[2022-09-28] The four stages of change
Today, I delivered a speech to staff at the Canada Revenue Agency. I had been asked to speak about change, something that many employees are facing—whether returning to the office, going through an organizational change or getting a new boss.
I used my story of being diagnosed with ovarian cancer to illustrate the four stages of change. I experienced many of the same emotions everyone faces when going through an unexpected and unwanted change: shock and fear at first followed by acceptance and commitment over time.
I began my story with my trip to the emergency department of my local hospital on July 29, 2020, for what I thought was an issue with my gallbladder. At this point, I was still "ADM Jen"—Assistant Deputy Minister of Communications for Health Canada and the Public Health Agency of Canada. Over the course of the day, between discussions with nurses and the doctor as well as various tests, I worked—approving documents, responding to emails and conducting meetings over Zoom. But by 4:00 PM, I would hear those fateful words from the ER doctor: "I have good news and bad news: the good news is that you don't have gallstones; the bad news is that you have ovarian cancer." In my surprise and disbelief, I asked whether it could be anything else. His response: "It's possible, but not likely, based on the size and shape of the mass."
I was in shock. I knew nothing about ovarian cancer. Perhaps that was a good thing; otherwise, I might have been even more frightened than I was. Later that day, my son asked whether I was worried, to which I said no. He was reassured that I was reassured, but in truth, I had no idea.
In the face of this bombshell news, I did what I had always done: I worked.
The next morning, I returned to the Queensway Carleton for a CT scan, which confirmed the presence of a mass consistent with ovarian cancer. I had a number of conversations with an ER doctor, who tried to answer my questions as best he could. He printed information and tried to interpret my CT scan (could be stage 1 or stage 3). In reality, he didn't have the answers I was seeking (answers that we all seek in the midst of a scary change), namely, what will happen to me? At 12:55 PM, while still at the hospital, I remembered that I had a 1:00 PM Zoom call with my entire staff of more than 300 people. At this point, I was still "Superwoman Jen"—not wanting to let anyone down. I could take the call; I just needed to find a room. At 1:05 PM, I found the hospital's quiet room, joined the Zoom, and started speaking. Fifteen minutes into the videoconference, a man came into the room to pray. I excused myself and insisted he stay. I then proceeded to walk through the hospital corridors looking for a new place to sit, all while my staff were watching. Really, what was I thinking? Within a few minutes, I realized that my attempt at leading a meeting from a hospital hallway wasn't working, so I asked one of my directors general to take over, and I signed off. I went home, where I continued to work.
Early Friday morning, I joined the daily morning teleconference with the Minister, her staff, the deputy heads of Health Canada and the Public Health Agency of Canada, and many colleagues. These calls were always intense, given the severity of the pandemic, but I felt especially overwhelmed that day. In perhaps my first moment of self-care since the diagnosis, I decided that I could no longer take those calls. Whatever I would do in the future—continue working full-time, switch to a different role or to part-time work while going through cancer treatment, or take medical leave—I couldn't handle that level of pressure anymore.
While I was mostly in the first two stages of change (shock and fear), I was also beginning to enter the third and fourth stages (acceptance and commitment). At 12:30 PM, I went with my husband to pick up a marriage certificate to make our 30-year common-law relationship official (no time like the present).
I continued to work throughout Friday and into the evening, as well as all day Saturday and Sunday, as was normal for me. Even so, I was starting to turn my head to other priorities, including informing my extended family of my diagnosis.
On Monday, I told my sister face to face at her house, outside, socially distanced (COVID was still raging, there was no vaccine, and now I had cancer). Understandably, she was shocked and upset. I would later come to realize that, for many people, it's harder to watch a loved one go through a disease than to experience it themselves. That same day, my husband and I drove to my mom's house, where I was able to tell my mom and my three brothers face to face. It was important to me that I do this in person, even while interacting virtually had become the norm. It was heartbreaking. My brother had died less than a year before, and here I was bearing bad news that could very easily have meant the loss of another child for my mom and another sibling for my sister and brothers. One of my brothers said to me, "You're not going back to work, are you?" I don't remember what I said, but I know that my response was non-committal. I wasn't yet firmly in the fourth stage of change: commitment. This is the point at which the change is not only accepted but embraced as a new reality requiring a new plan.
On Tuesday, October 4, less than a week after my diagnosis, I married Chris at 5:00 PM. Because of COVID, we held the wedding outside, despite the pouring rain. It was just the officiant, Chris and me along with our children, Shane and Melanie, as witnesses. Our wedding was perfect. No fuss, no muss, just us.
The following day, I finally realized that I couldn't do it anymore—that I didn't want to do it anymore. "It" included being an assistant deputy minister responsible for the Government of Canada's health communications during a pandemic. "It" included pretending I was fine when I wasn't fine, when I didn't know whether I had months or years to live. "It" included doing a demanding, stressful, can-never-give-enough job.
I used to marvel that it took a week for me to step away from my work, but as I've come to know the stages of change, I recognize that it's really not that surprising. I was losing one identity (ADM) and replacing it with another one that I didn't want (cancer patient). I was losing daily connections to my colleagues and staff, and grieving the loss of those interactions. I was mourning the person who could do it all—burn the midnight oil, be there for everyone even if that meant sacrificing myself and my needs. I was embarking on months of cancer treatment that I didn't understand, facing risks that scared me, all with no guarantee that I would survive.
On Thursday, August 6, I started my first day of health leave (I refused to call it "sick leave"). I had a new identity: cancer patient, daily blogger, full-time wife and mother (for the first time in three decades). I started blogging largely as a way of keeping my staff informed of my illness, prognosis and treatment. I couldn't imagine simply disappearing from their lives—here one day and completely gone the next. Blogging became my new job and was one of the best things I could have done. It helped me understand and work through my emotions. It allowed me to remain in contact with so many people, to reconnect with people from my past and to meet (virtually) many more people. It provided meaning to share my story and raise awareness about ovarian cancer.
As I shared today in my speech, a fact sheet from Nottingham University in the UK describes the four stages of change:
- Shock - People’s initial reaction to the change will likely be shock or denial as they refuse to accept that change is happening.
- Anger or Fear - Once the reality sinks in and people accept the change is happening, they tend to react negatively. They may feel angry or fearful, and actively resist or protest against the changes. (As an aside, the one thing I never felt was anger. I never asked myself "why me?" Fearful, yes, angry no.)
- Acceptance - People stop focusing on what they’ve lost and start to let go and accept the change. People will begin to test and explore what the changes mean to them.
- Commitment - When people reach the last stage, they not only accept the changes, but embrace them. They then start to restructure their ways of working and become more productive and positive.
I found it tremendously helpful to know that the emotions I experienced as a result of my unforeseen change were normal.
It's now been more than two years since I was diagnosed with ovarian cancer. After my initial shock due to bad medical news and my fear of what the diagnosis could mean, I moved to acceptance and commitment, doing whatever was necessary to make the best of what, at first, looked like a rather dire situation. While I've faced other health issues in the intervening months, I feel healthy, strong and content with where I am.
