Stages of Change

Dealing with Uncooperative clients…

As a new grad, I’m currently waiting for my PLMHP license to complete approval process by Nebraska DHHS before I can begin my new job in the meantime, I’m completing this new employee clinical training manual.   In one section it describes the uncooperative client who is unwilling to participate in treatment but often required to do so as a court-order (Capstone, n.d.).   “…Extroversion, assertiveness, empathy, honesty respect and openness, have been identified as the most important aspect of getting the uncooperative client to come around and begin working with the threapist” (Capstone, n.d.).  What follows are tips from my clinical training manual to work with involuntary clients…

  1. “Joining/Empathy: The therapist empathies with the feeling of being forced to come to therapy” (Capstone, n.d.).
  2. “Substitute a mutually acceptable goal: With the involuntary client, find something else the client does want to work on and demonstrate usefulness of psychotherapy in that area” (Capstone, n.d.)
  3. Family Therapy:  The biggest trap in family therapy is to take sides.  The therapist must remain above blaming and keep attention on how weveryone will ahve to adjust to the problem being gone” (Capstone, n.d.).
  4. What is of greatest importance is that you do enjoy your work.  Try to understand the client’s resistance, shift the responsibility towards the client for their life, don’t work harder than they are.

 Click here to read about what I learned from resistance from my internship at a substance abuse recovery center.


Click here to read a post on resistance as it is defined within the framework of motivational interviewing.


Click here to read my attempt to describe the differences between coercion and confrontation as it occurs in therapy.


References

Capstone, (n.d.) Clinical Skills & Clinical Skill Enhancement. Capstone Behavioral Health.
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Stages of Change & Domestic Abuse Survivors

In this post, I’m reviewing literature that discusses the stages of change as it applies to providing care to victims of intimate partner violence. As an intern working at a homeless shelter for women, I find the work highly relevant to what I see from day to day.  This post includes segments of old assignments…

“Why does’t she just leave him?!?!?!?”

“Queries like, “Why does she put up with that?” and “Why does she stay?” continue to haunt battered women…The implication is that the battered women’s behavior is problematic…This ego-deflating and incriminating element can serve to keep a woman trapped in a situation she may view as incapable of ending herself” (Burman, 2003, p. 83).

During my internship class last quarter, a fellow classmate began discussing a client she was seeing who was just left an abusive relationship.  At one point my professor made an interesting statement that made me stop and think:

“The key is to understand the unresolved issues they have yet to work through”

This statement made me stop and think a bit about my own history, and the “it years”.  Mind you, the abusive behavior was psychological and emotional.  However, there is certainly a parallel.   Throughout the relationship, I can’t tell you how many times I heard someone say: “Why don’t you just leave him?”  I recall thinking silently, “it’s just so complicated, you don’t understand.”  My response was, often to remain silent, and simply ignore the question.  There was no point in explaining to those who ask, what they are blind to and unable to conceive…

It is for this reason, that my professor’s comments really struck me.  In response to questions such as these I might say iterate what my own professor said, “what unresolved issues lay in their life history that I hadn’t worked out yet as an explanation for why they would be in a relationship like this?”

To put it another way, let’s look at this issue from a behavioral perspective.  Mind you, this theory isn’t necessarily my favorite since I feel we are much more than pavlovian dogs.  However, what’s clear about human behavior is that we do what works.  Even, if at first, behaviors appear self-destructive, we must ask ourselves what they “payoff” is.  In my own case, there was an emotional “hot potato” was the unresolved trauma of bullying and ostracism in my childhood.    I was so incredibly desperate to avoid the rejection and loneliness of my childhood, this relationship was the “lesser of two evils” as an alternative to re-experiencing the traumas of my childhood.

Admittedly, this personal perspective in my own life history, might not apply to many other cases of domestic violence.  However, the point is, rather than asking “why don’t they leave?”  We must ask ourselves, how this relationship reflects the the summative emotional impact of life experiences?  I love John Malkovich’s assertion that to a create character successfully we must see them without judgment.  Maybe this is also true with clients:  to see their life experiences without judgment.

“Attempting to understand the nature of the battering and how women cope, we can glean some insights into…the strengths that are utilized to make the decision to leave, act upon and sustain this goal” (Burman, 2003, p. 84).

Two articles are useful in providing information in understanding a domestic violence situation as a guide throughout the counseling process.  These articles describe a woman’s adaptations to spousal abuse in terms of the following stages: pre-contemplation, contemplation, preparation, action, maintenance, and termination (Burman, 2003; Fraser, et al, 2001).  According to this theory, change is not a singular event but a process that occurs in an observable sequence of stages.   For example, during pre-contemplation, a woman tends to minimize and deny the issues and their consequences. Traumatic bonds are quite pronounced at this point and a sense of isolation and dependence grows along with a growing feeling of responsibility and self-blame (Burman, 2003, p85). The contemplation phase marks a period of ambivalence during which an increasing level of cognitive dissonance develops and a woman vacillates on whether to leave (Burman, 2003, p85). Determination and Action involve the process of preparing to leave and enacting one’s plan. Finally, brief descriptions are provided of the maintenance and termination stages.  What follows is an overview of the stages of change as it applies to victims of intimate partner violence.

Overview of The Stages of Change

Pre-Contemplation

The pre-contemplation stage is characterized by either denial and minimization of the problem.  For example, during this stage a client may resist any attempts to discuss and acknowledge that abuse is occurring. This might can present as a defensiveness towards anyone who suggests and/or suspects that there is a problem (Burman, 2003).  Alternatively, the client might also present with a desire to accommodate “herself to the situation, constantly hoping that by pleasing her partner he will change his ways” (Burman, 2003, p. 84).  Sometimes expressions of hopelessness regarding the possibility of change can also be seen (Frasier, et al, 2001).  Alternatively, the client may describe the hopelessness of the situation while blaming herself and/or others:

“There is no need to talk about it; it won’t change a thing,”

“If the supper had been ready on time…”

“But, he is a good provider…”

“If the children weren’t so noisy…”

During this early stage, the traumatic bond begins to develop.  I prefer to call it a “boot camp” period, where you’re slowly broken in like a pair of new boots.  Momentary expressions of love and/or positive reinforcement are intermingled with various forms of abusive behavior.  You’re slowly isolated from others and dependency upon your partner grows slowly over time.  An extremely low self-esteem exists that one cannot see beyond, as an all-encompassing perspective of oneself.  This is the hardest to explain, for those who don’t understand.  However, I would simply like to note that people can’t see what they haven’t experienced, like explaining the color purple to a blind man.

