Motivational

Enhancement
Therapy

Pat Sandau-Beckler

New Mexico State University

Department of Social Work
 Life Change

Think of a time that you changed something
in your life . . .

I. How long did it take?

II. Where did the ideas for change come from?

III. Who provided you support?

IV. Who did not provide support?


What implications does the answer
to this question have for our
practice with families?
Frustrations
What are your greatest frustrations in
trying to motivate clients to
change?
 Life Change

How can we help people increase their motivation
to change?

What prevents people from being motivated to
change?

How do people get motivated to change on their
own?

How do we hinder people from being motivated to
change?

What are signs that people are motivated to
change?
Assessing Motivation for Change

Individual/Family
Change
Change process
Match skills
Change spiral
Change Process

Precontemplation
Precontemplation Contemplation
Contemplation

Maintenance
Maintenance Preparation
Preparation

Action
Action
 Change Process

Precontemplation- people not thinking
about or does not want to change a
particular behavior not aware of the
problem or aware of the problem and
have no concerns.

Contemplation- person is thinking about
changing but is ambivalent.
 Change Process

Preparation- seriously considering and
planning for change a behavior and is
preparing to take steps.

Action- actively doing things to change
or modify behavior.

Maintenance- works on maintenance of
behavior until it becomes permanent.
Stages of Change and
Therapist’s Tasks
Client Stage Therapist motivational
tasks
Precontemplation Raise doubt-increase the
client’s perception of
risk and problems with
current behavior
Contemplation Tip the balance-evoke
reasons to change,
risks of not changing;
strengthen the client’s
self-efficacy for
change of current
behavior
Stages of Change and
Therapist Tasks
Determination Help the client to
determine the best
course of action to
take in seeking
change

Action Help the client to take

steps toward change
Stages of Change and
Therapist Tasks
Maintenance Help the client to identify
and use strategies to
prevent relapse

Relapse Help the client to renew the

processes of
contemplation,
determination , and action
without becoming stuck
or demoralized because
of relapse
 A Spiral Model of the Stages of Change
Termination
Termination

Maintenance
Maintenance

Relapse
Relapse
Action
Action
Pre-contemplation
Pre-contemplation
Contemplation
Contemplation Preparation
Preparation
 Pre-contemplation

Consciousness
Consciousness
raising
Contemplation
raising
Engagement
Engagement
Dramatic
Dramatic Relief
Relief Preparation
Environmental
Environmental
evaluation
evaluation
Self-reevaluation
Self-reevaluation
 Preparation

Self-reevaluation
Self-reevaluation Action

Self
Self Liberation
Liberation Maintenance

Reinforcement
Reinforcement management
management
Helping
Helping relationship
relationship
Counter
Counter conditioning
conditioning
Stimulus
Stimulus control
control
 Processes of Change

Pre-contemplation

Consciousness Raising
Finding and learning new facts, ideas, and tips that support the healthy
behavioral change

Engagement
Experiencing empathy

Dramatic Relief
Experiencing the negative emotions (fear, anxiety, worry) that go along
with unhealthy behavioral risks

Environmental Re-evaluation
Realizing the negative impact of the unhealthy behavior or the positive
impact of the healthy behavior on one’s proximal social and physical
environment
 Processes of Change

Contemplation

Self-reevaluation
Realizing that the behavioral change is an important part of one’s
identity as a person

Preparation

Self-liberation
Making a firm commitment to change

Action

Social Liberation
Realizing that the social norms are changing in the direction of
supporting the healthy behavioral change
 Processes of Change

Maintenance

Reinforcement
Increasing the rewards for the positive behavioral change and
decreasing the rewards of the unhealthy behavior

Helping Relationships
Seeking and using social support for the healthy behavioral change

Counter-Conditioning
Substituting healthier alternative behaviors and cognitions for the
unhealthy behaviors

Stimulus Control
Removing reminders or cues to engage in the unhealthy behavior and
adding cues or reminders to engage in the healthy behavior
Factors Accounting for Change in Therapy

Client Factors
40.0%

Relationship Model and

Factors Technique
Hope 15.0%
30.0%
and
Expectancy
15.0%
Therapist Influences

Therapist empathy as defined by
Rogers (not to be confused with
recovery status) is associated with
more favorable client outcomes (see
Miller, 1985; Miller, Taylor & West,
1980; Valle, 1981).
 Therapist Influences

Motivation can be thought of not as
a client attribute, but as an
interpersonal process between
therapist and client. Research
clearly demonstrates that the
interaction between therapist and
client powerfully influences client
resistance, compliance and change.
 Therapist Influences

With relatively simple actions such as a
follow-up note or phone call, therapists
can double the probability that clients will
return for further counseling after an initial
or a missed session (see Miller, 1985).
Six Traps to Avoid in
Opening Sessions
1. The question-answer trap
2. The confrontational-denial trap
3. The expert-trap
4. The labeling trap
5. The premature trap
6. The blaming trap
What to do to Avoid the Trap?

