STAGES OF AND STRATEGIES FOR

CHANGE

4.1
Stages of Change

Pre-
contemplation

Recurrence

Maintenance Contemplation

Action Preparation

4.2
Ambivalence

 Ambivalence (having conflicting thoughts and

feelings) is part of any change process
 Each stage brings its own motivational conflict
 Clients need different types of motivational
support in each stage

4.3
Motivational Conflict: Precontemplation

 A personin precontemplation may not

experience ambivalence, but often does in some
way
 Example: “I know I don’t have a problem, but should
I talk to a counselor to get my wife off my back?”

4.4
Motivational Support: Precontemplation

 Client is not yet considering change

 Client may be unwilling or unable to change
 Client needs help raising awareness before he
or she can consider change

4.5
Motivational Conflict: Contemplation

 Ambivalence: to change or not to change?

 Example: “I know I’d feel better if I quit smoking
marijuana, but I’ll lose a bunch of friends if I do and I
won’t have fun anymore.”
 Example: “I feel good about setting a quit date, but
I’m not sure I have the guts to follow through with it.”
 Client may perceive there is cause for concern
and reasons to change
 Client has left the door open to consider change

4.6
Motivational Support Needed: Contemplation

 Help to resolve ambivalence and choose positive

change over current situation
 Help to “tip the motivational balance”
 Help to develop confidence in ability to change

4.7
Motivational Conflict: Preparation

 Clientsmay be fully ready to change but be unsure

of the best way to go about it
 Where do I go?
 What do I do?
 How do I find resources to help?

4.8
Motivational Support Needed: Preparation

 Help identifying potential change strategies and

choosing the most appropriate ones for the
circumstances
 Help planning for change and examining
capabilities for change
 An assessment of skills

4.9
Motivational Conflict: Action

 A client
may be doing all the right things but still
sometimes feel a strong desire to use
substances
 Example: “Staying off cocaine for the past 3 weeks
really makes me feel good, but part of me wants to
celebrate by getting high.”
 Motivation will naturally wax and wane over time
 For example: “Is all this really worth it?”
 Client is actively taking steps to change

4.10
Motivational Support Needed: Action

 Help choosing strategies for change

 Help carrying out strategies and learning how to
prevent or limit relapse
 Normalization of ambivalence
 Affirmation for continuing efforts and successes

4.11
Motivational Conflict: Maintenance

 Clients
in maintenance need to make a lot of
hard decisions about lifestyle
 Example: “I know I can’t play football with my old
using buddies anymore, but I really miss it.”
 Example: “I just can’t be around my brother when
he’s high, but it’s really hard to say ‘no’ to him.”

4.12
Motivational Support Needed: Maintenance

 Help developing new skills, relationships, and

activities for maintaining recovery and a lifestyle
without substance use
 Help sustaining gains made during action stage
 Help and support for coping with losses and
developing life goals

4.13
Motivational Conflict: Relapse

 Motivational conflicts may

vary
 Relapse leads to regression
to an earlier stage of change
 Clients may typically wonder:
 “Do I want to try again or not?”
 “Am I capable of maintaining
recovery?”

4.14
Motivational Support Needed: Relapse

 Help in recovering quickly and

resuming the change process
 Help repairing confidence in ability to
recover
 Help in moving into and through
recovery
 Recovery is not a straight, predictable
path!

4.15
Evoking Change Talk

 The more a client, rather than a counselor,

makes arguments for change:
 The more he or she will believe change is needed
 The stronger his or her commitment to change will
be
 The more likely he or she is to actually make a
change

Amrhein, P. C., Miller, W. R., Yahne, C. E., Palmer, M., & Fulcher, L. (2003). Client commitment language during
motivational interviewing predicts drug use outcomes. Journal of Consulting & Clinical Psychology . 71(5), 862–878. 4.16
Types of Change Talk

 DARN-C
 Desire
 Ability
 Reasons
 Need
 Commitment

Source: Amrhein, P. C., Miller, W. R., Yahne, C. E., Palmer, M., & Fulcher, L. (2003). Client commitment language
during motivational interviewing predicts drug use outcomes. Journal of Consulting & Clinical Psychology. 71 (5),
862–878. 4.17
DARN-C: Desire

 Statements clients make about preference for

change:
 I would like to stick to my medication regimen.
 I wish to stop using drugs.
 I really want to finish my treatment
program.

4.18
DARN-C: Ability

 Statements clients make about self-efficacy:

 I think I could stop using drugs because I want to.
 I can quit drinking.
 I am going to work on my program.

4.19
DARN-C: Reasons

 Statements clients make that are specific

reasons, or arguments for change:
 I know I would feel better if I quit drinking
 If I stop using drugs I will make my parents happy
 If I quit drinking alcohol I can go back to work.

4.20
DARN-C: Need

 Statements clients make about feeling an

obligation to change:
 I should quit smoking.
 I really need to stop using drugs; and
 I have to work on my treatment program.