Contemplation

This stage is characterized by feelings of ambivalence as the client vacillates between “concern and..unconcern, motivation to change and to continue unchanged” (Burman, 2003, p. 85).  The therapist’s primary goal is to addrress feelings of ambivalence.  As the situation continues in an unremitting manner, the client’s coping mechanisms wear down. Consequently, denial is no longer possible and they begin to recognize that a problem exists.  The client struggles to make sense of their partner’s behavior and process their feelings of ambivalence by weighing various options as “what if’s”.

“I wish that I could figure out what to do differently so he won’t get so angry with me,.”

“What would happen if I did leave, can I ‘go it alone’?”

Preparation

“Patients in this stage are consciously aware of their problems. They are `committed’ to taking action usually within the next month” (Frasier, et al, 2001, p. 214).  During this stage the primary goal is to “determine the best course of action and prepare to carry it out” (Burman, 2003, p. 86).  Planning is underway as the client seeks counseling, legal assistance, saving money, and a safe place to stay.  Both resources for this post mention that change is sometimes a fluctuating process and clients can occasionally be seen moving back and forth between preparation and contemplation (Burman, 2003; Fraser, et al, 2001).

Action

During this stage, the client begins putting her plans into action and makes efforts to change.  “The prospect of leaving, is often dangerous and scary, provoking feelings of fear and anxiety (Burman, 20030.  Therefore, great energy is now directed toward ensuring your personal safety and rebuilding your life.   Victims of abuse may seek counseling, participate in a local support group for victims of domestic violence, and/or request that their partner seek treatment as part of a court-ordered protective or restraining order. Some victims may also train for or seek work outside the home in order to establish economic independence.” (Fraser, et al, 2001 p. 214).

Maintenance

During the maintenance stage, clients are struggling to avoid problematic behaviors.  The goal during this stage is to prevent relapses into old destructive habits.  Burman, (2003) states that 5-7 attempts are commonly made to leave an abusive relationship before success is achieved. “Various reasons have been given for this action, including ‘fear, continuing emotional involvement, desire to keep the family together, and lack of viable alternatives'” (Burman, 2003, p.86).   “Maintenance depends not only on the thoroughness of the action plan but also on a continuing support system” (Fraser, 2001, p. 2014).

Assessment Client Needs

Nature of Abuse

It is also important to obtain more detail on the nature and severity of the past abuse history in order to begin working through the effects of these experiences (Burman, 2003).   This should also entail an assessment for symptoms of PTSD and dissociation.

Self-Esteem & Coping Style

Issues for women recovering from a history of spousal abuse include a diminished self esteem, as well as dysfunctional cognitive and affective adaptations (Holiman & Schlilit, 1991). This diminished self-esteem can be thought of as a sense of powerlessness and low self-worth. It causes individual’s develop maladaptive belief systems about themselves in relation to others (Holiman & Schlilit, 1991). Emotionally, long-term spousal abuse also causes a paradoxical attachment, in which victims come to rely on a hope for something they never receive (Holiman & Schlilit, 1991).

Readiness for Change

Interventions should be geared towards a client’s level of readiness for change and aimed addressing resistance. For example, for women who have not yet left relationships, you would note they are either one of two things. They may be in the pre-contemplative change and unwilling to acknowledge the problem. Or they may be in the contemplative change and considering leaving, but unsure of how they may do so.

Depression & self-care (Kakurt, 2014)

Participants in this article described feeling depressive symptoms and difficulty engaging in adequate self-care (Karkurt, et al, 2014). Additionally they felt a mixture of emotions including being overwhelmed and stressed about the big life decision they just made. These overwhelmed feelings would arise when they began discussing the tasks before them as they attempted to rebuild their lives. Others were angry for themselves for not having left sooner.

Shame & Self-Blame (Karakurt, 2014)

A subgroup of participants in this research suffered with several more severe co-morbid diagnoses that required additional interventions. Issues common in this group include bipolar disorder, depression, suicide, dissociative PTSD, borderline personality disorder (Karakurt, et al, 2014). Finally, individuals who had suffered longer-term severe abuse, were most likely to deal with feelings of excessive guilt and self-blame (Karakurt, et al, 2014).   These feelings of guilt and self-blame made their decision to leave particularly difficult to cope with. For example, this article describes one participant stating they felt they had betrayed the trust of their partner (Karakurt, et al, 2014). This insight points at the importance of understanding an abusive situation from the perspective of someone who has lived it.   From an outsider’s point of view, these feelings make little sense. On the other hand, from the perspective of someone living the experience, the feelings are altogether different. It is our job to work at appreciating things in this vantage point, and helping from within this perspective.

Emotional Response to Violence

Holiman, (1991) “describes a paradox for women in violent situations: the woman is trapped because she feels even more afraid when she contemplates separation than when she imagines being intimate in a battering relationship…the fear of being without a partner was overriding, more important than whether or not the violence stopped” (p. 346).

When I read the above quote, I was again reminded of that relationship in college.  I would like to reiterate it wasn’t physically violent,  however emotionally, psychologically and sexually abusive.  I can recall a similar feeling of fear upon separation.  I recall breaking up with him during a family vacation to London.  My mother had arranged it with his parents.  He was going to visit them for a week, while I went to London.  It was my first time away from him.  I recall breaking up with him from this safe distance, and feeling a nagging fear & anxiety throughout the remainder of the trip.  This paradoxical feeling is admittedly difficult to explain however quite overwhelming.  Holiman (1991) suggests this is due to a process of traumatic bonding takes place between the woman and her partner, similar to the relationship between hostage and captor.” (p. 346).

Interventions

“Effective Interventions Matched with Stages of Change” for victims of abuse. (Fraser, et al, 2001, p. 215).

“Roberts’ Seven-Stage Crisis Intervention Model & Battering Severity Continuum” (Holiman, 2003, p. 88).

Burman, (2003) includes a description of a Crisis Intervention Model based on research that focuses on domestic violence.  This Crisis Intervention Model is based on the idea that abuse can be observed to occur along a continuum of severity.  “Divided into seven stages, the model details hierarchical assessment and intervention activities that aim to subdue a crisis so that strength-oriented empowering cognitive, and independent function can be achieved” (Burman, 2003, p. 88).

Crisis Defined:

“An acute disruption of psychological homeostasis in which one’s usual coping mechanisms fail and there exists evidence of distress and functional impairment. The subjective reaction to a stressful life experience that compromises the individual’s stability and ability to cope or function. The main cause of a crisis is an intensely stressful, traumatic, or hazardous event, but two other conditions are also necessary: (1) the individual’s perception of the event as the cause of considerable upset and/or disruption; and (2) the individual’s inability to resolve the disruption by previously used coping mechanisms. Crisis also refers to “an upset in the steady state.” It often has five components: a hazardous or traumatic event, a vulnerable or unbalanced state, a precipitating factor, an active crisis state based on the person’s perception, and the resolution of the crisis.” (Roberts, 2005, p. 778)

Seven Stages of Intervention (Roberts, 2005).