The question –answer trap- open ended
questions

The confrontation-denial trap– maybe so,
maybe not, reflective listening, elicit
motivated strengths

The expert trap- you are the expert
What to do to Avoid the Trap?

The labeling trap- no I don’t care about
labels, what really matters is how the ____is
affecting your health and relationships

The premature trap- discuss larger issues,
start with their concerns.

The blaming trap- I am not interested in
blame.
Five Opening Strategies for
Relationship Development
1. Ask open questions
2. Listen Reflectively
3. Summarize
4. Affirm
5. Eliciting self-motivational
statements
Handling Resistance
1. How to recognize it
2. Ways to understand it
a. Describe how you thought,
felt behaved the last time you had
to do something you were
reluctant to do.
3. What is your role in influencing
resistance
Strategies for Handling
Resistance
1. Simple reflection
2. Amplified Reflection
3. Double-sided Reflection
4. Shifting focus
5. Reframing
6. Agreement with twist
7. Emphasizing personal control
8. Siding with the negative
 Decisional Balance
Pros The benefits of The benefits of
staying the same changing

Cons The costs of The costs of

staying the same changing
 Discrepancy Questions

How would your life be different if you followed this
idea and quit altogether?

You have said you would like to cut down, so let’s
talk about that for a while. How do you think this
would work?

So that’s your goal. What can you think of that
might go wrong with this plan?

If you succeeded in achieving this goal, what else
do you think might happen? What might be good,
and what might be not so good, about reaching
this goal?
 Self-Motivational
Statements
1. Problem Recognition
2. Concern
3. Intention to Change
4. Optimism for change
Eliciting Self-Motivation
Statements in Contemplation
1. Asking evocative questions
2. Exploring pros & cons
3. Asking for elaboration
4. Imagining extremes
5. Looking backward
6. Looking forward
 Summarizing

1. A summary of the client’s own perceptions of the problem, as

reflected in his or her self-motivational statements.

2. A summing-up of the client’s ambivalence, including what

remains positive or attractive about the problem behavior.

3. A review of whatever objective evidence you have regarding

the presence of risks and problems.

4. A restatement of any indication the client has offered of

wanting, intending, or planning to change.

5. Your own assessment of the client’s situation, particularly at

points where it converges with the client’s own concerns.
 Signs of Readiness for Change
1. Decreased resistance. The client stops arguing, interrupting, denying, or
objecting.

2. Decreased questions about the problem. The client seems to have enough
information about his or her problem and stops asking questions. There is a
sense of being finished.

3. Resolve. The client appears to have reached a resolution, and may seem more
peaceful, relaxed, calm, unburdened, or settled. Sometimes this happens after
the client has passed through a period of anguish or tearfulness.

4. Self-motivational statements. The client makes direct self-motivational

statements (see Chapter 6), reflecting recognition of a problem (“I guess this is
serious”), concern (“This worries me”), openness to change (“I need to do
something”), or optimism (“I’m going to beat this”).
 Signs of Readiness for Change
(continued)

5. Increased questions about change. The client asks what he or she could do
about the problem, how people change if they decide to, or the like.

6. Envisioning. The client begins to talk about how life might be after a change, to
anticipate difficulties if a change were made, or to discuss the advantages of
change.
7. Experimenting. If the client has had time between sessions, he or she may have
begun experimenting with possible change approaches (e.g., going to an
Alcoholics Anonymous meeting, going without drinking for a few days, reading a
self-help book).
 Key Change Questions
What do you think you will do?

What does this mean about your drinking?

It must be uncomfortable for you now, seeing all this…..What’s the next step?

What do you think has to change?

What could you do? What are your options?

It sounds like things can’t stay the way they are now. What are you going to do?

Of the things I have mentioned here, which for you are the most important reasons
for change?…How are you going to do it?

What’s going to happen now? Where do we go from here?

