Hi XXXXXXX

The ‘contemplation’ stage is one of the crucial stages in the transtheoretical model of behavioural change (proposed by Prochaska & DiClemente).In this model, people who are to change over to a healthy behaviour typically go through 5 stages of change – Pre-contemplation, Contemplation, Preparation, Action and Maintenance. In the Contemplation stage the client is aware that a problem exists and is seriously thinking about overcoming it but has not yet made a commitment to take action.

The importance of this stage is that many clients who come forward for help for various problems, especially substance abuse problems are in this stage. Also, many clients tend to drop out of therapy in this stage, if they are not sufficiently motivated. So, it largely depends on the motivational enhancement provided by a skilled therapist to retain the patient in therapy and help him move to the next stage.

One of the tactful and effective ways is to use the interview and the assessment itself to as a tool to enhance the motivation of the patient. It is often said that therapy begins from the first interview with the client itself. So, the interview and assessment tools themselves can be potent therapeutic tools for the therapist.
How can this be done effectively?

Firstly, it is important to understand that "therapeutic relationship" is starts during the first interaction with the patient, namely, during the initial interview. It is a well known fact that therapeutic relationship plays a very major role in the success of therapy. So, an empathetic attitude in the interview will help a lot in forming a good therapeutic relationship. Once a good therapeutic relationship is formed, then the client starts trusting the therapist and becomes more co-operative.

Secondly, the role of the therapist is to put forth the reality of the situation the client is in and help him or understand that the current situation he is in is unhealthy or harmful to him. The assessment tools which are used to assess the client's problem can serve as an eye opener to make the patient realize his /her problems. This itself will help the client realize that it is time for change. Remember, merely telling the client repeatedly to abandon his unhealthy and maladaptive behaviours is not going to help much. The client himself or herself has to realize his problems first. So, by sharing the findings on assessment with the client, he /she will be able to realize the extent and severity of his / her problems.

For example, most clients with alcohol or drug abuse problems come in denial. They deny the fact that they have lost control over their drinking or drug use. In such a case, getting the person into therapy itself becomes challenging, because the person simply thinks that he / she does not have a problem. In such cases, by using tactful interview techniques such as ‘self-questioning’ and ‘self-exploration’, the person can be made to realize the degree of harm or dysfunction the substance abuse has caused in his life – medical, social, marital, occupational, etc. Also, the findings on assessment tools like alcohol abuse questionnaires (e.g. AUDIT) can be shared with the client to help him /her realize the nature and extent of his problem. Clients would be more likely to believe the findings of an objective assessment tool rather than believe in the personal judgement of the therapist.

Thirdly, psycho-education is one of the important components in any form of therapy. And psycho-education begins right from the first interview itself. Very often the interview serves as a tool to clarify doudts or misconceptions of the client. For example, in a client with a sexual dysfunction who comes for sex therapy, during the process of the interview and assessment itself, the therapist will be able to make out what mis-informations, misconceptions and wrong ideas the client is harbouring. Clarifications and psycho-educative information can be provided during the interview process itself.

Fourthly, in the contemplation stage, many clients will come out with resistance to therapy. Though they may be seriously considering a change, still, there can be a lot of inner resistance which comes through. Now, the therapist should approach this part cautiously. If the therapist is too firm and confrontational, the client may get irritated and walk off. On the other hand, if the therapist is too lenient and accommodating, then the client can become manipulative and sometimes, overpowering. So, a right balance has to be struck. There is an effective technique which the therapist can adopt, called “rolling with resistance”, where the therapist rolls along with the patients efforts to resist, but still doesn’t stands firm in his stand.

Finally, it is important to remember that in the contemplation stage, the client is actually in a genuine dilemma whether to change or not. This confusion is often distressing to the client – because, on one hand the client realizes his problem, but on the other hand, it seems very difficult to change himself / herself. So, while dealing with a client who is in this delicate stage, the therapist should be supportive. It is important not to be judgemental or patronizing. This will only cause the rapport to suffer and the client will drop out of therapy. So, the approach should be supportive and flexible.

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist

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