Continuum of Abuse (Burman, 2003).

A treatment plan

The following is a hypothetical treatment plan I created for my practicum course some time ago.  I utilized the resources below to create it…

References

Burman, S. (2003). Battered women: Stages of change and other treatment models that instigate and sustain leaving. Brief Treatment and Crisis Intervention, 3(1), 83.
Fraser, P. Y., Slatt, L, Kowlowitz, V., & Glowa, P. T. (2001). Using the stages of change model to counsel victims of intimate partner violence. Patient Education and Counseling. 44, 211-217.
Holiman, M. & Schlilit R. (1991). Aftercare for battered women: How to encourage maintenance of change. Psychotherapy. 28(2), 345-353.
Karakurt, G., Smith, D., & Whiting, J. (2014). Impact of Intimate Partner Violence on Women’s Mental Health. Journal of family violence29(7), 693-702.
Roberts, A. R., & Ottens, A. J. (2005). The seven-stage crisis intervention model: A road map to goal attainment, problem solving, and crisis resolution. Brief Treatment and Crisis Intervention, 5(4), 329-339

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Stages of Change: Treatment Needs & Strategies….

In a previous post, I provide an overview of the Stages of Change from a personalized perspective.  “In the transtheoretical model, behavior change is conceptualized as a process that unfolds over time and involves progression through a series of five stages: precontemplation, contemplation, preparation, action, and maintenance” Norcross, Krebs & Prochaska, 2011, p. 143).  The point of this post was to illustrate that change is a process and not a singular event.  In other words, “Just Do It” doesn’t cut it as useful advice for those attempting to institute changes in their lives.

The purpose of this post is to review the stages of change from a pragmatic perspective.  I discuss each stage and review treatment needs and potential strategies.

STAGE #1: Precontemplation

“Precontemplation is the stage in which there is no intention to change behavior in the foreseeable future. Most patients in this stage are unaware or under-aware of their problems. Families, friends, neighbors or employees, however, are often well aware that the pre-contemplators suffer from the problems” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

“During the pre contemplation stage, individuals are not even considering changing and may not even see advice provided to them as applicable to their lives” (Zimmerman, et al, 2000, 1409).  The goal for a therapist with a client in the pre contemplation stage is to increase their concerns for problematic behaviors and/or situations and provide hope that change is possible (Sullivan & Flemming, 1997).   In order to achieve this goal, the primary task is expanding the client’s awareness of their life situation.  At times, this might entail simply providing the client information, such reviewing symptoms of a diagnosis, or the side-effects of a medication.  However, it is also essential that explore the client’s perspective of things.  How do they perceive their situation & what meaning do they live to current life events?  Have they attempted to change before?  These questions can assess what the barriers to change are.  People are rarely liable to change if there is no benefit to doing so.  Therefore, it is critical that we understand the factors the client is struggling with as they weigh their options (i.e. change vs. no change).

Strategies

  1. Establish Rapport & Build Trust
  2. Assess the client rationale for current life-style choices…
  3. Begin to assess barriers to change.
  4. Elicit the client’s current perception of the problem.
  5. Expand the client’s current perspective by providing factual information
  6. Build up the client’s confidence in the idea that change is realistic & possible.
  7. Examine discrepancies between the client’s perception and how others view things.
  8. Provide personal feedback on assessment findings.
  9. Discuss relevant diagnoses, symptoms, and possible treatment.

Interview Approach

The primary goal is to develop rapport and establish trust.  Take time to discuss the client’s understanding of the problem.  Non-judgmentally provide factual information regarding the client’s problematic and/or self-destructive behaviors and express your concern (Sullivan & Flemming, 1997).   Begin establishing an “agree to disagree” standard in order to begin discussing divergent perspectives of the client’s life-situation (Sullivan & Flemming, 1997).  Periodically assess the client’s readiness to change.

STAGE #2: Contemplation

“Contemplation is the stage in which patients are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. Contemplators struggle with their positive evaluations of their dysfunctional behavior and the amount of effort, energy, and loss it will cost to overcome it” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

“During the contemplation stage, patients are ambivalent about changing. Giving up an enjoyed behavior causes them to feel a sense of loss despite the perceived gain” (Zimmerman, et al, 2000, p1409).  In other words, they are now able to acknowledge that change needs to happen, however remain ambivalent.  The idea of change, is either overwhelming, or highly undesirable.  The therapeutic goal, therefore, is address the client’s feelings of ambivalence.  In other words, what factors weigh in heavily for and/or against the idea of change?  How can this decisional balance tipped in favor of change?  Increasing the client’s understanding of their options can help them make more informed decisions.

Strategies

  1. Acknowledge feelings of ambivalence & normalize this experience as a part of the change process.
  2. Develop a list of factors for & against change.
  3. Provide clear & nonjudgmental messages regarding the client’s need to change.
  4. Examine the client’s personal values in relation to change.
  5. Address intrinsic & extrinsic factors related to the client’s motivation to change.
  6. Assess the client’s feelings of efficacy & expectations regarding process of change.
  7. Ask the client to begin considering small changes and assess their outcome.

Interview Approach

Continue building the therapeutic relationship.  Validate & acknowledge the client’s feelings of ambivalence regarding the idea of change.  Explore the factors underlying feelings of ambivalence.   Discuss positive an negative factors associated with change (Sullivan & Flemming, 1997).  Create a discrepancy between the client’s values and actions (Sullivan & Flemming, 1997).  Consider making small changes in order to address feelings of ambivalence (Sullivan & Flemming, 1997).

STAGE #3: Preparation

“Preparation is the stage in which individuals are intending to take action in the next month and are reporting some small behavioral changes (‘‘baby steps’’). Although they have made some reductions in their problem behaviors, patients in the preparation stage have not yet reached a criterion for effective action” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

During the preparation stage, patients prepare to institute small changes. Sullivan & Flemming, (1997), note that while pre-contemplation and contemplation work well with motivational interviewing techniques, CBT and/or 12-step approaches are useful for the remaining stages.  During this stage, clients work on strengthening their commitment to change.  Therapists should help client’s work though various strategies to institute planned changes.

Strategies

  1. Assist the client in refining their goals & plans for change.
  2. Help the client review the options available & determine a best course of action.
  3. Review previous attempts to institute changes in order to understand what didn’t work.
  4. Elicit the assistant from the clients social support system.
  5. Encourage the client to take action daily to institute change.