How would you like things to turn out for you now, ideally?

What concerns you about changing your use of drugs?

What would be some of the good things about making a change?

 Key Change Questions (continued)

How would you like for things to be different?

What is it that you want to change?

If you were completely successful in accomplishing what you want now, what would
be changed?

Let’s take things one step at a time. What do you think is the first step?
Client Decision Making Process
1. List your personal values and prioritize
them.
2. List your options( the therapist can
brainstorm with the client).
3. Write the possible outcomes for each
option.
4. Get more information about the possible
outcomes.
5. Write the pros and cons for each option.
6. Talk with 3 supportive/trusted people about
the options.
Client Decision Making Process
7. Talk with 3 supportive/trusted people about
the options.
8. Determine which option corresponds most
closely with your values.
9. Determine which option is the healthiest for
all involved.
10. Make a decision that you can commit to for
specified period of time.
11. Re-evaluate and/or make changes after the
specified period of time.
 ADVICE GIVEN

I’ll be happy to give you some ideas, but I don’t want to get in the way of your
own creative thinking, and you’re the expert on you.

I’m not sure you really want my advice. Maybe you have some ideas of your
own about what to do.

Of course I can tell you what I think, if you really want to know. But I don’t want
you to feel like I’m telling you what you have to do.

Would my opinion really make a difference to you?

I don’t know if this would work for you or not, but I can give you an idea of what
had worked for some other people in your situation.

This may or may not make sense to you, but it’s one possibility. You’ll have to
judge whether it applies to you.

I can give you an idea, but I think you’d have to try it out to see if it would work
for you.

All I can give you, of course, is my own opinion. You’re really the one who has
to find what works for you.

Some people have…(make suggestion). I wonder whether that would work for
you?
 Six common core elements which involve
changes in problem drinkers - frames


Feedback of personal risk or impairment

Emphasis on personal responsibility for change

Clear advice to change

A menu of alternative change options

Therapist empathy

Facilitation of client self-efficacy or optimism
Five Basic Motivational Principles


Express Empathy

Develop Discrepancy

Avoid Argumentation

Roll with Resistance

Support Self-Efficacy
 Three Major Phases of MET
I. Building Motivation for Change

Eliciting self-motivational statement

Listening with empathy

Questioning

Presenting personal feedback

Affirming the client

Handling resistance

Re-framing

Summarizing
 Three Major Phases of MET (continued)
II. Strengthening Commitment to Change

Recognizing change readiness

Discussing a plan

Communicating free choice

Consequences of action and inaction

Information and advice

Emphasizing abstinence

Dealing with resistance

The Change Plan Worksheet

Recapitulating

Asking for a commitment

Involving a significant other

Goals for significant other involvement

Explaining the significant other’s role
 Three Major Phases of MET (continued)

III. Follow Through Strategies


Reviewing progress

Renewing motivation

Re-doing commitment

From Miller, W.R. & Rollnick, S. (1991). Motivational interviewing: Preparing people to change
addictive behavior. New York: The Guilford Press.
In Motivational Interviewing, it is the client who
presents the arguments for change.
Problem recognition


I guess there’s more of a problem here
than I thought.

I never realized how much I am drinking.

This is serious!

Maybe I have been taking foolish risks .

I can see that in the long run, my
gambling is going to do me in.
Expression of control

I’m really worried about this.

How could this happen to me? I
can’t believe it!

I feel pretty hopeless.
 Change Questions


The most important reasons why I want to make a change
are….

My main goals for myself, in making a change, are…

I plan to do these things in order to reach my goals:
Plan of action When

The first steps that I plan to take in changing are…

Other people could help me in changing in these ways:
Person Possible ways to help

I hope that my plan will have these positive results:
 Times of Change
Action Has changed overt
behavior for less
than 6 months
Maintenance Has changed overt
behavior for more
than 6 months
Contrast Between Nondirective and
Motivational Interviewing Approach
Nondirective approach Motivational interviewing
approach
Allows the client to Systematically directs the
determine the content client toward motivation
and direction of for change
counseling
Avoids injecting the Offers the counselor’s
counselor’s own advice own advice and
and feedback feedback where
appropriate
Contrast Between Nondirective and
Motivational Interviewing Approach
Empathetic reflection is Empathetic reflection is
used used selective, to
noncontingently reinforce certain
processes
Explores the client’s Seeks to create and amplify
conflicts and the client’s discrepancy in
emotions as they order to enhance
exist currently motivation for change
Responses that are not
Listening
1. Ordering, directing, or commanding
2. Warning or threatening
3. Giving advice, making suggestions, or
providing solutions
4. Persuading with logic, arguing, or lecturing
5. Moralizing preaching, or telling client what
they “should” do
6. Disagreeing, judging, criticizing, or blaming
Responses that are not
Listening
7. Agreeing, approving, or praising
8. Shaming, ridiculing, or labeling
9. Interpreting or analyzing
10. Reassuring, sympathizing, or
consoling
11. Questioning or probing
12. Withdrawing, distracting, humoring,
or changing the subject.
Motivational Interviewing, it is the client
who presents the arguments for
change
Problem recognition

