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From Precontemplation to Contemplation

There is a myth… in dealing with serious health-related addictive...problems, that more is always better. More education, more intense treatment, more confrontation will necessarily produce more change. Nowhere is this less true than with precontemplators. More intensity will often produce fewer results with this group. So it is particularly important to use careful motivational strategies, rather than to mount high-intensity programs...that will be ignored by those uninterested in changing the...problem behavior... We cannot make precontemplators change, but we can help motivate them to move to contemplation. –DiClemente, 1991

Before people enter treatment for substance use or quit or moderate substance use on their own, they may have been alerted by a crisis or series of escalating incidents that their current consumption pattern is an issue--at least to someone else.


If a significant other or a family member describes their substance-using behavior as problematic, substance users may react with surprise, hostility, denial, disbelief, or--occasionally--with acceptance. According to the stages-of-change model (presented in Chapter 1), those who are not yet concerned about current consumption patterns, or considering change, are in the precontemplation stage--no matter how much and how frequently they imbibe or how serious their substance use-related problems are.

Moreover, these substance users may remain in a precontemplation or early contemplation stage for years, rarely or possibly never thinking about change. Epidemiological studies indicate that only 5 to 10 percent of persons with active substance abuse disorders are in treatment or self-help groups at any one time (Stanton, 1997). One study estimated that at least 80 percent of persons with substance abuse disorders are currently in a precontemplation or contemplation stage (DiClemente and Prochaska, 1998).


Many scenarios present an opportunity for the clinician to help someone who is abusing or dependent on a substance to start on a pathway toward change--to move from precontemplation to contemplation. By definition, no one at the precontemplation stage willingly walks into a substance abuse treatment program without some reservations, but people who are at this stage are sent to or bring themselves to treatment programs.


The following situations might result in a call to a treatment facility by a substance user or by a person making a referral that could involve someone at this stage:

  • A college coach refers an athlete for treatment after he tests positive for cocaine.
  • A wife is desperate about her husband's drinking and insists she will file for divorce unless he seeks treatment.
  • A tenant is displaced from a Federal housing project for substance use.
  • A driver is referred for treatment by the court for driving while intoxicated.
  • A woman tests positive for substances during a prenatal visit to a public health clinic.
  • An employer sends an employee whose job performance has deteriorated to the company's employee assistance program, and she is subsequently referred for substance abuse treatment.
  • A physician in an emergency department treats a driver involved in a serious auto accident and discovers alcohol in his system.
  • A family physician finds physical symptoms in a patient that indicate alcohol dependence and suggests treatment.
  • A mother whose children have been taken into custody by a child protective services agency because they are neglected is told she cannot get them back until she stops using substances and seeks treatment.

In each of these situations, those with an important relationship to the substance users have stated that the substance use is risky, dangerous, aberrant, or harmful to self or others. The substance users' responses depend, in part, on their perception of the circumstances as well as the manner in which the facts are presented.


They will be better motivated to moderate their substance use or to abstain (either solely through their own efforts or with the help of a treatment program), if these key persons offer relevant information in a supportive and empathic manner, rather than being judgmental, dismissive, or confrontational. Substance users often respond to overt persuasion with some form of resistance (Rollnick et al., 1992a).


This chapter discusses a variety of proven techniques and gentle tactics that you, the clinician in a treatment facility, can use to raise the topic with people not thinking of change, to create client doubt about the commonly held belief that substance abuse is "harmless" and to lead to client conviction that substance-abuse is having, or will in the future have, significant negative results.


An assessment and feedback process is an important part of the motivational strategy, informing your clients about how their personal substance use patterns compare with norms, what specific risks are entailed, and what damage already exists or is likely to occur if changes are not made. Many clinicians have succeeded in helping significant others act as mediators and use appropriate motivational strategies for intervening with close relations who are substance users.