Interview Approach

Acknowledge the significance of the client’s decision to institute changes, and reaffirm their ability to successfully achieve their goals.  Help the client develop a plan of action and examine how the road ahead looks.  Reassure the client that progress sometimes involves relapse.

STAGE #4: Action

“Action is the stage in which individuals modify their behavior, experiences, and/or environment to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. Individuals are classified in the action stage if they have successfully altered the dysfunctional behavior for a period from 1 day to 6 months” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

Helping professionals are really eager to see their clients reach the action stage.  Helping the client implement strategies for change and develop a plan to prevent relapses into old habits.  Therapeutic goals during this stage can center around problem solving, developing a sense of self-efficacy and strengthening your support system.

Strategies

  1. Review the client’s plan for change and revise as necessary.
  2. Develop a relapse plan & prepare the client for this possibility.
  3. Help the client process the difficulties encountered in creating change.

Interview Approach

Be a source of support and encouragement and acknowledge feelings of withdrawal and/or discomfort that tend to accompany efforts to let go of unhealthy habits.  Reinforce the client’s resolve and the importance of remaining in recovery.

STAGE #5: Maintenance

“Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. This stage extends from 6 months to an indeterminate period past the initial action. Remaining free of the problem and/or consistently engaging in a new incompatible behavior for more than 6 months are the criteria for the maintenance stage” (Norcross, Krebs & Prochaska, 2011, p. 144).

Treatment Needs

Treatment needs during this stage involve maintaining changes & preventing old habits to crop up again. For example, I’ve tried to lose weight before, but have yet to realistically sustain it over a significant length of time. Life gets in the way, and I end up slipping and gaining a bit.  Recycling through the stages above is common & it is vital to normalize this experience with clients.  This can help clients examine what hasn’t worked out well in order to learn from past mistakes.

Strategies

  1. Help the client develop a support system that can help the client maintain life changes.
  2. Help the client develop new coping strategies in order to let go of old habits.
  3. Help the client examine behavioral & situational issues that can cause relapse.
  4. Help the client work through the beliefs & expectations that guide their progress.

Interview Approach

Help the client anticipate difficulties in creating lasting change and provide opportunities toward through this struggle.  Should relapses occur, help the client work through underlying factors that may have contributed to it.  Help client develop a sense of self-efficacy so that lasting change an be seen as realistic and achievable.

References

All of the information from this post has been adapted and summarized from the following resources below…

  1. Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of clinical psychology, 67 (2), 143-154.
  2. Sullivan, E., & Fleming, M. (1997). A guide to substance abuse services for primary care clinicians: Treatment Improvement Protocol (TIP) Series 24. Center for Substance Abuse Treatment, Rockville (MD): DHHS Publication, (1997).
  3. Zimmerman, G. L., Olsen, C. G., & Bosworth, M. F. (2000). A ‘stages of change’ approach to helping patients change behavior. American family physician, 61(5), 1409-1416.

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“Git Er Done!!!” – Motivation & Change

Motivation is Essential for Change….

“clients’ level of motivation for change is often a good predictor of outcome.  Motivation can be influenced by many naturally occurring interpersonal and interpersonal factors and by specific interventions…three are at least three critical components of motivation: readiness, willingness and ability” (Miller & Rollnick, p. 9).  

Willingness to Change

Change happens if an individual feels it is important for them.  Miller & Rollnick, (1991) describe a psychological self-monitoring function that acts like a thermostate.  Any aspects of our reality that are not in sync of our personal values produce a desire for change.  This discrepancy between our current reality and desired goals produces a willingness to change.  It’s polar opposite is resistance.

The Righting Reflex:  “When people perceive a discrepancy between how things are and how they ought to be, they tend to be motivated to reduce that discrepancy if it seems possible to do so.” (Miller & Rollnick, 1991, p. 20)

Ability to Change

Ability to change can be thought of a belief in our level of capability to achieve a specific goal..  When individuals believe they don’t have the ability to change, they are resistant to trying.  Individuals that face a discrepancy between actions and values (as desired above) who are do not feel capable of change can resort to using defense mechanisms.  Defense mechanisms provide an alternative to change via the adjustment of perceptions, beliefs, and thoughts.

Readiness to Change

“One can be willing and able to change, but not ready to do so…this third dimension, readiness, has to do with relative priorities: ‘I want to, but not now'” (Miller &Rollnick, 1991 p. 11).  Motivational Interviewing suggests we do not see low readiness in a pathological manner but as a normal part of the change process.

When Client’s are Not Motivated….

According to Motivational interviewing, human beings are seen as having a “built-in desire to set things right” (Miller & Rollnick, 1991, p. 20).  As stated earlier, change is a byproduct of motivation.  Motivation is a byproduct of any perceived discrepancies between what how things are and how they ought to be. So what happens when we encounter a client who is resistant to change despite clear evidence that it is needed?  Here are just a few examples from Miller & Rollnick (1991).

“You would think that having a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more and take his medication.” (Miller & Rollnick, 1991, p. 3).

“You would think that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking.” (Miller & Rollnick, 1991, p 3).

In the examples, it is often natural to react with frustration and sadness.  We see behavior that appears self-destructive, yet are unable to help the client see this.  Motivational interviewing, suggests not conceiving the client’s resistance in a self-destructive or maladaptive in nature, but instead a part of the process of change.  Consider the following:

What happens when someone with a righting reflex (R) [i.e. motivated]  meets a person who is ambivalent (A) [resistant]?  As A speaks to R about the dilemma of ambivalence, R develops an opinion as to what the right course of action would be for A to take. R then proceeds to advise, teach, persuade, counsel, or argue for this particular resolution to A’s ambivalence….By virtue of ambivalence, A is apt to argue the opposite, or at leastpoint out problems and shortcomings of the proposed solution. It is natural for A to do so, because A feels at least two ways about this or almost any prescribed solution. It is the very nature of ambivalence.” (Miller & Rollnick, 1991, p. 20-21)

In this above example, we see what happens when the client and the counselor are not on the same page.  So what is the missing piece of the puzzle that the counselor is missing? The client lacks motivation to change.  They are not ready, willing or able…

“Our perspective is that exploring and enhancing motivation for change is itself a proper task, at times even the most important and necessary task, within helping relationships such as counseling, health care, and education.” (Miller & Rollnick, 1991, p. 21)

OUR GOAL:  Developing Discrepancy

Miller & Rollnick, (1991) state that our goal should be to have the client voicing arguments in favor of change.  “When you find yourself in the role of arguing for change while your client (patient, student, child) is voicing arguments against it, you’re in precisely the wrong role” (Miller & Rollnick, 1991, p .22).

