Attrition and the Stages of Change

As I've discussed in the past, there are a complex array of factors that influence the seemingly simple fact of whether someone shows up for treatment. While absences can be a factor at any point in the treatment process, I'm reflecting today on a special kind of absence: attrition. Attrition (in other words, the drop-out rate) is a concern across programs and levels of care, because it affects productivity and financial sustainability. Managers have meetings, and more meetings, on how to reduce attrition. However, in this business, some attrition is inevitable.

To understand why attrition is inevitable, it helps to begin with the Stages of Change, a model developed by Prochaska and colleagues. This model suggests that people go through several stages as they move toward change (though these stages may not progress linearly, and people often go through them several times before reaching long-term change).

1. Precontemplation - The person does not recognize the existance of a problem, or see a reason to change. Denial is a significant factor. If someone enters treatment at this stage, they are just going through the motions to appease someone else.
2. Contemplation - The person is aware that there is a problem, but is ambivalent about change. They weigh pros and cons of both the problem, and of change. Which side is "winning" may vary from day to day, or even moment to moment. People may enter treatment to help them resolve the ambivalence, or when the balance tips more strongly toward change.
3. Preparation - The person has resolved the ambivalence in favor of change, but may not yet know how to go about changing. They begin to take small steps toward change, which may include seeking treatment.
4. Action - The person makes a significant commitment to change, and the time and energy it takes. They begin to actually change their behavior in meaningful ways. This stage may include finally making treatment a priority.
5. Maintenance - Change has happened, and the person works to maintain the changes, and prevent relapse. Changes solidify and stabilize over time. People in this stage may be preparing to leave treatment.
6. Relapse - The person reverts to the pre-change state.

People presenting for initial intake assessment at any level of care may be at any stage of change, but are most likely in the contemplation, preparation, or action stage (because earlier they are unlikely to seek treatment, and later they are likely to have already begun treatment). I would wager that a significant proportion of those who schedule, but do not attend an initial appointment, or drop out after one appointment, are in the contemplation stage. Sometimes people can even verbalize that, and say they're not ready, changed their mind, or were too anxious.

Attrition may also occur during the preparation stage as people try to determine what sort of treatment would be the best fit for them, and during the relapse stage as people either cease to be interested in change, or feel embarrassed about the relapse. In contrast, my sense is that people in the action and maintenance stages are more likely to have planned terminations.

Do your experiences line up with these hypotheses? How do you make sense of attrition?