This chapter also discusses the following strategies for helping those in the precontemplation stage build their readiness to change: unilateral family therapy, the community reinforcement approach, and community reinforcement approach to family training. Constructive means of encouraging those clients mandated to enter treatment are described in this chapter as well.

Raising the Topic

You may find it difficult to believe that some persons entering treatment are unaware that their substance use is dangerous or causing problems. It is tempting to assume that the client with obvious clinical signs of intense and long-term alcohol use must be contemplating or ready for change. However, such assumptions may be wrong.


The new client could be at any point in the severity continuum (from mild problem use to more severe dependence), could have few or many associated health or social problems, and could be at any stage of readiness to change. The strategies you use for beginning a therapeutic dialog should be guided by your assessment of the client's motivation and readiness.

In opening sessions it is important to

  • Establish rapport and trust
  • Explore events that precipitated treatment entry
  • Commend clients for coming

These recommendations are discussed further below.

Establish Rapport and Trust

Before you raise the topic of change with people who are not thinking about it, establish rapport and trust. The challenge is to create a safe and supportive environment in which the client can feel comfortable about engaging in authentic dialog. One way to foster rapport is first to ask the client for permission to address the topic of change; this shows respect for the client's autonomy.


Next, tell the client something about how you or your program operates and how you and the client could work together. This is the time to state how long the session will last and what you expect to accomplish both now and over a specified time. Try not to overwhelm the new client at this point with all the rules and regulations of the program.


Do specify what assessments or other formal arrangements will be needed, if appropriate. If there are confidentiality issues (discussed in more detail later in this chapter), these should be introduced early in the session. It is critical that you inform the client which information will be kept private, which can be released with permission, and which must be sent back to a referring agency.


Because you are using a motivational approach, explain that you will not tell the client what to do or how and whether to change. Rather, you will be asking the client to do most of the talking--giving her perspective about both what is happening and how she feels about it. You can also invite comments about what the client expects or hopes to achieve.


Then ask the client to tell you why she has come or mention what you know about the reasons, and ask for the client's version or elaboration (Miller and Rollnick, 1991). If the client seems particularly hesitant or defensive, one strategy is to choose a topic of likely interest to the client that can be linked to substance use. A clue to such an interest might be provided by the referral source or can be ascertained by asking if the client has any stresses such as illness, marital discord, or overwork.


This can lead naturally into questions such as "How does your use of...fit into this?" or "How does your use of...affect your health?" Avoid referring to the client's "problem" or "substance abuse," because this may not reflect her perspective about her substance use (Rollnick et al., 1992a). You are trying to understand the context in which substances are used and this client's readiness to change. Of course, if you discover that she is contemplating or committed to change, you can move immediately to strategies more appropriate to later change stages (see Chapters 5 and 6).


An important point to state at the first session is whether or not you will work with a client who is obviously inebriated or high on drugs at the counseling sessions. You are not likely to receive accurate and reliable information from someone who has recently ingested a mind-altering substance (Sobell et al., 1994). Many programs administer breath tests for alcohol or urine tests for drugs and reschedule counseling sessions if substances are detected at a specified level or if a client appears to be under the influence (Miller et al., 1992).

Explore the Events That Precipitated Treatment Entry

The emotional state in which the client comes to treatment is an important part of the gestalt or context in which counseling begins. Clients referred to treatment will exhibit a range of emotions associated with the experiences that brought them to counseling--an arrest, a confrontation with a spouse or employer, or a health crisis.


People enter treatment shaken, angry, withdrawn, ashamed, terrified, or relieved--often experiencing a combination of feelings. Strong emotions can block change if you, the counselor, do not acknowledge them through reflective listening. The situation that led an individual to treatment can increase or decrease defensiveness about change.


It is important that your initial dialog be grounded in the client's recent experience and that you take advantage of the opportunities provided to increase motivation. For example, an athlete is likely to be concerned about his continued participation in sports, as well as athletic performance; the employee may want to keep her job; and the driver is probably worried about the possibility of losing his driving license, going to jail, or injuring someone.