So how can we get our clients to begin arguing in favor of change?  In motivational interviewing, arguments in favor of change are called “Change talk”.  The client engages in “change talk when they are motivated.  “The larger the discrepancy, the greater the importance of change” (Miller & Rollnick, 1991, p. 22).  In other words, clients become motivated as feelings of ambivalence are resolved and they gain awareness of discrepancies between their reality and desires.   Change talk falls into one of four categories…

  1. “Disadvantages of the status quo. These statements acknowledge that there is reason for concern or discontent with how things are. This may or may not involve an admission of a ‘problem.’ The language generally reflects a recognition of undesirable aspects of one’s present state or behavior.” (Miller & Rollnick, 1991, p. 24).  
  1. Advantages of change. A second form of change talk implies recognition of the potential advantages of a change. Whereas the first type of change talk focuses on the not-so-good things about one’s current status, this second type emphasizes the good things to be gained through change. Both kinds, of course, are reasons for change.” Miller & Rollnick, 1991, p. 24).  
  1. “Optimism for change. A third kind of talk that favors change is that which expresses confidence and hope about one’s ability to change. It may be stated in hypothetical (I could) or declarative form (I can do it). The common underlying theme is that change is possible” (Miller & Rollnick, 1991, p. 24).  
  1. Intention to change. As the balance tips, people begin to express an intention, desire, willingness, or commitment to change. The level of intention can vary from rather weak to very strong commitment language. Sometimes the intention is expressed indirectly by envisioning how things might be if change did happen” (Miller & Rollnick, 1991, p. 24).  

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References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press

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Motivational Interviewing & Ambivalence

Misinterpreting Ambivalence

“It is easy to misinterpret ambivalent conflict as pathological — to conclude that there is something wrong with the person’s motivation, judgment, knowledge base, or mental state. A sensible conclusion from this line of reasoning is that the person needs to be educated about and persuaded to take the proper course of action” (Miller & Rollnick, 1991 p. 14)

Ambivalence is a frustrating dilemma that involves feeling two ways about something.   For example, I have been feeling lonely for a while and looking to establish new friendships.  I’m finding the task somewhat daunting with so little free time.  As adults, we establish friendships based on convenience, with those we have an opportunity to interact with regularly. Individuals at my stage in life tend to have quite a bit on their plate.  Between work and home life, where does one find time to establish new friendships?  My ambivalence reflects a conflict between two opposing desires. On the one hand, I feel lonely and desire to establish friendships. On the other hand, I have insecurities stemming from earlier childhood experiences, and am fearful of opening up to others.

When others misinterpret my ambivalence.

There is a coworker I chat with often via text at work.  We are both employed by healthcare float pools and often work at the same facilities, (although rarely on the same floor).  She is a social butterfly who is always urging me to just be more friendly and strike up conversations every so often.  From her perspective I would surmise she is frustrated by my lack of “motivation, judgment, and knowledge base” (Miller & Rollnick, 1991).  In other words, she could easily interpret my ambivalence as an unwillingness to take the initiative and establish friendships.  Alternatively, she might interpret my as a matter of social anxiety or ineptness on my part.  (Mind you, this is just an example, of the sort of consructive criticism I’ve heard before.  Coworkers, friends, and even my sister express advice of this sort from time to time regarding my “shyness & reclusive nature”)

What others miss about my ambivalence…

So what is my perspective? As I stated earlier, I have two conflicting emotional reactions to the idea of establishing friendships.  On the one hand, I feel lonely and wish to cultivate a few meaningful female friends.  Every once in a while, I might have something on that I want to share with somebody…Or mabye I might just simply want to sort things out: (I’m a verbal processor :))  From time to time, I can unknowingly bombard my poor hubby with assorted idle chatter.  As somebody who likes “thinking out loud” to verbally process my thoughts and come to a conclusion, it’s a habit I’ve have had difficulty breaking.   My hubby always tries his best to listen.  However, every once in a while he’ll comment jokingly: “You need to get a few female friends to go out with so you can talk about this at greater length.”  When he says this, I’m aware that he’s done all the listening he can take, and I need to find somebody else to talk to…

At moments such as these, when I need somebody to talk to, I become sad.  As feelings of loneliness arise, so do feelings of fear and anxiety.  I am fearful of opening up to others, primarily because I don’t want to re-experience the rejection and ostracism I dealt with in high school.  I can then berate myself for a lack of experience due to years of self-imposed isolation.  The alternative thought arrises at some point:  Wouldn’t it be much easier to stay home and lounge on the sofa while binge-watching something on Netflix?

…And then there are the pragmatic aspects of developing friendship that produce more frustration… First off, Idespise technology and/or social media as required forms of interaction in today’s social world. However, these things are here to stay and I’ve learned tried to adapt. For example, I might exchange texts occasionally with a coworker or fellow intern.  Every once in a while I might also call to ask a question, discuss a concern, and/or brain-pick.   I stress occasionally about how my text might be interpreted. I also worry about how my own texts are interpreted.   If she doesn’t call, I worry what that might mean.  If I call I worry about being a bother.

So here’s a breakdown of my example of misinterpreted ambivalence.

  1. 1st HAND P.O.V – My social ambivalence reflects unresolved insecurity and hurt stemming from early childhood bullying and ostracism.  In large part, I am anxious and fearful, because I don’t want to get hurt again.
  2. 2nd HAND P.O.V. – Other’s might misinterpret my social ambialence as reflecting the fact that I’m a shy or introverted.  Alternatively, someone could interpret this ambivalence as reflective of social ineptness or simply a lack of motivation to put a little effort into the establishment of friendships.  
  3. THE MAIN POINT – Ambialence is a normal part of the process of change,  it reflects a psychological conflict that needs to be resolved for change to happen.

A Different Perspective on Ambivalence…

“Ambivalence is a common human experience and a stage in the normal process of change. Getting stuck in ambivalence is also common, and approach-avoidance conflicts can be particularly difficult to resolve on one’s own. Resolving ambivalence can be a key to change, and indeed once ambivalence has been resolved, little may be required for change occur. However attempts to force resolution in a particular direction..can lead to a paradoxical response, evening strengthening the very behavior they were trying to diminish” (Miller & Rollnick, 1991, p. 19).

In order to resolve ambivalence, it is vital to understand that stuckness is a normal part of the process of change.  In fact, at the heart of the matter, is resolving one’s own conflicting feelings on an issue. Miller & Rollnick, (1991), suggest conceptualizing one’s dilemma’s as a decisional balance.  “Transactional analysis often regards the experience of ‘ feeling stuck’ as the manifestation of an impasse or an intrapsychic conflict or interpersonal roadblock…Impasses occur each time we encounter a situation in which our current adaptations cannot make sense of or handle meaningfully…(Petriglieri, 2007, pp. 185-187).”  Addressing the issue, from this perspective can be seen as a matter of weight costs and benefits for each course of action.   So how might this explanation apply to my social ambivalence?  

