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by Donald B. Ardell, Ph. D.
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Wellness in the Headlines
(Don's Report to the World)

The Seven Stages of Change, From A Wellness Perspective

Tuesday April 26, 2005

Most health educators exhibit a devotional reverence for five stages of change. The stages, called "The Transtheoretical Model of Change" by pedants, simply "Stages of Change" by others, was developed by James Prochaska. The five stages are:

  1. Pre-contemplation.
  2. Contemplation.
  3. Preparation.
  4. Action.
  5. Maintenance.

In his encyclopedic new book, The Seven Basic Plots: Why We Tell Stories, Christopher Booker provides another kind of model entirely unrelated to health. Yet, I prefer it for wellness purposes to Prochaska's change stages. Unlike the latter, the seven basic plot ideas described by Booker seem better suited to the stages of change for wellness seekers. The latter are not focused on overcoming addictions or solving negative problems, as is the case with Prochaska's stages. Yet, the alleged wellness change stages seem to fit the ever more interesting and socially consequential challenge of designing, modifying over time and sustaining a positive life. Besides that, Booker's model is more fun to work with. This matters because, you might remember, wellness is an adventure, not a treatment, and a wellness mindset is peculiarly suited for such dark times of mass delusion, religious fervor and widespread embrace of superstition as we are undergoing now in Republican America. 

Wellness promotion at its best rests on a foundation of reason, science and secular human decencies. Wellness enthusiasts therefore seek to extend their own human happiness, freedoms, liberties and exuberance while being quite delighted if others choose to come along. However, wellness promoters are not evangelists, missionaries or other "my way or the highway to hell"-type recruiters. Better to leave that to the devotees of pseudoscience and fundamentalist dogmas. 

All of which brings me back to Booker's model. I think it works nicely for explaining stages we often experience in the pursuit of wellness, how we can evolve from normalcy or a sickening state of mediocrity, to the heights of living consistent with positive, exceptional wellness principles. Though not sequential like Prochaska's stages of change, the Booker stages or plot types are common for wellness seekers. 

As in Booker's examples with English and other literature, a wellness change model has seven basic plots. In literature (and novels, movies, plays and operas) and in seeking wellness, these seven plots are recycled, again and again. The plots are:

  1. Overcoming the monster.
  2. Rags to riches. 
  3. The quest.
  4. Voyage and return.
  5. Rebirth.
  6. Comedy.
  7. Tragedy.

Overcoming the Monster
This kind of plot in Booker's model explains flicks like Jaws or books like David Copperfield wherein doom and gloom in varied guises threatens to wreak havoc on a life or a society until a hero or heroes save the day, or the world, as the case may be. In wellness terms, the monster is the deadening atmosphere of moderation, or norms that stifle individuality. At some point, a fortunate few decide they want to rise from the sorry standards of health (medically defined as non-sickness) and in other ways break away from benighted myths and traditions that stifle freedom and creativity. The first stage of wellness might be nothing more than a realization that it is time to emerge from the muddle of normalcy to pursue higher levels of physical and mental well being while finding new possibilities for meaning and purpose in life. Remember the first sentence in Dickens autobiographical David Copperfield? "Whether I shall turn out to be the hero of my own life, or whether that station will be held by anybody else, these pages must show." Young David had just overcome the monster of temptation to assign responsibility for his fate and the quality of his life to anyone else. 

Rags to Riches
In the book The Seven Basic Plots, Booker explains the "rags to riches" plot with examples like Jane Eyre, Raiders of the Lost Ark and A Christmas Carol, among others. In the rags to riches plot, an underdog has adventures (usually thrust upon her), overcomes crises, passes tests and in doing so becomes strong, confident, able and resilient. She assumes an enviable place in the world. Often, love follows. So, too, with wellness--though the love part is less certain in real life. While not as dramatic as the adventures of Harrison Ford (Indiana Jones), wellness seekers go from rags to riches in a sense when we lose fat and gain fitness, eliminate major stressors and experience continuing serenity, cease being easily fooled and delight in critical inquiry. In a wide range of wellness skill areas, rags to riches-like shifts are seen in going from weakness and victimhood to responsible and effective decision-making with attendant states of advanced functioning. While rags to riches stories are about material advances, the wellness equivalent seems deeper, richer and more substantial than a transition from no stuff to lots of stuff.

The Quest
Perilous quests are a third archetype. A literary example cited by Booker is Alice in Wonderland. A variant noted is the inner quest, a journey, for instance, from naivete to wisdom, psychological paralysis to emotional liberation, as in Snow White. The search for a desirable, fulfilling and successful combination of attitudes and behaviors at varied life stages surely marks the quest for wellness. What mix works for a while must be continually fine-tuned as career, family and other factors change over time. Wellness is often defined as a quest, a search for meaning that is furthered by a conscious regard for physical and mental disciplines.

