Prochaska & Diclemente’s Transtheoretical Model (1994) or Stage of Change Model is a very helpful framework that can guide our thinking about assisting clients to make behavior changes. The model is based on the assumption that intentions are the primary determinant of behavior change. Thus clients must have a want to make changes in their lives. In our practical work with clients we also integrate skills building because we know that many clients may want to change, but may not know how.
Precontemplation – In the Precontemplation Stage there is no want or motivation for change because the behaviors in question are believed to be acceptable. This may be due to a lack of information, a lack of consequences of behavior or an individual may have attempted change in past without success resulting in feeling hopeless or demoralized regarding the ability to change. There is an avoidance of thinking or talking about the behavior. Clients in this stage are often characterized as resistant, unmotivated or not ready for health promotion programs by providers. Reframing as precontemplative makes work easier with these clients.
Contemplation – This stage is characterized by ambivalence – knowledge of the pros and cons of the behaviors. There is an awareness that problems may exist and thoughts regarding change, but without firm commitment to change. Clients in this stage are often characterized as procrastinators by providers. Reframing as contemplative makes work easier with these clients.
Preparation – In the Preparation Stage there is intention to take action and make changes in the immediate future. Typically these clients have taken some significant action in the past year and have a current plan of action in place.
Action – In the Action Stage specific overt modifications in life-style have been made.
Maintenance – In this stage, clients are maintaining changes in lifestyle, working to prevent relapse and strength building.
Relapse – In this stage clients revert to the behavior they were trying to change.
Movement between stages is typical. The goal is to keep individuals moving forward to higher stages of change and to help them develop tools and abilities to maintain changes made and/or get back on track if stage of change shifts.
Exercise – Identifying a Client’s Stage of Readiness for Change
This exercise presents various vignettes that illustrate the different stages of change, and gives the reader the opportunity to guess the client’s stage before the answer is revealed.
Which stage of change do you think Keith is in?
Which stage of change do you think Steve is in?
Which stage of change do you think Tim is in?
Which stage of change do you think Doug is in?
Which stage of change do you think Shelly is in?
Which stage of change do you think Julia is in?
Stage Specific Interventions
To maximize chances for success, interventions must be matched to the client’s stage of readiness for change.
Precontemplation - Clients in this stage don’t think that they have a problem – even if those around them think so. These clients usually don’t show up at your door asking for help. The main goal in this phase, if you even see client at this stage, is to engage clients and establish a trusting rapport with them so that in the future – if they come to the conclusion that they want some help – you may be one of the people that they call.
Engaging a client doesn’t have to mean telling them that they should do something about their use and when they are ready to call you, but to get to know the client and what is important to them, what is going on in their lives and what issues they are dealing with. You can inform these clients of the work that you do. And give your contact information.
Very often you meet these clients in other contexts – they attend groups, trainings, presentations, they may have friends who receive services from you, they may be receiving other services from your agency not related to drug use.
Contemplation – Clients in this stage are characterized by ambivalence – a tricky scale that could be easily upset with the wrong intervention. The intervention goal at this stage is to engage the client in discussion of his/her ambivalence and to slowly and gently uncover discrepancies in you client’s own goals and behaviors. THAT’S IT!!!
Clients in this phase often struggle with identity questions – such as “Am I an addict?” They experience changes in their own personal rules (e.g., I’ll only use on the weekends; I’ll never use when I’m alone; I’ll never use outside of my apartment; I won’t let my use interfere with my ___________ (fill in the blank e.g., job, relationship, family life, etc.). Clients test themselves in this stage. They glamorize and normalize their using/war stories. And the line of “When is enough enough” changes. It is important in this stage to “put the words of change in the client’s mouth” rather than stating for the client that changes would benefit him/her.
For example our client Shelly – she worries about her appearance and the impact on her ability to attract clients who pay her for sex, she also doesn’t like the feel of coming off meth, she’s expressed feelings of frustration and sadness regarding making changes – there is a lot to explore here. Remember to explore without jumping to making treatment suggestions!
Preparation/determination - In this stage the typical reasons that clients seek treatment is that “bad things are happening’, negative consequences (legal, job, relationships, medical, family, financial, psychiatric). Clients may focus more on solving these problems than on addressing their crystal use. They may express a feeling that their life is out of control.
There are a few key elements that may assist in maximizing clients’ engagement in treatment at this stage as well as within the Action phase
- Maximize engagement – use all rapport building skills – convey empathy! Clients may be afraid, anxious, ashamed, depressed, irritable, fatigued & paranoid, exhibit poor concentration and memory & experience drug craving. Some of their behaviors may come across as difficult, provocative &/or manipulative.
- Clients should be supported and receive positive feedback for seeking treatment
- Providers should respond quickly to client requests for support and/or treatment (e.g., initial phone inquiries) because of the high level of ambivalence common regarding treatment (strike while the iron is hot)
- Methods (e.g., daily phone calls or appointments) to screen out “those not yet ready” may be counterproductive. Authoritative approaches are discouraged. The confrontation believed to “break through denial” may be counterproductive with meth users.
- Help clients identify expectations, fears, concerns (best to do this before you get them into a program so you can problem solve barriers before they arise) & give treatment options
- Meetings with clients during this phase should be frequent and brief – perhaps multiple weekly short visits
- Keep intake assessments brief and make orientations clear and client responsibilities concise
- Providers must help clients to remediate withdrawal from meth. Clients will require adequate sleep, nutrition and exercise and should be given the opportunity and permission to partake of these restorative behaviors.
Action - Clients in this stage are/can be engaged in active treatment. They are actively setting goals to make changes in their life and are developing the skills needed to successfully carry out these goals. Structure and support are key.
Goals should be manageable (not to big or too small), measurable (so that the client can tell whether they are moving forward or not) and time limited (with a clear endpoint). Relapse prevention skills should include the following: (TIP 33)
- How to cope with substance craving
- Development of trigger identification and avoidance strategies (e.g., people, places & things)
- Development of assertiveness skills around substance refusal
- Exploration regarding how seemingly irrelevant decisions may have an impact on the probability of later use (or how to recognize the straw before it breaks the camel’s back or even gets close to the camel)
- General coping and problem solving skills (slowing down the decision making process)
- Getting rid of paraphernalia
- How to apply skills in the real world
- Ways to prevent a full relapse should an episode of use occur
- Developing support systems
Maintenance - At this stage, clients can be engaged in the continued application of skills in order to maintain gains with a focus on relapse prevention and the identification of ongoing supports around their progress.
Work with these clients should include continued work on:
- Relapse prevention strategies
- Identify ongoing supports around recovery
- Set long-term goals and problem solving around how to best accomplish them. Clients should be taught functional analysis in which they learn to identify thoughts feelings and circumstances both positive and negative that surround their drug use, triggers, cravings etc.
Relapse - If clients come to you when they have relapsed this is an opportunity. It reveals a clients trust in you to assist him/her with their addiction. As shame and guilt often strongly accompany relapse for clients, it is important to maintain a nonjudgmental and supportive stance.
The provider’s tasks with a client in this stage are to:
- Reevaluate the client’s current stage of change – what are they ready to do?
- Explore the relapse episode in order to learn from it – was it longer, shorter than previous relapses – was client able to reduce use, reduce harm, use less, use for a shorter period of time, think of consequences sooner…
- If appropriate to the client’s stage of change, work with the client to continue to develop skills required to achieve their current goals.