The pregnant woman wants a healthy child; the neglectful mother probably wants to regain custody of her children; and the concerned husband needs specific guidance on convincing his wife to enter treatment.


However, clients sometimes blame the referring source or someone else for coercing them into counseling. The implication is often that this individual or agency does not view the situation accurately. To find ways to motivate change, ascertain what the client sees and believes is true.


For example, if the client's wife has insisted he come and the client denies any problem, you might ask, "What kind of things seem to bother her?" Or, "What do you think makes her believe there is a problem associated with your drinking?" If the wife's perceptions are inconsistent with the client's, you may suggest that the wife come to treatment so that differences can be better understood. Similarly, you may have to review and confirm a referring agency's account or the physical evidence forwarded by a physician to help you to introduce alternative viewpoints to the client in nonthreatening ways.


If the client thinks a probation officer is the problem, you can ask, "Why do you think your probation officer believes you have a problem?" This enables the client to express the problem from the perspective of the referring party. It also provides you with an opportunity to encourage the client to acknowledge any truth in the other party's account (Rollnick et al., 1992a).


In opening sessions, remember to use all the strategies described in Chapter 3: Ask open-ended questions, listen reflectively, affirm, summarize, and elicit self-motivational statements (Miller and Rollnick, 1991).

Commend Clients for Coming

Clients referred for treatment may feel they have little control in the process. Some will expect to be criticized or blamed; some will expect you can cure them. Others will hope that counseling can solve all their problems without too much effort. Whatever their expectations, affirm their courage in coming by saying, "I'm impressed you made the effort to get here." Praising their demonstration of responsibility increases their confidence that change is possible. You also can intimate that coming to counseling shows that they have some investment in the topic and an interest in change.


For example, you can commend a client's decision to come to treatment rather than risk losing custody of her child by saying, "You must care very much about your child." Such affirmations subtly indicate to clients that they are capable of making good choices in their own best interest.

Gentle Strategies To Use With the Precontemplator

Once you have found a way to engage the client, the following strategies are useful for increasing the client's readiness to change and encouraging contemplation.


Agree on Direction


In helping the client who is not yet thinking seriously of change, it is important to plan your strategies carefully and negotiate a pathway that is acceptable to the client. Some are agreeable to one option but not another. You honor your role as a clinician by being straightforward about the fact that you are promoting positive change.


It also may be appropriate to give advice based on your own experience and concern. However, do ask whether the client wants to hear what you have to say. For example, "I'd like to tell you about what we could do here. Would that be all right?"


Whenever you express a different viewpoint from that of the client, make clear that you intend to be supportive--not authoritative or confrontational. The client still has the choice about whether to heed your advice or agree to a plan. It is not necessary at this early stage in the process to agree on treatment goals.

Types of precontemplators

Persons with addictive behaviors who are not yet contemplating change can be grouped into four categories (DiClemente, 1991). Each category offers you guidance about appropriate strategies for moving clients forward:


Reluctant precontemplators lack sufficient knowledge about the dimensions of the problem, or the personal impact it can have, to think change is necessary. They often respond to sensitive feedback about how substance use is actually affecting their lives.
Rebellious precontemplators are afraid of losing control over their lives and have a large investment in their substance of choice.


Your challenge is to help them shift this energy into making more positive choices for themselves rather than rebelling against what they perceive as coercion. Emphasizing personal control can work well with this type of client.


Resigned precontemplators feel hopeless about change and overwhelmed by the energy required. They probably have been in treatment many times before or have tried repeatedly to quit on their own to no avail. This group must regain hope and optimism about their capacity for change. This can sometimes be accomplished by exploring specific barriers that impede new beginnings.


Rationalizing precontemplators have all the answers. Substance use may be a problem for others but not for them, because the odds are against their being at risk. Double-sided reflection, rather than reasoned argument, seems the most effective strategy for this type of client. Acknowledge what the client says, but add any qualms the client may have expressed earlier (see Chapter 3).