Voyage and Return
The Wizard of Oz is probably the first movie that comes to mind to fit this category of Booker's plot types. The wellness equivalent might include going off somewhere on a heroic quest (for xample, to a distant city to run a marathon) or on a religious pilgrimage (to Mecca, the Vatican), to find space aliens (Roswell, for instance) or to pursue transcendence of a hedonistic nature (Hedonism Resort in Jamaica), returning home changed by the experience. Alternatively, it could be other than a physical trip, perhaps a journey to find something about yourself. In Thomas Wolfe's You Can't Go Home Again, the main character (George Webber) writes a novel based on his family and hometown. When he returns to that town, he finds the home he knew is not there anymore. Everyone in the town is embarrassed by the book, he's treated badly and made unwelcome. This response sparks a voyage of discovery. The author travels widely seeking his true identity. Eventually, the journey comes full circle when he returns from the voyage with new insights and rediscovers home, not the same but with qualities previously overlooked. As in our pursuit of wellness over time, things change as we learn more about the world and ourselves.

E.T embodied the classic coming-of-age-story pattern. In the tale, Elliott encounters E.T., his alien alter ego, who helps him learn be a leader and bring harmony to a dysfunctional family. As with the four preceding plot types, rebirth stories have happy endings. Wellness change efforts usually turn out well, contrasted with single purpose attempts to stop doing something negative (such as smoking) without a larger, positive context. 

The human comedy is played out in countless ways, and include attempts to cope with parental authority, ventures into the world on our own, dealing with innumerable tests of varied kinds leading to degrees of interdependence and independence. Along the way, we must explain things to others, and ourselves. Thus, we adopt a narrative, a story of our attempts at discovery about who we are and what kind of person we want to become, in time. Our narratives, just like in Hamlet, are skewed from reality (and, for wellness seekers, from sickening normalcy), some a lot more so than others (thus, the comedy). The comedy plot is the one most of us recognize, since it unites us in a pleasant shared reality. In the wellness model, the importance of comedy is reflected in the skill areas of humor and play. In Prochaska's stages, by contrast, not a mention is made of humor or anything remotely akin to lightness or playfulness; health educators see nothing funny about dealing with bad habits and addictions. A pity, for literature is rich with comic fodder, though often served with equal parts tragedy. 

Booker mentions The Snow Queen, Romeo and Juliet, and Peer Gynt as examples of his seventh and final plot genre, though everyone has his own favorites in this popular category. My favorite is not a novel but rather the American health (medical) care system. This fragmented non-system is the ultimate tragedy, for never has so much been spent for so little, from a wellness perspective. Almost none of the spending is devoted to supporting citizens to choose and sustain wellness lifestyles. That is a tragedy Shakespeare could appreciate, Hardy would applaud and Hemingway would drink to. Compounding the tragedy is the fact that this illness treatment system is no bargain or even good value. (This country spent $1.4 trillion or $5,267 for each man, woman and child on medical care in 2002. Almost half of the spending is by government, mainly for Medicare and Medicaid. However, we rank below most other Western nations that spend a lot less on sickness remedies and interventions. Canada, for example, spent $2,931 per person, France $2,736 per person. Why do we spend more? The three main reasons cited are the greater expenses of American doctors, American pharmaceuticals and American paperwork--31 cents out of every dollar.)
Those who choose wellness anyway essentially opt out of the tragic system wherein the best that can be hoped for is a state of non-sickness. The medical system can be vital if you get sick or hurt AND have insurance or otherwise can pay for expensive, highly rationed care. However, even under the best of circumstances, you are well advised to adopt and practice a strong degree of responsibility for the quality of your life by remaining highly fit and skilled in varied lifestyle disciplines (in other words, critical thinking, sound relationships, the search for added meaning, etc.) After all, advances from illness to wellness states along the illness/wellness continuum cannot be made via reliance on the US health care (sickness) system. The tragedy in this case is that so few Americans seem to understand this or live in a manner consistent with such comprehension.  
Fortunately, you won't need to rely on the tragic medical system, most of the time, if you live well and have the good fortune to enjoy a bit of luck (genetics and chance). So, next time health educators bring up the topic of change theory, tell them about the plot lines of all good wellness lifestyles, ranging from overcoming monsters, going from rags to riches, quests, voyages and returns, rebirths, comedies and last but not least, tragedies--of missed opportunities because of public reliance on a broken health or medical system rather than personal initiatives.  
Be well. Always look on the bright side of life.

Domain: mental
Subdomain: mental health

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