4.21
DARN-C: Commitment

 Two levels of commitment statements:

 Intention or low-level commitment statements
 High-level commitment statements

4.22
DARN-C: Commitment (continued)

 Intention or low-level commitment statements:

 I will think about cutting back on my drug use.
 I plan to go into treatment.
 I will try to talk to a counselor about my substance
use

4.23
DARN-C: Commitment (continued)

 High-level commitment statements:

 I am going to cut back on my drug use.
 I am going to enter a treatment program.
 I promised my husband I would talk to a counselor
about my substance use problem.

4.24
Ways of Evoking Change Talk

1. Ask evocative, open-ended questions: “What

would you like your life to be like 5 years from
now?”
2. Ask for elaboration: “How would that look?” or
“Say more about that.”
3. Ask for examples: “How might you do that?” or
“Can you give me some examples?”

Source: Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive
behavior. New York: Guilford Press. 4.25
Ways of Evoking Change Talk (continued)

 4. Look back: “When in the past have you made

a successful change?”
 5. Look forward: “How will you know whether you
are successful with this change?”
 6. Query extremes: “What would be the best
result you could imagine if you made a change?”

4.26
Ways of Evoking Change Talk (continued)

 7. Use a readiness ruler: “What would it take to

go from a 4 to an 8?”
 8. Weigh pros and cons (decisional balance):
“What do you like about what is happening in
your life now?”
 9. Explore goals and values: “Tell me what is
most important to you in life.”
 10. Come alongside: “Perhaps your drug use is
too important for you to give up.”
4.27
Responding to Change Talk: EARS

 Explore
 Affirm
 Reflect
 Summarize

4.28
Responding to Change Talk: Explore

 Ask leading questions:

 Tell me more about how you see that.
 What else?
 What do you think would happen if _____?
 Can you give me some examples?
 Exploring lets the client express even more
positive thoughts about change

4.29
Responding to Change Talk: Affirm

 Expressagreement, appreciation, or
encouragement and reinforce change talk in
any way:
 I think it’s great that…
 Wow—you’ve come a long way
 I think you could really make that work
 That’s a very insightful statement

4.30
Responding to Change Talk: Reflect

 Reflecting back a positive statement about

change allows the client to hear the statement
from a different perspective and to agree with
him- or herself!

4.31
Responding to Change Talk: Summarize

 Create“bouquet” summaries that pull together

incidents of change talk

4.32
Readiness Ruler

 Developed by Stephen Rollnick

 Multi-purpose tool

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change
addictive behavior. New York: Guilford Press. 4.33
Readiness

 A fundamental concept of motivational

approaches
 Having some idea of how ready a person is to
change or learn new skills is useful in many
situations

4.34
Using the Ruler: Be Specific!

 “On a scale of 1 to 10, where 1 is not at all ready

and 10 is very ready, how ready are you to start
talking about abstinence?”

NOT 

 “How ready do you feel to change?”

4.35
Using the Ruler: Ask for Elaboration

 “Tell me why you chose that number.”

 “I’m curious; why did you rate your readiness at
4 rather than at 2 or 3?”
 “Wow—you rated your readiness at 9! Tell me
more about why you think you’re so ready for
this change.”

4.36
Using the Ruler: Look Toward the Future

 “What could happen that would move you to a

higher number?”
 “What do you think it would take for you to feel
more ready for this change?”

4.37
Using the Ruler: Tailor Intervention

 “Not ready” (0 to 3): Express concern, offer

information, provide support, follow up
 “Unsure” (4 to 7): Explore positive and negative
aspects of making the change
 “Ready” (8 to 10): Help plan action, identify
resources, convey hope

4.38
Using the Ruler: Track Readiness Over Time

 “Last month you rated your readiness for this

change at 4. Today you rated it 9. What’s helped
change your thinking?”
 “Last month you rated your readiness for this
change at 8. Today you rated it 5. What’s
happened to decrease your readiness?”

4.39
Using the Ruler: Tracking Importance or
Confidence

 Importance: “On a scale of 1 to 10 how important

is it that you make this change?”
 Confidence: “On a scale of 1 to 10 how confident
are you that you can make this change?”

4.40
Using the Ruler To Assess Importance or
Confidence

 Be specific:
 “How important to you is your relationship with your
husband?” NOT “…how important to you are
relationships?”
 “How confident do you feel about saying ‘no’ to
offers of cocaine?” NOT “How confident are you that
you can maintain abstinence over the long term?”

4.41
Using the Ruler To Assess Importance or
Confidence (continued)

 Ask for elaboration

 “Tell me more about how you see your relationship
with your husband.”
 “The last time we talked, you seemed a lot more
confident; what do you think changed?”  

4.42
Using the Ruler To Assess Importance or
Confidence (continued)

 Look toward the future:

 “Your relationship with your husband is clearly very
important to you. How do you think your substance
use could affect it over time?”
 “What do you think might help you become more
confident in making this change?”