Assess Readiness To Change

When you meet the client for the first time, ascertain her readiness to change. This will determine what intervention strategies are likely to be successful. There are several ways to assess a client's readiness to change. Two common methods are described below (see Chapter 8 for other instruments to assess readiness to change).

Readiness Ruler

The simplest way to assess the client's willingness to change is to use a Readiness Ruler (see Chapter 8 and Figure 8-2) or a 1 to 10 scale, on which the lower numbers represent no thoughts about change and the higher numbers represent specific plans or attempts to change.


Ask the client to indicate a best answer on the ruler to the question, "How important is it for you to change?" or, "How confident are you that you could change if you decided to?" Precontemplators will be at the lower end of the scale, generally between 0 and 3. You can then ask, "What would it take for you to move from an x (lower number) to a y (higher number)?"


Keep in mind that these numerical assessments are not fixed, nor are they always linear. The client moves forward or backward across stages or jumps from one part of the continuum to another, in either direction and at various times. Your role is to facilitate movement in a positive direction.

Description of a typical day

Another, less direct, way to assess readiness for change, as well as to build rapport and encourage clients to talk about substance use patterns in a nonpathological framework, is to ask them to describe a typical day (Rollnick et al., 1992a). This approach also helps you understand the context of the client's substance use.


For example, it may reveal how much of each day is spent trying to earn a living and how little is left to spend with loved ones. By eliciting information about both behaviors and feelings, you can learn much about what substance use means to the client and how difficult--or simple--it may be to give it up. Substance use is the most cohesive element in some clients' lives, literally providing an identity.


For others it is powerful biological and chemical changes in the body that drive continued use. Alcohol and drugs mask deep emotional wounds for some, lubricate friendships for others, and offer excitement to still others.


Start by telling the client, "Let's spend the next few minutes going through a typical day or session of...use, from beginning to end. Let's start at the beginning." Clinicians experienced in using this strategy suggest avoiding any reference to "problems" or "concerns" as the exercise is introduced. Follow the client through the sequence of events for an entire day, focusing on both behaviors and feelings. Keep asking, "What happens?"


Pace your questions carefully, and do not interject your own hypotheses about problems or why certain events transpired. Let clients use their own words and ask for clarification only when you do not understand particular jargon or if something is missing.

Provide Information About the Effects and Risks of Substance Use

Provide basic information about substance use early in the treatment process if clients have not been exposed to drug and alcohol education before and seem interested. Tell clients directly, "Let me tell you a little bit about the effects of..." or ask them to explain what they know about the effects or risks of the substance of choice.


To stay on neutral ground, illustrate what happens to any user of the substance, rather than referring just to the client. Also, state what experts have found, not what you think happens. As you provide information, ask, "What do you make of all this?" (Rollnick et al., 1992a).


It is sometimes helpful to describe the addiction process in biological terms to persons who are substance dependent and worried that they are crazy. Understanding facts about addiction can increase hope as well as readiness to change. For example, "When you first start using substances, it provides a pleasurable sensation.


As you keep using substances, your mind begins to believe that you need these substances in the same way you need life-sustaining things like food--that you need them to survive. You're not stronger than this process, but you can be smarter, and you can regain your independence from substances."


Similarly, people who have driven under the influence of alcohol may be surprised to learn how few drinks constitute legal intoxication and how drinking at these levels affects their responses.


A young woman hoping to have children may not understand how substances can diminish fertility and potentially harm the fetus even before she knows she is pregnant. A client may not realize how alcohol interacts with other medications he is taking for depression or hypertension.

Use Motivational Language in Written Materials

Remember that the effective strategies for increasing motivation in face-to-face contacts also apply to written language. Brochures, flyers, educational materials, and advertisements can influence a client to think about change. However, judgmental language is just as off-putting in these contexts as it is in therapy.


