CATR: Mr. Gamble, what is the ADKAR change model?
Mr. Gamble: ADKAR is a model for facilitating change that is widely used in business and government. It was developed by Jeffrey Hiatt in the 1990s. ADKAR is an acronym for a way research has identified that people effectively change. The elements of that acronym are awareness, desire, knowledge, ability, and reinforcement. [The basics of ADKAR can be found in Hiatt’s book ADKAR: A Model for Change in Business, Government and Our Community. Loveland, CO: Prosci Research; 2006.]
CATR: And how was this model developed?
Mr. Gamble: Toward the end of the last century, more and more companies were investing millions of dollars into automating their processes, but finding out that people weren’t using them. They were doing workarounds and reverting back to their old way of doing things, and so a lot of money was squandered. It was in researching why people resist change and what makes people respond to change that ADKAR was developed.
CATR: How is ADKAR used in the healthcare industry?
Mr. Gamble: ADKAR is used by healthcare organizations to help employees with change. In terms of mental health, it can assist with managing a department or service line (Oakley C & Sugarman P, Adv Psychiatr Treat 2013;19(2):108–114). From a clinical standpoint, ADKAR can support quality improvement efforts (Varkey P & Antonio K, Am J Med Qual 2010;25(4):268–273; Burleton L, Nurs Stand 2013;27(39):35–40).
CATR: ADKAR is used widely in the business world. The part that is really intriguing for readers of CATR is that it is dissimilar in many ways from how addiction treatment often goes. So it gives another option to clinicians who are having trouble with the “traditional” models of change for patients.
Mr. Gamble: Yes, while designed for corporations, ADKAR is truly an individual change model that can be applied to projects and scenarios that require people to change the way they operate. The biggest point to ADKAR is that the process of change must be linear. It needs to go through the elements of awareness, desire, knowledge, ability, and reinforcement sequentially in order to work. So you can’t just start at “K,” knowledge, before everything else. Research shows you must build the awareness of the need to change and desire to support the change before the knowledge step may be achieved.
CATR: Theoretically that makes a whole lot of sense. So when you actually get down to implementation, how does it work?
Mr. Gamble: The first thing you have to do is build that awareness. And it is not awareness of the change; it is awareness of the need for the change. Why does this change need to happen? What will happen if you don’t change right now? Those messages are the most important to send in building awareness. This often has to be hammered home through repetition.
CATR: Then the next step—the desire.
Mr. Gamble: If that awareness of “why” is established sufficiently, the “D”—the desire—sort of takes care of itself because you have established in that person’s mind that, indeed, this change has to happen, and it has to happen now, and there will be consequences if it doesn’t. With that said, desire is often the most difficult to achieve, and comes down to a personal decision.
CATR: You said that in many cases desire naturally follows from awareness. What if it doesn’t? How can you boost desire?
Mr. Gamble: That has to be done on a very personal level. So in the business world, that may be achieved by a manager sitting down with a person, or in a therapeutic relationship with the therapist, and talking about WIIFM—“what’s in it for me,” which is a very compelling message, and that can often be key to that desire part.
CATR: How critical is knowledge to the overall equation once you get people who have awareness and desire?
Mr. Gamble: Well, the knowledge piece really ties into the specific change that is happening. This step can be really simple, and with awareness and desire in place, you will often find a natural urgency to learn the new ways.
CATR: What are the best strategies for approaching ability?
Mr. Gamble: That is a good question. Knowledge and ability are sometimes used interchangeably, but they are not the same. The analogy that I hear often is related to golf. I may have the knowledge of how to execute a perfect golf swing—I can watch videos on it, read books about where to keep my head, how to position my body, all that sort of thing. Yet that does not mean that I have the ability to execute that perfect golf swing. Ability comes down to the actual implementation of the knowledge; applying that knowledge to achieve the desired outcome.
CATR: What does reinforcement look like?
Mr. Gamble: Celebrating wins is one of the main ways, regardless of their size or scope. Any small victories should be celebrated. Setting people up with milestones provides achievable goals, and are certainly worth celebrating. Any acknowledgement of people successfully implementing the change, using the new tools, or doing things correctly. Another part of the reinforcement is a certain element of accountability and policing to make sure people are indeed doing things the way they are supposed to.