I guess there’s more of a problem here that I
thought.

I never really realized how much I am
drinking.

This is serious!

Maybe I have been taking foolish risks.

I can see that in the long run, my gambling is
going to do me in.
Expression of concern


I’m really worried about this.

How could this happen to me? I
can’t believe it!

I feel pretty hopeless.
Intention to Change

I think it’s time for me to think
about quitting.

I’ve got to do something about this.

This isn’t how I want to be. What
can I do?

I don’t know how I’m going to do it,
but I’ve got to ma a change.

How do people quit a habit like
this?
Optimism

I think I can do it.

Now that I’ve decided, I’m sure I
can change.

I’m going to overcome this
problem.
Sample Questions to Evoke
Self-Motivational Statements
1. Problem Recognition
What things make you think that his is a
problem?
What difficulties have you had in relation to
your drug use?
In what ways do you think you or other people
have been harmed by your drinking?
In what ways has this been a problem for
you?
How has your use of tranquilizers stopped you
from doing what you want to do?
2. Concern

What is there about your drinking that
you or other people might see as a
reason for concern?

What worries you about your drug use?
What can you imagine happening to
you?

How do you feel about your gambling?

How much does that concern you?

In what ways does this concern you?

What do you think will happen if you
don’t make a change?
3. Intention to Change

The fact that you’re here indicates
that at least a part of you thinks it’s
time to do something.

What are the reasons you see for
making a change?

What makes you think that you
need to make a change?
3. Intention to Change

If you were 100% successful and
things worked out exactly as you
would like, what would be
different?

What things make you think that
you should keep on drinking the
way you have been?…And what
about the other side ? What
makes you think it’s time for a
change?
3. Intention to Change

What are you thinking about your
gambling at this point?

What would be the advantages of
making a change

I can see that you’re feeling stuck
at t he moment. What is going to
have to change?
4. Optimism

What make you think that if you did
decide to make a change, you
could do it?

What encourages you that you can
change if you want to?

What do you think would work for
you, if you decided to change?
Using extremes

What concerns you t he most?

What are your worst fears about
what might happen if you don’t
make a change?

What do you suppose are the
worst things that might happen if
you keep on the way you’ve been
going?
Looking Back

Do you remember a time when
things were going well for you?
What has changed?

What were things like before you
started drinking so heavily? What
were you like back then?
Looking Back

Tell me about how you two met
each other, and what attracted you
to each other back then. What
was it like?

What are the differences between
that Pat of 10 years ago and the
Pat of today?

How has your use of drugs
stopped you from growing, from
moving forward?
 Looking Forward

If you decide to make a change, what are
your hopes for the future?

How would you like things to turn our for
you?

I can see that you’re feeling really
frustrated right now. How would you like
things to be different?

What are the options for you now? What
could you do?

What would be the best results you could
imagine if you make a change?
Four Categories of Client
Resistance Behavior
1. Arguing. The client contests the
accuracy, expertise, or integrity of the
therapist.
1a. Challenging. The client directly
challenges the accuracy of what the
therapist has said.
1b. Discounting. The client questions
the therapist’s personal authority and
expertise.
1c. Hostility. The client expresses direct
hostility toward the therapist.
 2. Interrupting

The client breaks in and interrupts the
therapist in a defensive manner.
2a. Talking over. The client speaks
while the therapist is still talking,
without waiting for an appropriate
pause or silence.
2b. Cutting off. The client breaks in with
words obviously intended to cut the
therapist off. (e.g., Now wait a
minute. I’ve heard about enough”).
3. Denying.