4.43
Using the Ruler To Assess Importance or
Confidence (continued)

 Track importance or confidence over time:

 “Last month you rated the importance of fitting in
with the popular kids very high. This time, you’ve
rated it quite low. What has changed your thinking
about that?”
 “Last month you rated your confidence in making
this change at 4; today you rated it 8. What do you
think has helped you become more confident?”

4.44
Partner Exercise: Readiness Ruler

 Find a partner; decide who will be the counselor

first
 Select a client from Resource Page 4.4 OR think
of a personal change you are considering or
involved in
 Begin a discussion
 Practice three role-play sessions with the ruler:
Readiness, importance, and confidence
 Switch roles in 10 minutes

4.45
Decisional Balancing

 The process of appraising or evaluating the

"good" aspects of substance use—the reasons
not to change, and the less good aspects—the
reasons to change

4.46
Goals of Decisional Balancing

 Helping a client recognize and weigh negative

aspects of substance use so that the scale tips
toward positive change
 Helping a client move from external motivation to
internal motivation

4.47
Decisional Balancing: Process

 A conscious linking of negative aspects of a

situation (costs, problems, other undesirable
features), often for the first time

Source: Baumeister, R. F. (1994). The crystallization of discontent in the process of major life change. In: T.
F. Heatherton & J. L. Weinberger (Eds.). Can personality change? (pp. 281–294). Washington, DC: American
Psychological Association. 4.48
Decisional Balancing: Process (continued)

 Conscious linking of negative aspects changes a

person's perception of a situation "so that a
broad pattern of dissatisfaction and shortcoming
is discerned"

Source: Baumeister, R. F. (1994). The crystallization of discontent in the process of major life change. In: T.
F. Heatherton & J. L. Weinberger (Eds.). Can personality change? (pp. 281–294). Washington, DC: American
Psychological Association. 4.49
Decisional Balancing: Objectives

 Emphasize, from the client's perspective, the

costs of the client's substance use
 Lessen, when possible, the perceived rewards of
substance use
 Make the benefits of change apparent
 Identify and minimize, if possible, potential
obstacles to change

Source: Sobell, L. C., Cunningham, J. A., Sobell, M. B., Agrawal, S., Gavin, D. R., Leo, G. I., et al. (1996).
Fostering self-change among problem drinkers: A proactive community intervention. Addictive Behaviors, 21 (6),
817–833. 4.50
Listing Pros and Cons of Behavior Change

4.51
Listing Pros and Cons of Behavior Change
(continued)

Behavior: Substance Use

Changing (Pros) Not Changing (Cons)
Benefits Benefits
-Increased control over my life -More relaxed
-Support from family and friends -More fun at parties
-Decreased job problems -Don't have to think about my problems
-Financial gain
-Improved health

Costs Costs
-Increased stress/anxiety -Disapproval from friends and family
-Feeling more depressed -Money problems
-Increased boredom -Could lose my job
-Sleeping problems -Damage to close relationships
-Increased health risks

4.52
Decisional Balancing: Lists

 A written list can help clients quantify the factors

going into any decision about change
 A long list of reasons to change and a short list of
reasons not to may finally shift the balance toward
change
 A long list of reasons not to change and a short list
of reasons to change can indicate how much work
still must be done

4.53
It’s Not Just About the Numbers

 The number of items in each column is not the

only important thing
 One or two reasons not to change can outweigh
a dozen reasons to change

4.54
Importance to Client

 The reasons for and against continuing

substance use are highly individual
 Factors that shift the balance toward positive
change for one person may scarcely matter to
another
 Reasons are often more emotional than rational
 The value or weight given to a particular item is
likely to change over time

4.55
Decisional Balancing and Values

 Decisional balancing helps clients explore and

articulate their values
 Values will be reflected both in reasons to
change and in reasons not to change
 If clients can frame the process of change within
the larger context of values shared with their
family, community, and culture, they may find it
easier to contemplate change

4.56
Decisional Balancing: Process Summary

 Decide on a format
 Introduce the exercise and ask permission to
continue
 Explain the format
 Use open-ended questions and active listening

4.57
Decisional Balancing: Process Summary
(continued)

 Startwith the reasons to continue substance use

 Asking clients to express what they like about
substance use:
 Establishes rapport
 Seems to lead clients to spontaneously talk about
what is less good about substance use
 Can be helpful with a client in precontemplation

Source: Saunders, B., Wilkinson, C., & Allsop, S. (1991). Motivational intervention with heroin users attending a
methadone clinic. In: W. R. Miller & S. Rollnick (Eds.). Motivational interviewing: Preparing people to change
addictive behavior (pp. 279–292). New York: Guilford Press. 4.58
Decisional Balancing

 Isn’t for everyone!

 If a counselor tries to do decisional balancing
with clients who have already made a decision to
change, they can become impatient or frustrated

4.59