  1. Unresolved insecurities stemming from childhood experiences pollute my thinking today.
  2. My interpretations of others’ opinions becomes a foundational element of how I see myself.  
  3. When I think with my feelings in a knee-jerk manner, my unresolved insecurites turn into self-fuffilling prophecies, by withdrawing and isolating myself.  
  4. Examining how my knee-jerk coping styles perpetuate my insecurity and loneliness can provide the clarity necessary to overcome this ambivalence.
  5. Tipping the decisional balance chart, involves carefully breaking down decisional alternatives in this manner. Which route is the preferable alternative???

In these posts, I share how I’ve worked through ambivalence & feelings of stuckness in my life:

“Getting Unstuck & Why I Started this Blog” 

“An Underdog’s Credo: Choking vs. Panic”

Types of Psychological Conflict…

Miller & Rollnick (1991) describe three types of ambivalent conflict. “In the approach–approach conflict, the person must choose between two similarly attractive alternatives An avoidance–avoidance conflict, in contrast, involves having to choose between two evils—two (or more) possibilities Still more vexing is the approach–avoidance type. This kind of conflict seems to have special potential for keeping people stuck and creating considerable stress. Still more vexing is the approach–avoidance type. This kind of conflict seems to have special potential for keeping people stuck and creating considerable stress” (p. 15).
  1. Here is an example avoidance-avoidance conflict, in which I keep a crappy job because it pays well to support my family.  My choices here: a shitty job or being broke.  

  2. Here is an example of approach-avoidance, described my Miller & Rollnick (1991) as a “fatal attraction..kind of love affair”

Ambivalent Paradoxical Responses…

“The theory of psychological reactance predicts an increase in the rate and attractiveness of a ‘problem’ behavior if a person perceives that his or her personal freedom is being infringed or challenged. Secondary effects of a change within the person’s social environment may also account for detrimental shifts” (Miller & Rollnick, 1991, p. 18)

Miller & Rollnick, (1991) note that  common response to the utilization of deterrents to curb negative behavior is an increase of that behavior.  I like to think of this as a passive-agressive rebelliousness.  As a married mother of two boys, I’m the only source of estrogen.  The males in my family tend to utilize this response to any repetitive requests for them to do/not do something, (i.e. nagging) 🙂 ….  For example, my son hates being late for school, if I keep nagging him to get up earlier he can rebel by dragging his feet in the morning.  The consequence is he gets to school even later and complains about it more.  My youngest complains about being tired at school, yet responds similarly when I tell him to get to bed earlier.  When I  discussed this with my husband, he noted this knee-jerk, response is probably a result of the boy’s picking up on his bad habits 🙂 … These behaviors could be interpreted as an innate desire to challenge the restrictions placed on personal freedom.

A Solution to Ambivalence

So how do you resolve ambivalence?  I’ve spent too many years on a hamster wheel in my own life. Overcoming my own stuckness has been at the heart of my efforts to create forward-motion.  As I mentioned earlier, Miller & Rollnick (1991) discuss a decisional balance chart as a useful tool to overcome ambivalent. When I reflect on my own decision making processes at different points in life, I see flaws in my thinking.  At the heart of the matter, underlying my stuckness, were unresolved hurts and traumas that caused flaws in my thinking.  Addressing these issues head on and allowing healing to occur has been critical for forward progress.

Understanding & Handling Resistance

“My Mental Merry Go Round”

In conclusion Miller & Rollnick, (1991) also suggest the following as a solution to ambivalence:

“Instead of focusing, then, on why a person doesn’t want to make a particular change, it is sensible to explore what the person does want. This is not to ignore the topic of change. Rather, it provides a context for change. Sometimes a behavioral course adjustment does not occur until people perceive that change is relevant to achieving or preserving something that is truly important or dear to them” (Miller& Rollnick, 1991, p. 18).

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press
Petriglieri, G. (2007). Stuck in a moment: A developmental perspective on impasses. Transactional Analysis Journal. 37(3), 185-194.

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Motivational Interviewing & Resistance

It seems apparent that what a person is doing either isn’t working or is self-destructive; you can see a better way, yet the person persists in the same behavior. In a way, it is captured in the words, “You would think . . . ”

“You would think that having a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more and take his medication.” (Miller & Rollnick, 1991, p. 3).

“You would think that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking.” (Miller & Rollnick, 1991, p 3).

Change vs. Resistance: Two Sides of The Same Coin (Miller & Rollnick, 1991).

In a previous post, we discussed the nature of motivation: Here we consider it’s opposite: Resistance.

The Therapeutic Relationship: Consonance vs. Dissonance

“When things are going well in a motivational interview, there is a sense of moving together smoothly…the feeling is quite different when instead of moving together, the counselor and client seem to be struggling against one another” (Miller & Rollnick, 1991, p. 43).  In fact, conversations between therapist and
client occur along continuum, falling somewhere between understanding and misunderstanding.  Miller & Rollnick, (1991) utilize the terms consonance and dissonance to describe these extremes.  With consonance we have compatibility of perspectives between client and therapist: everybody is on the same page.  In contrast, dissonance involves an inconsistency and contradiction of perspectives: complete misunderstanding.

Miller & Rollnick, (1991) caution against defining dissonant conversations with clients as byproduct of resistance.  Resistance is a term that tends to implicitly apply blame to the therapist.  In reality, dissonant conversations with clients reflects more on the quality of the therapeutic relationship.  “Dissonance in a counseling relationship is not the product…of only one person’s behavior.” (Miller & Rollnick, 1991, p. 43). So what is the solution?  Miller and Rollnick, (1991) state it is the therapist’s job to recognize dissonance, interpret it accurately, and adjust accordingly in order to restore a feeling of consonance between therapist and client.

Client Behavior: Change Talk vs. Resistance

Miller & Rollnick, (1991) also assert that the insights on consonance and dissonance can apply to the understanding of client behavior.  “Resistance is a signal of dissonance in the client relationship…a meaningful signal” (Miller & Rollnick, 1991, p. 46).  The opposite of resistance is change talk, (discussed in a previous post).  Change talk reflects an increase in internal motivation and the resolution of ambivalence.  Resistance, in contrast reflects a high ambivalence, and low internal motivation.  Miller & Rollnick describe four categories of resistant behavior:

  1. ARGUING: The client contests the accuracy, expertise, or integrity of the counselor.”  (Miller & Rollnick, 1991, p. 48).
  2. INTERRUPTING: The client breaks in and interrupts the counselor in a defensive manner.”m(Miller & Rollnick, 1991, p. 48).
  3. NEGATING: The client speaks while the counselor is still talking, without waiting for an appropriate pause or silence.” (Miller & Rollnick, 1991, p. 48).
  4. IGNORING: The client shows evidence of not following the counselor.”  (Miller & Rollnick, 1991, p. 48).