The client expresses an
unwillingness to recognize
problems, cooperate, accept
responsibility, or take advice.
3a. Blaming. The client blames
other people for problems.
3. Denying.
3b. Disagreeing. The client
disagrees with a suggestion that
the therapist has made, offering no
constructive alternative. This
includes the familiar “yes but…”,
which explains what is wrong with
suggestions that are made.
3c. Excusing. The client makes
excuses for his of her own
behavior.
3. Denying.
3d. Claiming impunity. The client
claims that he or she is not in any
danger (e.g., from drinking.
3f. Pessimism. The client makes
general statements about self or
others that are pessimistic,
defeatist, or negativistic in tone.
3. Denying.
3g. Reluctance. The client
expresses reservations and
reluctance about information or
advice given.
3h. Unwillingness to change. The
client expresses a lack of desire or
an unwillingness to change, or an
intention not to change.
4. Ignoring.

The client shows evidence of not
following or ignoring the therapist.
4a. Inattention. The client’s
response indicates that he or she
has not been following or attending
to the therapist.
4. Ignoring.
4b. Nonanswer. In answering a therapist’s
query, the client gives a response that is
not an answer to the question.
4c. No response. The client gives no
audible or nonverbal reply to a
therapist’s query.
4d. Sidetracking. The client changes the
direction of the conversation that the
therapist has been pursuing.
 Advice

I’ll be happy to give you some
ideas, but I don’t want to get in the
way of your own creativity.

I’m not sure you really want my
advice. Maybe you have some
ideas of your own about what to
do.
 Advice

Of course I can tell you what I
think, if you really want to know.
But I don’t want you to feel like I’m
telling you what you have to do.

Would my opinion really make a
difference to you?

I don’t know if this would work for
you or not, but I can give you an
idea of what has worked for some
other people in your situation.
 Advice

This may or may not make sense to you, but
it’s one possibility. You’ll have to judge
whether it applies to you.

I can give you and idea, but I think you’d have
to try it out to see if it would work for you.

All I can give you, of course is my own opinion.
You’re really the one who has to find what
works for you.

Some people have….(make suggestion). I
wonder whether that would work for you.
Signs of Readiness for Change
1. Decreased resistance. The client stops
arguing, interrupting, denying, or objecting.
2. Decreased questions about the problem.
The client seems to have enough
information about his or her problem, and
stops asking questions. There is a sense
of being finished.
3. Resolve. The client appears to have
reached a resolution, and may seem more
peaceful, relaxed, calm, unburdened, or
settled. Sometimes this happens after the
client has passed through
Signs of Readiness for Change
4. Self-motivational statements. The
client makes direct self-motivational
statements, reflecting recognition of
a problem (“I guess this is serious”),
concern (“This worries me”),
openness to change (“I need to do
something”), or optimist (I’m going to
beat this”).
5. Increased questions about change.
The client asks what he or she could
do about he problem, how people
change if they decide to, or the like.
Signs of Readiness for Change
6. Envisioning. The client begins to talk
about how life might be after a
change, to anticipate difficulties if a
change were made, or to discuss the
advantages of change.
7. Experimenting. If the client has had
time between sessions, he or she
may have begun experimenting with
possible change approaches (e.g.,
going to an Alcoholics Anonymous
meeting, going without drinking for a
few days, reading a self-help book).
Therapy Technique May Not
Matter Much

The fist and largest variance in
outcome, 40 percent, can be attributed
to factors outside the therapy itself.

These include the client’s context
(neighborhood and family, peer, social,
workplace and spiritual supports) and
the client as the common factor (therapy
facilitates naturally occurring healing
aspects of client’s lives, like intelligence,
motivation, trust and resilience).
Therapy Technique May Not
Matter Much

The number, symptoms and severity of
problems identified; capacity to relate;
and ability to identify a focal problem.


Lambert estimates that 30 percent of
outcome variance comes from the
therapeutic relationships, which included
caring, warmth, empathy, acceptance,
mutual affirmation, and encouragement.
Therapy Technique May Not
Matter Much

What is more important is hoe the
therapist comes across to the client,
how the (clients) interpret us connected
to their context-that’s the real deal. Is
how we act for that one person to that’s
pivotal to their success. That’s the
caring, warmth, empathy and basic
things that also fit with NASW’s Code of
Ethics.
Therapy Technique May Not
Matter Much

Lambert attributes only 15 percent of
outcome variance to therapy technique
unique to a specific treatment, such as
systematic desensitization, biofeedback,
the miracle question in solution-focused
therapy, genograms in Bowenian family
therapy, the psychodynamic therapists’
focus on strengths, or behavior
therapists’ focus on behavior.
Therapy Technique May Not
Matter Much

“The catch is, it may be that my belief in
a model and my ability to convey that
persuasively to the client, and their
belief in my faith, in turn, is what makes
it work.

