
Mastery experience, defined as the successful accomplishment of a task, provides strong positive self-efficacy beliefs. Failure to master a task has a discouraging effect. Therefore, it is important to structure therapy tasks that are likely to lead to success.
Vicarious experience (ie, learning by observing others) is the second strongest source of self-efficacy. An observer’s self-efficacy is increased when a social model successfully achieves a desired goal, if the observer perceives this model’s inherent abilities as comparable with his or her own. Thus, for a model’s success to have a positive effect on an observer’s self-efficacy, the observer must identify with the model. If the model is perceived as less capable than the observer, and yet succeeds, the observer’s self-efficacy also increases (“If they can do it, I can do it.”). Conversely, self-efficacy is lowered if the observer perceives the model’s abilities to be higher than his/her own potential. The latter experience suggests that the skill to succeed is out of reach.
In the voice therapy session, the voice clinician serves as the social model for vicarious learning. Although the clinician’s skill in producing the target voice is a useful model for motor learning, the clinician’s high skill level may suggest that only vocally talented individuals can improve voice production mechanics. As such, the voice clinician may not be an optimal source of self-efficacy. The importance of group therapy in providing comparable social models should not be underestimated.
The third source of self-efficacy is verbal persuasion, defined as verbal encouragement from others. Bandura44 proposes that the salience of such verbal support is weaker than that of mastery experiences and vicarious learning because verbal support (“You can do it!” or “I know it’s hard right now, but I think you can succeed”) can be discredited by failure experiences or seeing others fail. However, recent investigation suggests that there may be a gender difference in the salience of verbal persuasion compared with vicarious learning: women may derive more self-efficacy from verbal persuasion than from vicarious learning, while this may be reversed for men.59
Negative verbal persuasion is thought to carry substantial weight, resulting in self-limiting beliefs. In the voice clinic, spousal statements such as “You’ll never rest your voice- you just can’t shut up” most likely have a substantial negative effect on setting and attaining voice goals.
Physiological and emotional states also provide self-efficacy information. Feeling physically or emotionally uncomfortable (as may be the case when habituating to a different voice quality) is thought to decrease self-efficacy.
When a treatment intervention is applied that is not appropriate to the patient’s given stage of change, we speak of a “strategy-to-stage mismatch.”64 Traditional health behavior change programs may fail because they are designed only for patients who are ready to take action, whereas most patients do not present to a clinic in this stage.39,61
Individuals can consult the voice clinic at varying levels of readiness to change, and may exhibit different degrees of readiness for each individual treatment goal (eg, dietary changes, phonotrauma reduction, and daily voice exercise practice). Mismatch can occur when a clinician recommends a change process that aids the action stage (eg, a counter-conditioning strategy such as finding the quieter room for conversation at a noisy party) while the patient resides in the contemplation stage as to whether to take action. Thus, the patient is ambivalent (or perhaps entirely disinterested) in pursuing change, whereas the clinician recommends action. The patient is then unlikely to follow the clinician’s action-oriented recommendation. Moreover, a verbal dispute with the clinician may occur, in which the patient asserts his or her anti-change standpoint. This phenomenon has been described as “patient resistance” and can be expected when action-oriented advice is provided before the patient’s ambivalence about taking action is resolved.65 As medical professionals are traditionally trained to advise and persuade, encountering patient resistance is not unusual.21
Mismatch can be avoided by identifying stage of change and then drawing on appropriate processes of change to guide intervention as illustrated in Figure 1. Resistance can be avoided (or diffused) by using a client-centered (rather than confrontational) communication style21,22,66,67 that includes active listening techniques. Examples of client-centered, stage-based statements are provided in Table 2. Motivational Interviewing, a communication approach particularly useful for working with patients in preaction stages,66,67 is one approach that holds promise for application in the voice clinic.68
Self-efficacy plays a role throughout the stages of change and requires consideration to avoid resistance and adherence failure. For example, poor patient compliance and continuing pathology on laryngeal exam may prompt the clinician to “lecture” the patient on the importance of behavior change. In this case, the clinician assumes that change has not been sufficiently important to the patient, whereas lack of change may be may be due to poor self-efficacy. If poor self-efficacy underlies poor compliance, a different treatment strategy (ie, increasing self-efficacy) is warranted than if low importance is present. Reframing of past failure experiences and restructuring of the treatment plan may be necessary to counteract self-defeating beliefs.
Although traditional health behavior programs typically end when the action stage is completed, long-term treatment adherence may require continued follow-up support.69,70 Likewise, voice patients may require follow-up voice therapy appointments. As a side note, it is not known how long maintenance-supporting processes of change such as self-reward and social support are needed to maintain a new behavior. For each individual, certain behaviors may never become fully “automatic” or integrated, and always require some conscious implementation.
As patient needs and therapeutic strategies vary by stage, so does the role of the clinician. In the preaction stages, the clinician in the motivational interviewing approach is perceived as a client-centered counselor who directs the conversation about change, but does not attempt to control the decision to pursue change.66–68 As the patient begins to take action, the clinician’s role becomes that of a “coach,” and as greater independence is reached, that of a “consultant.”70
Exploring and supporting patients’ readiness for change can, but does not, fundamentally require a modification in session length or treatment duration. Rather, the key modification consists of a shift in the clinical interacting style. For instance, where previously a clinician might have spent time persuading the patient to take action, the clinician could alternatively use this time to help the patient weigh the pros and cons of change. As a patient’s readiness level may vary by goal, clinician style might vary by goal as well, ranging from a very client-centered discussion (“Tell me a little bit about what singing means to you”) to a more directive coaching style (“Here’s what you can do to improve”) as shown in Table 3.