How Should Counselor’s Respond???

“With patients in precontemplation, often the role is like that of a nurturing parent, who joins with a resistant and defensive youngster who is both drawn to and repelled by the prospects of becoming more independent. With clients in contemplation, the role is akin to a Socratic teacher, who encourages clients to achieve their own insights into their condition. With clients who are in the preparation stage, the stance is more like that of an experienced coach, who has been through many crucial matches and can provide a fine game plan or can review the participant’s own plan. With clients who are progressing into action and maintenance, the psychotherapist becomes more of a consultant, who is available to provide expert advice and support when action is not progressing smoothly” (Norcross & Krebs & Prochaska, 2011, p. 145)

Miller & Rollnick (1991) suggest that clients are “understood within the context of the counseling relationship” (p. 51).  Recognizing the fluctuation between dissonance and consonance in the therapeutic relationship is essential, so the therapist can adjust accordingly.  What follows are examples of what not to do:  

  1. “ARGUING FOR CHANGE: The counselor directly takes up the pro-change side of ambivalence on a particular issue and seeks to persuade the client to make change.” (Miller & Rollnick, 1991, p. 50).
  2. ASSUMING THE EXPERT ROLL:  The client structures the conversation in a way that communicates that the counselor ‘has the answers’.” (Miller & Rollnick, 1991, p. 50).
  3. “CRITICIZING, SHAMING, BLAMING, OR LABELING.”  (Miller & Rollnick, 1991, p. 50).
  4. “BEING IN A HURRY: Sometimes the perceived shortness of time causes the counselor to believe that clear, forceful tactics are called for in order to get through…if you act like you only have a few minutes, it can take all day to accomplish a change.”  (Miller & Rollnick, 1991, p. 50).

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of clinical psychology, 67(2), 143-154.

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What is Motivational Interviewing

Everybody knows someone who is making perplexingly unhealthy choices detrimental to their well-being.   It’s quite tough to watch helplessly as a loved one acts self-destructively.  We see their lives heading down a path leading to nowhere.  We are brutally where the end of the road can take them but are helpless to stop them.   All we can do is stand by and watch in horror.  I experience this all-too-often as a student therapist and healthcare worker.

What is motivational interviewing?

Motivational interviewing is a unique client-centered approach that helps the client’s achieve lasting changes in their lives.  It does this by helping the client resolve an feelings of ambivalence to change while clarifying internal motivations to change.  Motivational interviewing is defined by the following characteristics (Miller & Rollnick, 1991).

A Client-Centered Approach

Motivational interviewing has an indebtedness to the work of Carl Rogers in its client-centered approach.   It focuses on developing a concern and understanding of the client’s perspective.  Miller & Rollnick (1991), note that by utilizing a client-centered approach to encourage change, Motivational Interviewing has the following unique characteristics.

  1. It is collaborative in nature and avoids the authoritarian approach (Miller & Rollnick, 1991, p. 22).
  2. This approach focuses in drawing out client insight and develop intrinsic motivation (Miller & Rollnick, 1991).
  3. This method respects individual by asserting that responsibility for change rests upon the client.  (Miller & Rollnick, 1991).

A Consciously Directive Approach

Motivational interviewing, however, diverges from the Rogerian approach, as a consciously directive alternative to instituting change.  This approach is intentionally directed toward resolving any feelings of ambivalence to change.  Getting unstuck, involves working through ambivalence by creating discrepancies between behavior, goals, values, and beliefs.

It is a Method of Communication

“Third, we emphasize that motivational interviewing is a method of communication rather than a set of techniques It is not a bag of tricks for getting people to do what they don’t want to do. It is not something that one does to people; rather, it is fundamentally a way of being with and for people—a facilitative approach to communication that evokes natural change” (Miller & Rollnick, 1991, p. 18).

It Elicits Intrinsic Motivation to Change

“The focus of motivational interviewing is on eliciting the person’s intrinsic motivation for change. It differs from motivational strategies intended to impose change through extrinsic means: by legal sanctions, punishment, social pressure, financial gain and such. Behavioral approaches often seek to rearrange the person’s social environment so that one kind of behavior is reinforced and another discouraged” (Miller & Rollnick, 1991, p. 19).

It Focuses on Resolving Ambivalence

This method focuses on exploring and resolving ambivalence within the client and is based on the idea that change cannot happen unless the client is willing to do so.  Change cannot be imposed upon a client if it conflicts with their beliefs, values, and goals (Miller & Rollnick, 1991).  By addressing the cause of a client’s own “stuck-ness” they develop an internal motivation for change.

Lessons to Learn about Motivational Interviewing…

An article I found titled “Eight Stages in Learning Motivational Learning” provides an overview of skills practitioners must develop in order to utilize Motivational Interviewing successfully (Miller & Moyers, 2006, p. 3).

“practitioners acquire expertise in this method through a sequence of eight stages: (1) openness to collaboration with clients’ own expertise, (2) proficiency in client-centered counseling, including accurate empathy, (3) recognition of key aspects of client speech that guide the practice of MI, (4) eliciting and strengthening client change talk, (5) rolling with resistance, (6) negotiating change plans, (7) consolidating client commitment, and (8) switching flexibly between MI and other intervention styles” (Miller & Moyers, 2006, p. 3).

STAGE #1: THE SPIRIT OF MOTIVATIONAL INTERVIEWING

The first lesson a new therapist must encounter in utilizing motivational interviewing adeptly is to appreciate how it is unique.  What follows are three key descriptive characteristics of motivational interviewing:

  1. COLLABORATION – “Certainly one key component of the spirit of motivational interviewing is its collaborative nature. The counselor avoids an authoritarian one-up stance, instead communicating a partner-like relationship. The method of motivational interviewing involves exploration more than exhortation, and support rather than persuasion or argument” (Miller & Rollnick, 1991, p. 33).
  2. EVOCATIVE – “Consistent with a collaborative role, the interviewer’s tone is not one of imparting things (such as wisdom, insight, reality) but rather of eliciting, of finding these things within and drawing them out from the person…It is not an instilling or installing but, rather, an eliciting, a drawing out of motivation from the person. It requires finding intrinsic motivation for change within the person and evoking it, calling it forth” (Miller & Rollnick, 1991, p. 33).
  3. AUTONOMY – “In motivational interviewing, responsibility for change is left with the client—which, by the way, is where we believe it must lie, no matter how much professionals may debate what people can be ‘made’ or ‘allowed’ or ‘permitted’ to do and choose. Another way to say this is that there is respect for the individual’s autonomy” (Miller & Rollnick, 1991, p. 33).