The specific technique is less important
than my allegiance to it and the comfort
it gives me that this can make a change
so you can take comfort in it.
Therapy Technique May Not
Matter Much

The other 15 percent of outcome
variance Lambert attributes to the
placebo effects, the hope and
expectance that comes from knowledge
clients have that they are working in a
ritualized format that is an accepted
approach to successful change.
Therapy Technique May Not
Matter Much

Seventy-nine percent of people
treated with psychotherapy will do
better at a point four months our than
people untreated.


Empirical evidence shows that
therapy works.
Therapy Technique May Not
Matter Much

Theory and technique are important, but
social work places great value on
relationships, and the profession needs
to emphasize this component of
psychotherapy.

Attention to contextual factors, client
factors like readiness to change and
therapist variables deserve consistent
attention in social work education, along
with theory and technique.
Therapy Technique May Not
Matter Much

We should pay more attention to
relationships. Nobody in the world
would disagree with that.

“Given the weight of the evidence, it
may make sense to consider differential
effects or the lack thereof in respect to
specified problem, population and
intervention match-ups rather than to
refer to a general tie-score effect…,”
wrote Reid.
Summarizing Ambivalence

A summary of the client’s own
perceptions of the problem, as reflected
in his or her self-motivational statements.

A summing-up of the client’s
ambivalence, including what remains
positive or attractive about the problem.

A review of whatever objective evidence
you have regarding the presence of risks
and problems.
Summarizing Ambivalence

A restatement of any indications
the client has offered of wanting,
intending, or planning to change.

Your own assessment of the
client’s situation, particularly at
points where it converges with the
client’s own concerns.
Shortcomings of a Characterologic
View of Motivation

For alcoholism:
 that half a century of research has failed
to reveal a unique alcoholic, addictive or
co-dependent personality type or types.
 Specifically, research has failed to
demonstrate that alcoholics show
atypically high levels of any particular
defensive style or are inherently less
honest than others in their self report.
Shortcomings of a Characterologic
View of Motivation

More generally:
 ascribing motivation to an inner client trait
often involves circular reasoning: one
might infer that a client is motivated or
not from the extent to which they change,
then use the concept of motivation to
explain the behavior.
 this view is a thinly-veiled version of a
moral model: failure is in essence
blamed on the client and specifically
attributed to internal, stable
characteristics.
The People’s Own Resources

Natural recovery. Contrary to popular
belief, most people with alcohol
problems (like most smokers) change on
their own, without formal treatment or
self-help group assistance. “Self-
change” without formal treatment is not
the exception, it is the most common
form of change in many problem areas.
The People’s Own Resources


Placebo effect. The placebo effect is a
well demonstrated phenomenon not only
in pain relief but in addiction treatment
as well. People who faithfully take
placebo medication, for example, are
significantly more likely to have favorable
outcomes (e.g., Fuller et al., 1986).
The People’s Own Resources

Compliance effect. More
generally, people who faithfully
comply with virtually any change
effort are more likely to succeed in
changing.
The People’s Own Resources

Brief invention. A large literature (for
review see Bien, Miller and Tonigan, 1993)
shows that brief motivational counseling of
1-3 sessions is sufficient to trigger change
for many problem drinkers, is significantly
better than no intervention and produces
outcomes that are often surprisingly similar
in magnitude to those following more
extensive treatment.
 Responsibility
Effective brief interventions have also
emphasized the individual’s freedom
of choice and personal responsibility
for change. General themes are: 1)
It’s up to you; you’re free to decide to
change or not; 2) No one else can
decide for you or force you to change;
3) You’re the one who has to do it if
it’s going to happen.
Conceptual Models
PRECONTEMPLATION is the state in
which people are not considering
change. Sometimes this stage is
placed outside the wheel, implying that
people leave it permanently once they
began to contemplate. When
Precontemplation is drawn inside the
wheel, the implication is that people
can go back to it or recycle around to it
again.
 Conceptual Models
CONTEMPLATION is the stage characterized
by ambivalence or a more conscious
decisional balance process. “Confronting”
contemplators is likely to evoke resistance by
eliciting counterargument (Miller, 1983).
Prochaska and DiClemente have at times
distinguished between early and late
contemplators, depending on the extent to
which they are
approaching change.
 Conceptual Models
DETERMINATION or DECISION was
a stage included in the original
transtheoretical model. It implied a
moment or window of opportunity in
which the person had made a firm
decision or commitment to change,
but may not yet have taken action.
 Conceptual Models

