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Advancing from the PREPARATION to the ACTION Stage of Change With Stage Matched Interventions

By: Pamela Carrisalez Consider the people on your journey in life who helped you walk through some painful, devastating, and stormy situations. You were feeling stuck and paralyzed, not knowing what to do, or who to trust. Remember when that person expressed genuine concern, patience and honesty, as you moved in the stages of change to prepare for action. You imagined how life would be on the other side of the situation and began setting goals. And the rest is history.


The same way you and I will never forget those who were there helping us through tough times, neither will the unique individuals that we are entrusted to serve. On a personal note, I can still remember the day when a caring Supervisor, who didn’t really know me, made a statement that affirmed my feelings in my difficult time. Her statement, just three powerful words, moved me from the preparation to action stage and it gave me hope for the future.


The TIP 35 series is a helpful reference guide for cooccurring problems, matching stages of change with stage-matched interventions. Change is a process of identifiable stages through which people pass- precontemplation, contemplation, preparation, action, and maintenance. The stages that will be discussed here are preparation to action. For most people, behavior change occurs gradually over time, with the person progressing from being uninterested, unaware, or unwilling to make a change.


Preparation is a stage that combines intention and behavioral criteria. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year. In the preparation stage, people have made a commitment to make a change. Their motivation for changing is reflected by statements such as: “I’ve got to do something about this.“ “This is serious.” “Something has to change.” or “What can I do?” In this phase, people are now taking small steps toward taking action. As clients move from contemplating to actually implementing change in their lives, they are in an intermediate stage in which they increase their commitment to change by exploring, clarifying, and resolving their ambivalence, and making a decision to act. In the transtheoretical model, this stage is known as preparation. Clients must see change as in their best interest before they can move into action.


The negative consequences of ignoring the preparation stage can be a brief course of action, followed by rapid return to substance use. Too often, people skip this stage. They try to move directly from contemplation, into action and fall flat on their faces because they haven’t adequately researched, or accepted what it is going to take to make this major lifestyle change in order to overcome their problems.


Recognizing Readiness To Move Into Action

As clients proceed through the preparation stage, be alert for signs of their readiness to take action. At this stage, if the client remains in an uncomfortable state for too long, it leads to the risk of retreat back to old defenses, such as minimizing or denying. Initiating change is helpful to reduce discomfort.


Remember verbalizing a desire to change is not necessarily a sign of determining to change. The following are several signs of readiness to act:

  • Decrease resistance

  • Fewer questions about the problem

  • Resolve

  • Self- motivational statements

  • More questions about change

  • Envisioning

  • Experimenting

Negotiating a Plan for Change

In this stage the client conflict may sound like this, “ I'm feeling good about setting a quit date, but I'm wondering if I have the courage to follow through.”


Creating a plan for change is a final step in readying your client to act. A solid plan for change enhances your client's self-efficacy and provides an opportunity to consider potential obstacles and the likely outcomes of each change strategy before starting. Offering a menu of change options and treatment resources enhances motivation and meet clients’ multiple needs. Although the change plan is the client's, creating it is an interactive process between you and the client. One of your most important tasks is to ensure that the plan is feasible.


Using a Change Plan Worksheet is a helpful tool to assist the client to prioritize action steps and as a guide to follow. As you discuss treatment choices with clients, you can acquaint them with the concepts of levels of care, intensities of care, and appropriate fit. Do not, however, overwhelm them with a complicated description of all possibilities. Avoid professional jargon and technical terms for treatment types or philosophies. Limit options that are most appropriate, and describe these, one at a time, in language that is understandable and relevant to individual concerns of clients.


Because most people typically move around the cycle several times before exiting into stable recovery, let clients know that they should not become discouraged if their first treatment option does not work. Point out that, with all the possibilities, they are certain to find some form of treatment that will work. Reassure them that you are willing to work with them until they find the right choice.


Recognizing barriers to action

Health problems present obstacles to recovery for many clients with serious physical or mental health disorders. Some become sick after entering treatment; others have chronic conditions that require monitoring and treatment and can produce periodic health crises (e.g., HIV/AIDS, diabetes, hypertension). Clients may be in chronic pain from injuries or self-neglect (e.g., back pain, dental problems). Abstinence sometimes reveals underlying mental illnesses, such as depressive or psychotic disorders Medications taken for physical and mental health problems may cause distressing side effects. A depressed client, for example, may plan to see a mental health worker for an evaluation if she is still feeling depressed after 30 days of abstinence, or she may decide to see one sooner if her symptoms increase the risk of returning to substance use. It should be reemphasized that some clients (e.g., those with coexisting disorders) need more intensive services.


Enlisting Social Support


When your client has few or no significant others who are encouraging sobriety, it is important to help your client build a new social structure that will support the effort to change. As a clinician, you are a central support for your clients, but you cannot provide all the support they need. In addition to repairing or resuming ties with helpful family members and significant others, clients can find supportive people in, for example, churches, recreational centers, and community volunteer organizations.


To make these connections, encourage clients to explore and discuss a time in their lives before substance use became a central focus. Ask them what gave meaning to their lives at that time. For some clients, especially those with chronic physical problems or severe mental illness, case management teams provide a sense of safety, structure, and support.


Finally, in helping clients enlist social support, avoid the stereotype of the self-sufficient loner. The “alley cat” existence. Studies show family support is effective. Concerned partners can learn the skills and techniques of motivational interviewing and become effective partners in change.


Educating your client about treatment


Role induction- elicit your clients expectations to reduce misunderstandings. Research consistently demonstrates that retention in treatment has a strong positive relation with the client’s expectancy and that the role induction prevents early dropout. If you refer clients to another program, review with them what you know of its philosophy, structure and rules, as well as any idiosyncrasies with which you may be familiar. Another important aspect of role induction is educating clients about what to expect in terms of physical withdrawal from substances. The symptoms-or rebound reaction. Normalizing this process with accurate information helps give clients a sense of control and reassurance.


Initiating the plan


A new beginning with a start date may entail symbolic rituals. For example, choosing a specific date (today) to throw away substance paraphernalia to leave the old behavior behind with no reserves or temptations. Decide on how often they will check in with you. Show support and interest by offering to call them if they don’t plan to continue counseling services with you.


Clients with a carefully drafted plan, a knowledge of both risky situations and potential barriers to getting started, and a group of supportive friends or concerned relatives should be fully prepared and ready to move into action. Ten helpful stage matched interventions to help the client move from the Preparation stage, to the Action stage:

  1. Clarify the client’s own goals and strategies for change.

  2. Offer a menu of options for change or treatment.

  3. With permission, offer expertise and advise.

  4. Negotiate a change-or treatment-plan and behavior contract.

  5. Consider and lower barriers to change.

  6. Help the client enlist social support.

  7. Explore treatment expectancies and the client’s role.

  8. Elicit from the client what has worked in the past for either themselves, or others whom they know.

  9. Assist the client to negotiate finances, child care, work, transportation, or other potential barriers.

  10. Have client publicly announce their plan to change.

For more information and resources visit www.samhsa.gov, under the Treatment Improvement Protocol (TIP) 35.