It may be helpful to ascertain how motivated the client is to change their current AOD use. This process involves an exploration of the client’s perception of the positive and negative aspects of continued AOD use. Prochaska and DiClemente [446] suggest that clients fall into one of six stages of change, which clients cycle through dynamically rather than in an ordered linear manner [389], indicating that the focus of treatment for people in the earlier stages of change should incorporate motivational interviewing/motivation enhancement techniques to assist the person in progressing to further stages. In general, clients in the later stages of change have better AOD use and mental health treatment outcomes than clients in earlier stages [447]. Table 25 summarises these stages and outlines some useful interventions and motivational strategies for each stage of change. The choice of treatment type can be informed in part by the client’s readiness to change; for example, harm reduction may be an appropriate treatment for someone in the pre-contemplation stage, whereas goal setting or relapse prevention may be more suitable for someone in later stages (e.g., preparation or action stages) [389].
The stages of change model is also relevant in assessing the client’s motivation to receive treatment for co-occurring mental health conditions. Just because a person has presented for treatment for their AOD use, this does not necessarily mean that they have the same readiness to receive mental health treatment. For example, just because the client is willing to consider reducing AOD use, this does not automatically mean that they are also ready to deal with the trauma-related symptoms they experience due to abuse experienced as a child. Appendix H provides a useful matrix for assessing motivation for both AOD and mental health treatment.
Table 25: Readiness for change
| Stage |
Description |
Interventions |
Motivational strategies |
| Pre-contemplation |
Not yet considering behaviour change.
Little awareness of, or concern for negative consequences.
E.g., ‘I get out of breath, but I feel fine, so I don’t think there’s a problem with my smoking’.
|
Aim to raise doubt about perceptions.
Link behaviour with consequences.
Reduce harm. Highlight negative consequences.
Build confidence and hope.
|
Establish rapport, build trust, ask permission.
Raise concern in the client about their behavioural patterns (feedback). |
| Contemplation |
Considers change but rejects it.
Ambivalence remains. Wavers between reasons to change and reasons to stay the same.
E.g., ‘I see it would be better for me if I quit smoking, but it’s the only time of the day I have for myself’.
|
Motivational interviewing can assist in resolving ambivalence.
Elicit reasons for change and risks of not changing.
|
Normalise ambivalence (reflect).
Elicit change talk, self-motivational statements.
|
| Preparation or determination |
Balance tips towards change.
Window of opportunity where client is preparing for change.
E.g., ‘I really want to quit smoking, I just don’t know how I would do it’.
|
Goal setting, problem-solving, match to needs. Identify risks for relapse, including triggers.
Build self-efficacy.
Discuss treatment options.
|
Clarify goals and strategies for behaviour change (affirm).
With the client’s permission, offer information and guidance.
|
| Action |
Engage in behaviours designed to bring about change.
May occur with or without assistance.
E.g., ‘After my last appointment, I bought some NRT patches’.
|
Support self-efficacy.
Assist with coping and education.
Reinforce positive behaviour.
Avoid exposure to AOD use environment.
|
Reinforce the importance of changing. |
| Maintenance |
Sustain change. Prevent relapse.
E.g., ‘I’ve felt great the last few months, but I’m wondering if I still need to be using the NRT patches’.
|
Reinforce positives and assist with lapses.
Self-help groups.
Provide relapse prevention techniques.
Emphasise client alertness. Work towards longer-term goals.
|
Affirm the client’s determination and self-efficacy. |
| Lapse/recurrence |
Not so much a stage in itself, but rather a normal and expected part of the process.
Any slip or lapse into any of the previous stages.
E.g., ‘I slipped over the New Year’s break and had a few ciggies while watching the fireworks’.
|
Avoid demoralisation or judgement.
Remain positive.
Normalise the process of lapsing.
Help re-start the stages of change and avoid being stuck in this stage.
Help the client to learn from mistakes.
|
Explore meaning. |
Adapted from Clancy and Terry [448], Fullerton [449], Figlie and Caverni [450], and Stone et al. [389].