CATR: Part of the subtitle of the ADKAR book is “How to Implement Successful Change in our Personal Lives.” How can ADKAR translate to personal change, for instance, for a client who wants to stop drinking alcohol?
Mr. Gamble: That gets back to the idea of awareness of the reason for the change. I personally like to equate it to the 12-steps that are part of Alcoholics Anonymous (AA), as well as other addiction recovery-type programs. Those first two steps—giving yourself up, surrendering to the change that you know needs to happen—that is the “A” in ADKAR, because you are aware of the need for this change and become willing to do whatever it takes. And there is the third step in AA: desire. There is desire to the extent that you become willing to turn over your life to, in this case, a higher power that is able to end that insanity.
CATR: Does this translate further?
Mr. Gamble: I see parallels throughout those 12 steps to ADKAR. I think steps four through six illustrate the “knowledge” piece, because people start learning about how their lives are controlled by resentments. You start to realize that maybe you are the source of the very things that you are angry about. And that knowledge is very empowering and liberating. Steps seven through nine track with the concept of “ability.” Steps 10 through 12 correlate with “reinforcement.” The tenth step is the epitome of “reinforcement,” where you basically are doing an inventory each night and turning things over to a higher power. You continue to reinforce that behavior by ultimately working with others to share that very gift that you have been given.
CATR: A problem drinker may have an awareness that something bad might happen if his wife says, “You can’t live here anymore unless you clean up your act.” But are you talking about another type of awareness?
Mr. Gamble: Often we hear about the need for a person with addiction to hit rock bottom. I think for every person there is a certain situation that will trigger that moment of clarity. While the ADKAR model certainly speaks to the fact that there are different ways that people change and the 12-step model follows that, it still doesn’t mean that there is a silver bullet for getting people to that level of awareness/desire where they are indeed willing to give up control of their lives.
CATR: So someone has awareness that change must occur, but must they also have a reason to change?
Mr. Gamble: It is the awareness of why it has to happen. The scenario you give of a wife telling a husband, “Look, you either quit drinking or get out of the house,” doesn’t necessarily give him the “why” he needs to quit drinking. All she has done is given him options. That doesn’t necessarily lead to understanding why this change needs to happen to him, personally, right now. That is probably the hardest part, getting people to that point, because once you get them to that point there are methods and solutions.
CATR: So, in the case of a problem drinker, he may say, “I finally acknowledge that my life is unmanageable.” But what motivates desire then?
Mr. Gamble: Someone in recovery may see the freedom in others who have been down that road before them. They see people who have stories to tell like theirs and yet seem to be enjoying themselves, seem to actually be living a life that has some joy in it. Someone in recovery might say, “I saw something I wanted and I became willing to do what it took to get it.” That desire may come from seeing other people living the life they want to live.
CATR: What is the knowledge piece, then, to a problem drinker’s recovery?
Mr. Gamble: For some people, once you have the awareness and desire, they may need a program or model, a roadmap of how to stop drinking. It may be AA’s 12 steps—the knowledge of getting a sponsor and embarking on that journey. Within those steps, you learn more about yourself and you do a fearless evaluation of yourself. There are obviously other programs, too.
CATR: So what does ability consist of?
Mr. Gamble: Unlike in business where someone may not have the ability to do a new job, everybody has the ability to change the way they are if they are given the right circumstances and tools to do so.
CATR: And just more specifically, is it an ability to not drink or a different type of ability?
Mr. Gamble: For those in recovery, it may be an ability to work the program, to do the steps necessary such as identifying people you wronged and making amends.
CATR: How would reinforcement work in this model for the problem drinker who is making progress in stopping drinking?
Mr. Gamble: In AA, for instance, in the beginning people pick up a chip every month to mark their sobriety. Later, they do so once a year. That is reinforcement with that acknowledgement, in front of your peers, of length of time sober.
CATR: Thank you for sharing your knowledge with us, Mr. Gamble.