The TTM has received a considerable amount of criticism in the past 10 years.71,72 Criticism of the TTM is primarily, but not exclusively, focused on the stage construct as empirical entity. Use of the term “stage” is disputed73 as it suggests a strict linear progression, whereas in actuality, relapse into previous stages can occur. Also, the categorical nature of change stages has been called into question: it is thought that their existence may comprise an arbitrary artifact caused by measurement methodology.74 In the clinical setting, clinician interaction style may influence the patient’s perceived readiness level as in the case of eliciting resistance, resulting in inaccurate assessment of stage. From a voice patient’s perspective, multiple motivations may play a role in his or her readiness to take action regarding the voice problem, and this balance may change when the patient is contemplating the issue further after the clinic visit. Therefore, it may be more useful to view stages as cognitive benchmarks for the clinician66,67,75 than as conceptual realities present in the patient. Such benchmarks can inform clinician choice of interaction style and therapeutic strategies, taking into account the fluidity of the perceived and actual stage.
Another general limitation of a model such as the TTM is that while providing categories of experiences that may move someone forward, it cannot suggest exact experiences that do so with certainty. For example, for one voice patient, a near brush diagnosis of cancer can result in commitment to quit smoking, whereas for another, this experience has no such effect. In addition, the very assumption of stage-matching may be violated and still result in a positive outcome. Although empirical study of matched versus deliberately mismatched treatment showed improved outcomes for the matched treatment group,64 other studies have shown mixed results in effectiveness.19 In the voice clinic, a patient who is ambivalent about voice therapy may be provided with “trial voice exercises” for 1 week, receive benefit from these exercises, and return with high commitment to change. In this case, “action” was taken before ambivalence was resolved. Similarly, a directive clinical style may elicit resistance in some, but not all, preaction patients. Thus, clinical decision making regarding therapeutic approach and style remains directed by clinical judgment.
Lastly, the TTM is based on behaviors that are similar to, but not exactly like, vocal (re)habilitation. For instance, barriers to physical exercise adherence and barriers to completing voice exercises are likely to differ substantially. Other issues unique to vocal development, such as kinesthetic ability and voice-related self-awareness, may influence self-efficacy in unique ways. Validation of TTM constructs in the voice clinic would fill in the voice-specific details not outlined by the general TTM framework. Identifying the most common barriers to our patients’ vocal improvement could be useful in developing ways to avoid or manage these.
Alternative to the categorical stage-based model is the conceptualization of readiness to change as a combination of importance and confidence.66,67 Together, the perceived importance of change and self-efficacy (confidence) for change add up to an individual’s total readiness or commitment to take action as illustrated in Figure 2. When either (or both) of these is low, readiness for action will be reduced, but readiness increases as either (or both) increases. At any time, we can consider patients as belonging grossly to one of four categories of readiness66 as shown in Figure 3. Patients who rate themselves high in both perceived importance and confidence are likely to be ready to take actions. Those who rate importance as low but report high confidence for hypothetical change (eg, “I think I could do it, if I put my mind to it”) are unlikely to take action unless a change can be elicited in the perceived importance. Those who value the importance of change but are not confident in their abilities, require support in confidence through the sources of self-efficacy. Patients low in both importance and confidence place low value on changing and are not confident they would achieve hypothetical change: in this case, both exploration of importance and self-efficacy are warranted.
One way to estimate and discuss importance and confidence is by asking the patient to rate both constructs on a visual analog scale or “readiness ruler”66 as pictured in Figure 4. The patient can then be asked why they rated themselves as they did. Asking the patient why they did not rate themselves lower than their chosen point (“Why did you give yourself a 5, and not a 2?) will elicit statements of confidence and importance (eg, “Well, I’ve been able to do it before, so I should be able to succeed again” or “My hoarseness does bother me.”) and subsequently asking them what it would take to raise the score (“What would it take to get you to an eight?”) focuses the patient on identification of goals and barriers (“To get higher, I’d really have to find ways to remind myself of using my resonant voice”) which in turn will aid in developing a treatment plan. The movement toward increased readiness based on therapeutic exploration of importance and support of confidence is conceptualized in Figure 2.
The TTM provides a practical model of intentional behavior change that may bear relevance to voice therapy. The model illustrates the pursuit of behavior change in a stage-like manner, from the initial internal conceptualization of change to the long-term integration of a new outward behavior. Self-efficacy and processes of change affect movement from stage to stage. The suggestions of matching processes of change to stages, and supporting self-efficacy throughout treatment, may provide guidance for voice clinicians looking to improve treatment adherence, whereas empirical data are not yet available in our field. Further interesting implications include that (1) the role of the clinician varies by stage and (2) the definition of treatment “success” may need to be broadened to include progress within the preaction stages.
Clinicians can influence but not control the process of change. Active participation and collaboration is required of both parties. Investigation into strategies that facilitate change (both in the areas of treatment adherence and treatment efficacy) is necessary to help demarcate the boundary between clinician and patient responsibility in pursuing vocal improvement.