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Moving Clients Through the Pre-Contemplative Stage of Change

I think we have all asked ourselves before, “How easy would this be if they would just do what I say?” As if we know how best to live our clients’ lives. It’s so easy to become discouraged when it seems like changes are not being made fast enough or when the changes are so minute that they are hard to recognize. As clinicians we have the tendency to take on the sole responsibility of our client’s set backs, sometimes overlooking the experience of the process. We’ve all heard this at one time or another, “You are working harder than the client.” When that happens I have to step back and refocus, so that I’m not spending my time trying to convince my client, but rather helping them become aware of their current situation.

The SAMHSA’s Treatment Improvement Protocol (TIP) Series 35 provides a way to build a collaborative relationship. The clinician should be directive yet client centered; have a clear goal of eliciting self-motivational statements and behavioral change from the client; and seek to create a discrepancy in the client’s beliefs in order to enhance motivation for positive change. The early stages of readiness are focused on encouraging change by increasing awareness. Motivational Interviewing should not be seen as a set of techniques or tools, but rather as a way of connecting with our clients. Change itself is influenced by biological, psychological, sociological, and spiritual variables. The client is ultimately responsible for change, however the clinician shares in the responsibility of developing the therapeutic relationship. Being aware that our style influences our client’s level of motivation, is fundamental to change.

The topic of change being raised with people who are not thinking of changing should be done after you have established rapport and trust. The challenge is to create a safe and supportive environment in which the client can feel comfortable addressing the topic of change. Some clients don’t know why they were even referred to treatment or what mental health treatment really means. By presenting the information on how the program functions and their rights will increase their readiness to start the discussion. Identifying elements in our client’s values that present potential barriers to change, and learning what personal and community resources are available will aid in reducing the barriers. The process of incorporating the issues of poverty, social isolation, or recent losses will provide opportunity to probe our client’s personal values and assess their level of readiness.

Giving the client feedback from the assessment by exposing the client to information about the etiology, the interactive effects between mental illness and substance-related disorders, and the process of treating their diagnoses will help them come to terms with their painful reality of having a co-occurring disorder. Finding an approach that is both educational and empathetic is essential in reaching your goal of creating doubt about their commonly held beliefs that their behaviors are harmless. It is important that the client has the opportunity to critique the information presented to them from their own experiences and beliefs, rather than just being told to accept all the facts; it will help them build an allowance that involves treatment for both. By encouraging a dialogue on the specific risks, the damage that already exists and the potential damage that may occur if changes are not made, will give them the opportunity to acknowledge the possibility of a problem. Exploring the client’s positive experience while identifying the negative consequences and the benefit of making a change can result in the cognitive shift. A shift in thinking and feeling may move the client away from their ambivalence and toward a place of recognition. They will become more accepting of their symptoms when they understand the true properties of addictive disorders and mental illness, resulting in them letting go of the judgment and stigma of their problem.

By tailoring the interventions based on the client’s level of readiness will allow you to better address their current needs, instead rushing to find the solution. In the Precontemplation stage, clinicians should practice the following:

  • Commend the client for coming to treatment

  • Establish rapport, ask permission to address the topic of change, and build trust.

  • Elicit, listen to, and acknowledge the aspects of the problem behavior the client enjoys

  • Explore the meaning of the events that brought the client to treatment or the result of previous treatments

  • Obtain the client’s perceptions of the problem

  • Offer factual information about the risk of the problem behavior

  • Provide personalized feedback about the assessment findings

  • Help a significant other intervene

  • Examine discrepancies between the client’s and the other’s perceptions of the problem behavior.

  • Express concern and keep the door open

There are special considerations with coerced clients:

  • Honor the client’s anger and sense of dehumanization.

  • Avoid assumptions about the type of treatment needed.

  • Make it clear that you will help the client derive what the client perceives is needed and useful out of your time together.

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

By: Melinda Santiago, MFT

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