Because of the difficulty in isolating this
stage in their research subjects,
Prochaska and DiClemente removed
the stage, returning to a five-stage
model. They subsequently began to
differentiate early from late
contemplation and later they added a
PREPARATION stage between
Contemplation and Action, during which
Conceptual Models
the person has decided to take
action but has not yet done so.
PREPARATION corresponds with
“late Contemplation” as well as
certain aspects of the original
Decision stage.
Conceptual Models
ACTION is the stage characterized by the
taking of action in order to achieve
change. It persists as long as active
change efforts are underway and the
change goal has not been attained.
This is the stage corresponding to most
“treatment” as well.
 Conceptual Models
MAINTENANCE. Once a change goal
has been attained, the challenge is to
prevent backsliding or relapse. Efforts
to maintain change often involve
different strategies from those used to
achieve change in the first place.
Conceptual Models
RELAPSE. Sometimes Relapse is
described as a separate stage
occurring when the person’s
maintenance efforts have failed
and sometimes the event of
relapse is seen simply as
movement from Maintenance back
into Precontemplation or
Contemplation.
 Conceptual Models
The overall model has 4, 5 or 6 stages
depending upon whether
Precontemplation and Relapse are
considered separate stages within the
wheel. If both are excluded, individuals
are seen as cycling through
Contemplation, Preparation or
Determination, Action and Maintenance.
We prefer the full six-stage model. Note
that whatever the number of stages,
movement is possible in either direction.
Basic Steps
1. Recapitulation. This is a grand
summary reflection of all that has
transpired so far, with particular
emphasis on self-motivational
themes that have emerged.
Basic Steps
2. Key Question. The immediate
transition from the summary
statement is to ask a key question.
Examples we have provided
include:
What do you think you will do?
What does this mean about your
drinking?
What do you think has to change?
 Basic Steps
2. Key Question - cont.
It must be uncomfortable for you now,
seeing all this… What’s the next step?
What could you do? What are you
options?
It sounds like things can’t stay the way
they are now. What are you going to do?
Of the things I have mentioned here, which
for you are the most important reasons for
a change?
 Basic Steps
3. Reflective Listening. Follow what the
client offers in response to key questions.
Continue to use reflective skills.
4. Provide Information and Advice. When
needed and requested, offer information
and advice. The key is to present options
in a way that the client finds them
acceptable.
Among the recommendations are:
 Basic Steps
4. Provide Information and Advice - cont.
First, always ask for the client’s own
ideas. Often clients have a very good
sense of what they need to do and what
will work for them. This is useful as a
first approach, even when the client has
asked you what to do.
Basic Steps
4. Provide Information and Advice -
cont.
If ideas seem to be needed, ask
permission before offering
suggestions. Be sure the client
wants to hear your ideas
 Basic Steps
4. Provide Information and Advice -
cont.
Give the client permission to reject
your ideas. “I don’t know whether any
of these will make sense for you, but
here are some things that have worked
for other people.” This tends to defuse
resistance, emphasizing personal
control and choice.
 Basic Steps
4. Provide Information and Advice - cont.
Don’t make just one suggestion. That
leads the client to explain why it won’t
work and can lead back to the
confrontation/denial spiral. Rather,
present a number of options and ask the
client which seems most appropriate,
attractive or promising.
 Basic Steps
5. Negotiate a Change Plan. If the client
seems ready to do so, negotiate a
specific change plan. What does the
person want to happen (goals)? What
are the possible options for pursuing
these goals? Which of these options
seem the best strategies to try first?
 Basic Steps
6. Summarize the Plan. Review once
more the most important reasons for
change (SMS) and the client’s plan
for change.
7. Endgame. Confirm the client’s
commitment to this plan. “Is that what
you want to do?” If the client is not
ready to commit, leave the door open.
 Timing of Change
Constructs Description
Stages of change
Precontemplation Has no intention within the
next 6 months
Contemplation Intends to take action
within the next 6 months
Preparation
Intends to take action
within the next 30 days
and has taken some
behavioral steps in this
direction