Stages of Readiness “Principles” Motivation exists along a continuum of readiness; Clients progress through stages in a spiral (not linear); When enhancing motivation, if the clinicians use strategies in a stage other than the one the client is in, the result could be treatment noncompliance; If clinicians push clients at a faster pace than they are ready to take, the therapeutic alliance may break down; Relapse is an event, not a stage. Will describe typical client attitudes and actions at each stage and suggest strategies & techniques clinicians can use to move clients from one stage to the next. Explain the relapse process

Stage of Change Model Prochaska & DiClemente (1992) PRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE

Stage 1: Pre-Contemplation Individual is unaware, unable, unwilling to change. No intent to change. Indicators: argue, interrupt, deny, ignore, avoid reading, talking, or thinking about the behavior… Individual is traditionally characterized as resistant, unmotivated.

Stage 1: Pre-Contemplation: Clinical Tools Establish rapport Determine why the client has come to you. Introduce ambivalence about recovery – why it might be a good idea, e.g., “why do you thing other people decide to manage their disorders?” Give information on risks, pros & cons of use Acknowledge the client’s thoughts, feelings, fears, and concerns. Keep the interview informal Ask permission Build trust Explore the meaning of events that brought the client to treatment or the results of previous treatments Elicit client’s perception of the problem Providing personalized feedback about assessment findings (if applicable) Helping significant other intervene Examine discrepancies between the client’s and others’ perceptions of the problem behavior Express concern Keep the door open. Effective catalysts for change: Consciousness raising Environmental reevaluation Emotional arousal and dramatic relief.

Stage 2: Contemplation Individual is ambivalent or uncertain regarding behavior change. Indicators: Individual meets clinician “half way,” willing to look at pro and cons of behavior change Individual is traditionally characterized as unpredictable, time intensive.

Stage 2: Contemplation Clinical Tools Discuss & weigh pros/cons of recovery Emphasize client’s free choice & responsibility Elicit self-motivational statements Discuss the client’s goals in life, how will recovery affect these? Reduce the fear of recovery through example and problem solving Ask questions that clarify motivation e.g., “what’s most important to you… why?” Normalize ambivalence Help the client “tip the decisional balance scales” toward change by: Changing extrinsic to intrinsic motivation Examine the client’s personal values in relation to change Elicit self-motivational statements of intent and commitment from the client Elicit ideas regarding the client’s perceived self-efficacy and expectations regarding treatment Summarize self-motivational statements. Effective catalysts for change: Self-reevaluation Emotional arousal and dramatic relief Environmental re-evaluation “When you want to keep your motivation for doing something, what are some of the things you say to yourself?”

Stage 3: Preparation Individual shifts from thinking about behavior change to planning first steps. Indicators: Individual asks questions, considers options, demonstrates openness in considering behavior change. Individual is traditionally characterized as compliant, “coming along,”, “good to work with.”

Stage 3: Preparation Clinical Tools Support efforts to change Clarify goals & identify successful strategies Structure plan of action with client based on client’s history and willingness, allowing client to decide Encourage client to commit to action Give client clear, consistent and unequivocal message about recovery With permission, offer expertise and advice Consider and lower barriers to change Help the client enlist social support Explore treatment expectancies & client’s role Elicit from the client what has worked in the past either for him or others whom s/he knows. Assist client negotiate finances, child care, work, transportation, other potential barriers. Have the client publicly announce plans to change get into treatment.. Effective catalysts for change: Self-liberation Counterconditioning Helping relationships

Stage 4: Action Individual demonstrates steps toward behavior change such as periods of abstinence. Indicators: Individual is receptive to clinical interventions. Treatment compliance is normal. Demonstrated behavior change affects positive outcomes in other areas (i.e., relationships at home and work). Individual is traditionally characterized as “successful,” “working the program.”

