Stages of Change – A Summary of Treatment Needs and Strategies

Precontemplation Treatment Needs Appropriate Motivational Strategies for the Clinician

The user is not considering change, is This client needs information linking his problems • Establish rapport, ask permission, and build
aware of few negative consequences, and is and potential problems with his substance abuse. trust.
unlikely to take action soon. A brief intervention might be to educate him about • Raise doubts or concerns in the client about
the negative consequences of substance abuse. substance-using patterns by
For example, if he is depressed, he might be told - Exploring the meaning of events
how his alcohol abuse may cause or exacerbate the that brought the client to
depression. treatment or the results of
previous treatments
- Eliciting the client’s perceptions
of the problem.
- Offering factual information about
the risks of substance use.
- Providing personalized feedback
about assessment findings.
- Explore the pros and cons of
substance use
- Helping a significant other
intervene.
- Examining discrepancies
between the client’s and others
perceptions of the problem
behavior.
• Express concern and keep the door open

Interview Approaches
1. Express concern about the patient and substance use. 2. State non-judgmentally that substance use is a problem.
3. Agree to disagree about the severity of the problem. 4. Consider a trial of abstinence to clarify the issue.
5. Suggest bringing a family member to an appointment. 6. Explore the patient’s perception of a substance use problem.
7. Emphasize the importance of seeing the patient again.
Source: Center for Substance Abuse Treatment, “A Guide to Substance Abuse Services for Primary Care Clinicians” Treatment Improvement Protocol (TIP)
Series. Department of Health and Human Services. 1-800-729-6686 or www.health.org

Contemplation Treatment Needs Appropriate Motivational Strategies for the Clinician

The user is aware of some pros and cons of This client should explore feelings of ambivalence • Normalize ambivalence.
substance abuse but feels ambivalent about and the conflicts between her substance abuse • Help the client “tip the decisional balance
change. This user has not yet decided to and personal values. The brief intervention might scales” toward change by
commit to change. seek to increase the client’s awareness of the - Eliciting and weighing pros and
consequences of continued abuse and the cons of substance use and
benefits of decreasing or stopping use. change
- Changing extrinsic to intrinsic
motivation.
- Examining the client’s personal
values in relation to change
- Emphasizing the client’s free
choice, responsibility, and self-
efficacy for 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.

Interview Approaches
1. Elicit positive and negative aspects of substance use. 2. Ask about positive and negative aspects of past periods of abstinence.
3. Summarize the patient’s comments on substance use 4. Make explicit discrepancies between values and actions.
and abstinence.
5. Consider a trial of abstinence.
Source: Center for Substance Abuse Treatment, “A Guide to Substance Abuse Services for Primary Care Clinicians” Treatment Improvement Protocol (TIP)
Series. Department of Health and Human Services. 1-800-729-6686 or www.health.org
 Preparation Treatment Needs Appropriate Motivational Strategies for the Clinician

This stage begins once the user has This client needs work on strengthening • Clarify the client’s own goals and strategies
decided to change and begins to plan steps commitment. A brief intervention might give the for change.
toward recovery. client a list of options for treatment (e.g., inpatient • Offer a menu of options for change or
treatment, outpatient treatment, 12-Step meetings) treatment.
from which to choose, then help the client plan how • With permission, offer expertise and advice.
to go about seeking the treatment that is best for • Negotiate a change-or treatment-plan and
him. behavior contract.
• Consider and lower barriers to change.
• Help the client enlist social support
• Explore treatment expectancies and the
client’s role.
• Elicit from the client what has worked in the
past either for him or others who he knows.
• Assist the client to negotiate finances child
care, work transportation, or other potential
barriers.
• Have the client publicly announce plans to
change.
Interview Approaches
1. Acknowledge the significance of the decision to seek treatment. 2. Support self-efficacy
3. Affirm patient’s ability to successfully seek treatment. 4. Help the patient decide on appropriate, achievable action
5. Caution that the road ahead is tough but very important 6. Explain that relapse should not disrupt the patient-clinician
relationship.
Source: Center for Substance Abuse Treatment, “A Guide to Substance Abuse Services for Primary Care Clinicians” Treatment Improvement Protocol (TIP)
Series. Department of Health and Human Services. 1-800-729-6686 or www.health.org

Action Treatment Needs Appropriate Motivational Strategies for the Clinician

The user tries new behaviors, but these are This client requires help executing an action plan • Engage the client in treatment and reinforce
not yet stable. This stage involves the first and may have to work on skills to maintain sobriety. the importance of remaining in recovery.
active steps toward change. The clinician should acknowledge the client’s • Support a realistic view of change through
feelings and experiences as a normal part of small steps.
recovery. Brief interventions could be applied • Acknowledge difficulties for the client in early
throughout this stage to prevent relapse. stages of change.
• Help the client identify high-risk situations
through a functional analysis and develop
appropriate coping strategies to over come
these.
• Assist the clients in finding new reinforcers of
positive change.
• Help the client assess whether she has
strong family and social support

Interview Approaches
1. Be a source of encouragement and support 2. Acknowledge the uncomfortable aspects of withdrawal.
3. Reinforce the importance of remaining in recovery.
Source: Center for Substance Abuse Treatment, “A Guide to Substance Abuse Services for Primary Care Clinicians” Treatment Improvement Protocol (TIP)
Series. Department of Health and Human Services. 1-800-729-6686 or www.health.org
 The Stages of Change (cont’d.) – A Summary of Treatment Needs and Strategies

Maintenance Treatment Needs Appropriate Motivational Strategies for the Clinician

The user establishes new behaviors on a This client needs help with relapse prevention. A • Help the client identify and sample drug-free
long term basis. brief intervention could reassure, evaluate present sources of pleasure (ie, new reinforcers).
actions, and redefine long-term sobriety • Support lifestyles changes.
maintenance plans. • Affirm the client’s resolve and self-efficacy
• Help the client practice and use new coping
strategies to avoid a return to use.
• Maintain supportive contact (e.g., explain to
the client that you are available to talk
between sessions).
• Develop a “fire escape” plan if the client
resumes substance use.
• Review long-term goals with the client.

Interview Approaches
1. Anticipate difficulties as a means of relapse prevention. 2. Recognize the patient’s struggle
3. Support the patient’s resolve. 4. Reiterate the relapse should not disrupt the medical care
relationship.

Source: Center for Substance Abuse Treatment, “A Guide to Substance Abuse Services for Primary Care Clinicians” Treatment Improvement Protocol (TIP)
Series. Department of Health and Human Services. 1-800-729-6686 or www.health.org

Relapse Appropriate Motivational Strategies for the Clinician

The client has experienced a recurrence of • Help the client reenter the change cycle and
symptoms and must now cope with commend any willingness to reconsider
consequences and decide what to do next. positive change.
• Explore the meaning and reality of the
recurrence as a learning opportunity
• Assist the client in finding alternative coping
strategies.
• Maintain supportive contact.

Interview Approaches
1. Explore what can be learned from the relapse. 2. Express concern and even disappointment about the relapse
3. Emphasize positive aspect of the effort to seek care. 4. Support patient’s self-efficacy so that recovery seems achievable
Source: Center for Substance Abuse Treatment, “A Guide to Substance Abuse Services for Primary Care Clinicians” Treatment Improvement Protocol (TIP)
Series. Department of Health and Human Services. 1-800-729-6686 or www.health.org