This week I’ve been working on reading and editing the page proofs for the forthcoming 5th edition of Clinical Interviewing (John Wiley & Sons). The information below is from a “Putting It Into Practice” box from the 4th chapter. It focuses on a brief Q&A regarding the application of Prochaska and DiClemente’s “Stages of Change” concept in clinical interviewing and presupposes that you have basic knowledge of that particular piece of their Transtheoretical Model.
A General Guide to Using Stages of Change Principles in Clinical Interviewing
Below we pose and answer four basic questions about how to apply stages of change principles (Prochaska & DiClemente, 2005) to guide the techniques and responses you choose to use within a clinical interviewing context.
Q1: When should I use directive techniques like psychoeducation or advice?
A1: When clients are in the action or maintenance stages of change you’re free to be more directive (provided you have useful information to share that fits with what the client recognizes as his or her problem).
Q2: When should I use less directive listening responses like paraphrasing, reflection of feeling, and summarization?
A2: As a general rule, if your client is in the precontemplative or contemplative stages of change, you should primarily use nondirective listening skills to help the client look at his or her own motivations for change. This would include: (a) attending behaviors, (b) paraphrasing, (c) clarification, (d) reflection of feeling, and (e) summarizing. Many questions, especially open questions and solution-focused or therapeutic questions, may be appropriate for clients who are precontemplative or contemplative. When you’re with clients who present as precontemplative or contemplative, your best theoretical orientation choices will likely be person-centered, motivational interviewing, and/or solution-focused. Using more directive approaches can produce defensiveness or resistance with clients in precontemplative or contemplative stages.
Q3: How do I know what stage of change my client is in?
A3: We’re tempted to suggest you’ll know it when you see it . . . and there’s some truth to that. If you try directly recommending a strategy for change and the client responds defensively, you may be moving forward too fast and it’s advisable to retreat to using reflective listening skills. Conversely, if your client seems frustrated with your nondirective listening and expresses interest in changing now, then you’ve got the green light to be more directive. Also, we recommend using George Kelly’s (1955) credulous approach to assessment, meaning you can always just directly ask clients what they prefer. In our work with parents we do this explicitly by stating something like:
“I want to emphasize that this is your consultation. And so if I’m talking too much, just tell me to be quiet and listen and I will. Or, if you start feeling like you want more advice and suggestions, let me know that as well.” (J. Sommers-Flanagan & Sommers-Flanagan, 2011, p. 60)
There are also standardized methods for assessing clients’ readiness for change. Interestingly, most of these involve asking clients very direct questions about their motivation to change, how difficult they expect change to be, and how ready they are to change (all of which seem in the spirit of George Kelly’s credulous approach; for example, see (Chung et al., 2011) for a study on the predictive validity of four different measures assessing client readiness to stop smoking cigarettes).
Q4: Is the stages of change concept supported by empirical evidence?
A4: The data are mixed on whether and how much attending to and using interventions that fit your clients’ stages of change makes a difference. Of course, this is true for nearly every phenomenon in counseling and psychotherapy. Overall, some studies show strong support for gearing your interviewing techniques to your clients’ stage of change (Johnson et al., 2008). Other studies show that stages of change focused interventions do no better than interventions that don’t tune into clients’ particular motivational stage (Salmela, Poskiparta, Kasila, Vähäsarja, & Vanhala, 2009). We recognize this isn’t the clear and decisive research outcome you might hope for, but such is the nature of our profession.
For more information on Clinical Interviewing, 5th edition, go to: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118270045.html