Stage 4: Action Clinical Tools Seek commitment to specific behavioral change at each session Acknowledge difficulties, support even minimal progress Identify risky situations, triggers & coping strategies Help client find new reinforcers Support perseverance (“Sticking to the plan”) Engage the client in treatment Reinforce the importance of remaining in recovery Support a realistic view of change through small steps. Help the client assess whether s/he has strong family and social support. Effective catalyst for change: Counterconditioning Stimulus control Reinforcement management Helping relationships Self-liberation At this stage, clients are receptive to the full range of counselor techniques, but client motivation often wax and wane along a spiral. If relapse occurs, the counselor “backs up” and applies techniques from earlier stage. For example, “Relapse is an event, but not an cat of magic, se let’s look at what was going on just before you resumed using. One we identify some of what you were thinking and feeling, we can devise some ways to choose differently.”

Stage 5: Maintenance Individual sustains treatment goals. Indicators: Individual has made behavior changes, practices stable abstinence, met treatment goals, and practices healthy coping strategies. Individual is traditionally characterized as “ready for successful discharge,” “no longer needing treatment,” “ready for aftercare.”

Stage 5: Maintenance Clinical Tools Support and affirm changes Rehearse new coping strategies and countermeasures to triggers Review personal growth long-term goals Encourage client to contribute to recovery of others Help client identify and sample drug-free sources of pleasure (new reinforcers) Affirm the client’s resolve and self-efficacy Help the client practice & use new coping strategies to avoid relapse Explain to the client you are available to talk between sessions Together develop a “fire escape” plan if client relapses Such as: Treatment Plan Awareness of risky situations Coping strategies for each situation Participation in 12-Step programs Pursuit of hobbies & cultural activities Volunteer opportunities The counselor reminds the client of progress. Effective catalysts for change: Helping relationships Environmental reevaluation Self-liberation Reinforcement management

Appropriate Motivational Strategies for Each Stage of Change Client's Stage of Change Appropriate Motivational Strategies for the Clinician Stage 1: Precontemplation The client is not yet considering change or is unwilling or unable to change. Establish rapport, ask permission, and build trust. Raise doubts or concerns in the client about substance-using patterns Express concern and keep the door open

Client's Stage of Change Appropriate Motivational Strategies for the Clinician Stage 2: Contemplation The client acknowledges concerns and is considering the possibility of change but is ambivalent and uncertain. Normalize ambivalence. Help the client "tip the decisional balance scales" toward change Elicit and summarize self-motivational statements of intent and commitment from the client. Elicit ideas regarding the client's perceived self-efficacy and expectations regarding treatment.

Client's Stage of Change Appropriate Motivational Strategies for the Clinician Stage 3: Preparation The client is committed to and planning to make a change in the near future but is still considering what to do. Explore treatment expectancies and the client's role. Clarify the client's own goals Negotiate a change--or treatment--plan and behavior contract. Consider and lower barriers to change. Help the client enlist social support. Offer a menu of options for change or treatment. With permission, offer expertise and advice. Elicit from the client what has worked in the past either for him or others whom he knows. Assist the client to negotiate finances, child care, work, transportation, or other potential barriers. Have the client publicly announce plans to change.

Client's Stage of Change Appropriate Motivational Strategies for the Clinician Stage 4: Action The client is actively taking steps to change but has not yet reached a stable state. Engage the client in treatment and reinforce the importance of remaining in recovery. Acknowledge difficulties for the client in early stages of change. Help the client identify high-risk situations through a functional analysis and develop appropriate coping strategies to overcome these. Support a realistic view of change through small steps. Assist the client in finding new reinforcers of positive change. Help the client assess whether she has strong family and social support.

Client's Stage of Change Appropriate Motivational Strategies for the Clinician Stage 5: Maintenance The client has achieved initial goals such as abstinence and is now working to maintain gains. Support lifestyle changes. Affirm the client's resolve and self-efficacy. Help the client practice and use new coping strategies to avoid a return to use. Develop a "fire escape" plan if the client resumes substance use. Review long-term goals with the client. Help the client identify and sample drug-free sources of pleasure (i.e., new reinforcers). Maintain supportive contact (e.g., explain to the client that you are available to talk between sessions).