As I’ve previously written, I believe that making change is about resolving ambivalence. Miller and Rollnick wrote that when facilitating change in others, “It is useful in understanding a person’s ambivalence to know his or her perceptions of both importance and confidence” (p. 53). This balance between importance and confidence can be thought of as an individual’s readiness for change (Miller & Rollnick, p. 54).
Within the chemical dependency field, an individual’s readiness to change is given much important. Per standards set by the American Society of Addiction Medicine (ASAM), readiness to change has been identified as one of six areas, or dimensions, to be evaluated during an initial substance abuse assessment and to be re-evaluated during monthly updates.
As a drug/alcohol counselor, I clearly think a lot about readiness to change in others. Indeed, much of what I do as a clinician is really about helping clients to increase their readiness to change. However, it seems to me that this is presented as a vague concept within the ASAM assessment criteria. Basically, the more resistant an individual appears, the lower his readiness to change. However, if resistance truly is “an unhelpful idea that has handicapped therapists” (Selekman, p. 32), it seems unproductive to use it as a means of assessment. Worse, this pessimist mindset seems likely to keep the client stuck.
After all, if a client is resistant and therefore completely unwilling to engage in treatment, even the most skilled clinician would be left with no options. These clients sit in treatment for a while, refusing to engage, then get discharged for being non-compliant, not amiable to treatment, or unwilling to participate in their own recovery. Shame on them! Clients may not enter treatment resistant to the process, but they do sometimes leave that way. Or, as Seligman wrote, “Pessimistic prophecies are self-fulfilling” (p. 6).
Recently, I began working with “Michael.” Michael had been working with another clinician for about two months when he was referred to me. The clinician stated, “He doesn’t want to do any work and is completely unwilling to engage in treatment. I think he needs mental health services.” Michael’s attendance at group and individual sessions had been poor thus far, and the referring clinician stated that he was “adamant” about continuing to use marijuana and alcohol. The referring clinician also used that word resistant many, many times during our one conversation about this client.
The Process of Change
I believe a useful way to evaluate readiness to change is by assessing the individual’s Stage of Change. According to Stages of Change theory, lasting change is a process, with the individual moving through six distinct stages. These are pre-contemplation, contemplation, preparation, action, maintenance, and termination. Each stage “entails a series of tasks that need to be completed before progress to the next stage” (Prochaska, Norcross & DiClemente, p. 39). Sometimes, an individual returns to a prior stage in order to do more work. Within this model, that’s not a failure, just part of the process. In fact, I believe that recovery is an experiential process, and that relapse can be the most important part of that process.
Traditionally, most substance abuse programs assumed all clients entering treatment were in the action stage. To me, this is just absurd, especially when you consider that most clients—like Michael—are mandated in the first place. Perhaps resistance is really about this misfit of stages. If an individual is pre-contemplative and being treated as if he is ready to take action, wouldn’t he appear non-compliant, not amiable to treatment, and unwilling to engage? That certainly describes Michael. When I first met him, my perspective was a bit different than the referring clinician’s.
Michael was—and remains—a challenging client who tests boundaries, is likely to debate minor details, and always does the minimum required. However, he wasn’t resistant. Rather, he was stuck in pre-contemplation. Like anyone in pre-contemplation, Michael didn’t believe he had a problem. Since he didn’t have a problem, why should he change anything? And, the more people pushed him to take action, the less likely it would happen.
Miller and Rollnick wrote, “ When the idea of change or treatment is forced on an unwilling recipient it is not uncommon for the individual to engage in the problem behavior to a greater extent in an attempt to assert his or her freedom” (p. 337). According to the referring clinician, Michael’s using had increased since starting treatment. In fact, the referring clinician offered this information as proof of Michael’s resistance.
If Michael was actually stuck in pre-contemplation, my efforts shouldn't be to get him to take action. My efforts should be to help him get unstuck. Prochaska, Norcross and DiClemente have identified specific tasks for each Stage of Change. I have found these stage-specific tasks to be useful when working with clients. I've also found that the Stages of Change model and motivational interviewing have much in common. In fact, Miller and Rollnick wrote, “[M]otivational interviewing can be used to assist individuals to accomplish the various tasks required to transition form the pre-contemplation stage through the maintenance stage” (p. 202). Employing basic motivational interviewing principles when doing Stages of Change work seems a natural choice.
Miller and Rollnick identified four general principles for motivational interviewing. These are express empathy, develop discrepancy, roll with resistance, and support self-efficacy (p. 36). Especially when combined with stage-specific tasks, these principles are highly effective in helping clients move through the Stages of Change (Miller & Rollnick, p. 203). And, when the clients are successful, they are also developing the confidence to continue their change process.
The Confidence to Change
Miller and Rollnick wrote, “Readiness [to change] implies at least some degree of both importance and confidence. A person who does not see change as important is unlikely to be ready to change. Similarly, people who see change as impossible are unlikely to say they are ready to do it” (p. 54). Initially, Michael didn’t see change as important, but he also had doubts about his ability to make meaningful change.
I proposed two goals for Michael. First, address the tasks of pre-contemplation so he could start making some movement on the Stages of Change. Second, increase his sense of self-efficacy and thereby improve his optimism. When I presented this plan to Michael, his only response was, “Whatever. As long as I don’t get my probation revoked.” That lead to a third goal for Michael: do what is necessary to stay out of detention, which meant attending weekly individual sessions with me and having clear UAs.
Michael was reluctant to stop his use, but agreed to this plan because, in his words, “I’ll go to detention if I don’t.” I’ve only been working with this client for a short time, but clear progress has already occurred. Michael has been present at all his scheduled appointments. He's also making reasonable progress on pre-contemplation tasks. In our last appointment, he stated, “I don’t think I’ve got a problem using, but everyone else does, and that’s a problem, I guess. ” This may not sound like progress to some. I’m sure it wouldn’t to that referring clinician. To me, though, it clearly represents signs of becoming unstuck.
Instead of the pessimism of resistance, a new perspective is offered by the combination of the Stages of Change model and motivational interviewing: Even the most reluctant clients are simply working on the tasks of their current stage. Thought of this way, the job of a professional helper is reframed from the thankless task of overcoming resistance to that of assisting clients to increase their readiness to change.
Works Cited
Miller, W., & Rollnick, S. (2002). Motivational Interviewing. New York: Guilford Press.
Prochaska, J., Norcross, J., & DiClemente, C. (1994). Changing for Good. New York: Harper Collins.
Selekman, M. (2005). Pathways to Change. New York: Guilford Press.
Seligman, M. (1990). Learned Optimism. New York: Random House.