For example, such words as "abuse" or "denial" may be turnoffs. All literature on the counseling services you provide should be written with motivation in mind. If your brochure starts with a long list of rules, the client may be scared away rather than encouraged to come in for treatment. Review written materials from the viewpoint of the prospective client and keep in mind your role as a partner in a change process for which the client must take ultimate responsibility.

Create Doubt and Evoke Concern

As clients move beyond a precontemplation stage and become aware of or acknowledge some problems in relation to their substance use, change becomes an increased possibility. Such clients become more aware of conflict and feel greater ambivalence (Miller and Rollnick, 1991). The major strategy for moving clients from a precontemplation to a contemplation stage is to raise doubts in them about the harmlessness of their substance use patterns and to evoke concerns that all is not well after all.


One way to foster concern in the client is to explore the good and less good aspects of substance use. Start with the client's perceptions about the possible "benefits" of alcohol or drugs and move on a continuum to less beneficial aspects rather than setting up a dichotomy of bad things or problems associated with substance use. If you limit the discussion to negative aspects of substance use, the client could end up defending the substance use while you become the advocate for unwanted change.


In addition, the client may not be ready to perceive any harmful effects of substance use. By showing that you understand why the client values alcohol or drugs, you set the stage for a more open acknowledgment of emerging problems. For example, you might ask, "Help me to understand what you like about your drinking. What do you enjoy about it?" Then move on to ask, "What do you like less about drinking?" The client who cannot recognize any of the less good things related to substance use is probably not ready to consider change and may need more information.


After this exploration, summarize the interchange in personal language so that the client can clearly hear any ambivalence that is developing: "So, using...helps you relax, you enjoy doing...with friends, and...also helps when you are really angry. On the other hand, you say you sometimes resent all the money you are spending, and it's hard for you to get to work on Mondays" (Rollnick et al., 1992a).Chapter 5 provides additional guidance on working with ambivalence.


You can also move clients toward the contemplation stage by having them consider the many ways in which substance use can affect life experiences. For example, you might ask, "How is your substance use affecting your studies? How is your drinking affecting your family life?" As you explore the effects of substance use in the individual's life, use balanced reflective listening: "Help me understand. You've been saying you see no need to change, and you also are concerned about losing your family. I don't see how this fits together. It must be confusing for you."

Assessment and Feedback Process

Most treatment programs require that clients complete assessment questionnaires and interviews as part of the intake process. Sometimes these are administered all at once, which places a significant burden on the client and poses an obstacle to entering treatment. The program may request that the client go to one or more locations to complete the assessment, requiring the investment of considerable time and energy.


Although the treatment counselor may conduct intake evaluations, assessments often are administered by someone the client does not know and may not see or be involved with again. Too often, programs do not use the results of intake evaluations for treatment planning but, rather, to confirm a diagnosis or to rule out physical or emotional problems that it cannot treat.


More and more programs, however, now emphasize comprehensive evaluations along a number of dimensions that will help clinicians tailor care to individual needs and set priorities for treatment. The domains assessed usually depend on the types of clients treated and the kinds of services offered.


For example, an inner-city substance abuse treatment program will probably have more interest in an applicant's criminal history, employment skills, housing arrangements, and HIV test results than an outpatient evening program for alcohol-abusing middle class professionals.


Clinicians also have discovered that giving clients personal results from a broad-based and objective assessment, especially if the findings are carefully interpreted and compared with norms or expected values, can be not only informative but also motivating (Miller and Rollnick, 1991; Miller and Sovereign, 1989; Miller et al., 1992; Sobell et al., 1996b).


This is particularly true for clients who misuse or abuse alcohol because there are social norms for alcohol use, and numerous research studies show levels beyond which consumption is risky in terms of specific health problems or physical reactions.

Source

Enhancing Motivation for Change in Substance Abuse Treatment, Treatment Improvement Protocol (TIP) Series 35, Chapter 4. SAMHSA 1999-2012