STAGE #2:  (OARS) CLIENT-CENTERED COUNSELING SKILLS

“The second stage of skill development is not unique to MI. It involves acquiring proficiency in the use of classic client-centered counseling skills…Along with reflective listening, three other counseling micro-skills are particularly emphasized in MI, using the mnemonic acronym OARS: asking open questions (O), affirming (A), reflecting (R), and summarizing” (Miller & Rollnick, 1991, p. 8).

Basic Attending Skills

Active Listening Skills

Questions & Listening Responses

Confrontation, Reflecting, Focusing & Influencing

STAGE #3: RECOGNIZING CHANGE TALK

“MI departs from client-centered counseling in being consciously and strategically goal-directed. Originally developed to help people change addictive behaviors…[it] is directed toward particular behavior change goals. A key process is to help clients resolve ambivalence by evoking their own intrinsic motivations for change. When MI is done well, therefore, it is the client rather than the counselor who voices the arguments for change. Particular attention is given to client “change talk,” verbalizations that signal desire, ability, reasons, need, or commitment to change…If unable to recognize change talk when it occurs, the counselor cannot reinforce and shape it toward commitment” (Miller & Moyers, 2006 p. 7). Another resource for this article notes paradoxically, that it is the reflective, supportive, and client-centered approach that increases a client’s openness to change (Miller & Rollnick, 1991).  In contrast, traditionally confrontational and directional techniques increase resistance (Miller & Rollnick, 1991)

STAGE #4: REINFORCING CHANGE TALK

Once the client recognizes the client’s openness  & desire to change, therapists utilizing MI, must learn to further reinforce it.  This intentional reinforcing can happen through a series of strategies such as the following: “(e.g., ‘In what ways might this change be a good thing?’), and is cautious with questions the answer to which is resistance (e.g., ‘Why haven’t you changed?’)” Miller & Rollnick 1991, p. 8)

STAGE #5: ROLLING WITH RESISTANCE

“The client rather than the counselor should present the arguments for change. Change is motivated by a perceived discrepancy between present behavior and important personal goals or values.” (Miller & Rollnick, 1991, p. 26).  Using this method effectively requires therapists to understand that arguing directly with a client’s resistance to change, only reinforces it.  Rolling with resistance means inviting arguments against change and seeing resistance as a need to change the way you are communicating with the client.  Change can be enabled through a process of active problem solving the includes an acknowledgment the client’s concerns.

STAGE #6: DEVELOPING A CHANGE PLAN

“Miller and Rollnick described therapeutic skillfulness in timing, in knowing when to move on to the development of a change plan. The usual procedure is to offer a transitional summary of change talk (desire, ability, reasons, need) that the client has offered for making a change, and then to ask a key open question, the essence of which is “What next?”… Part of the skill here, then, is knowing when to attempt the transition from Phase 1 to Phase 2…is proficiency in developing a specific change plan (not necessarily treatment plan) without evoking resistance” (Miller & Moyers, 2006, p.10)

STAGE #7: CONSOLIDATING CLIENT COMMITMENT

Once the client has been to acknowledge a need for change, helping them follow through with their plans is the next critical task.  Commitment talk implies that a decision has been made, the client is committing to it and attempting to develop a plan.

STAGE #8: SWITCHING BETWEEN MI AND OTHER COUNSELING METHODS

“MI was never meant to be the only tool in a clinician’s repertoire. It was developed primarily to help clients through motivational obstacles to change. Within the language of the transtheoretical stages of change (Prochaska & DiClemente, 1984), MI was originally conceptualized for helping people move from precontemplation and contemplation, through preparation and on to action” (Miller & Moyers, 2006, p. 21).  Therefore, therapists must learn to utilize it alongside other methods.

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press
Miller, W. R., & Moyers, T. B. (2006). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions, 5(1), 3-17.

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Stages of Change

That Nike commercial that tells us “Just Do It!”, irks the hell out of me.  While intended as an inspirational message of empowerment, it misses the mark on how to create and sustain lasting change.  As I’ve come to realize (both professionally and personally) change is a process that takes time.  When I reflect on my own steady progression of growth thru life, two resources seem to describe this journey well.  The first is the transtheoretical stages of change model which addresses feelings of ambivalence toward change:

“People who successfully make changes in their lives progress along a continuum of predictable stages: 1) precontemplation – not aware of, or minimizing the problem; 2) contemplation – acknowledging the problem and considering possible changes; 3) preparation – making plans; 4) action – following through with plans and 5) maintenance – keeping the new actions as a part of daily activity” (Frasier, et al, 2001).

The second resource which inspires this post is a book by Carl Rogers (2012) titled “On Becoming A Person”.  While the stages of change model provides a witnesses acount of the change process, Roger’s description is a first-hand perspective.  In one interesting segment of this book, he describes a continuum of openness to change.  In an attempt to describe this continuum he makes the following observation:

“[this] Process involves a loosening of feelings. At lower end remote and unowned…At the upper end process of experiencing a continually changing flow of feelings becomes characteristic of the individual.” (Rogers, 2012, p. 157)

It is worth noting that while Rogers, (2012) description of change is similar in many respects to the Prochaska’s Transtheoretical model, it is comprised of 7 stages. Additionally, Rogers theory describes an abstract growth process as we move from ridgidity toward openness to change.  What I like about Rogers theory is it describes this process of change as a gradual transformation in how we relate to our feelings.

In this post I intend to discuss the process of change from two unique standpoints. One perspective will provide a theoretical overview of the stages of change from those in the helping professions. Another perspective will be a first-hand accounting of my experiences in a past relationship.  In this emotionally abusive situation, I underwent the very stages of change described here.   With the benefit of 20-20 hindsight, I am grateful for where I am today.  That experience is a stark contrast to my current marriage to a wonderful and loving man, almost 17 years.  I’ve honestly had to step back and debate whether or not I wish to share this experience in such an open forum. My decision is that openness & honesty will be 2 essential guiding standards in the creation of this blog.  After all, hiding experiences like these implies shame – which is unwarranted.  It just also happens to be the “badass” alternative, 🙂 🙂 🙂 …

image

Pre-Contemplation

22033“Precontemplation is the stage in which there is no intention to change behavior in the foreseeable future” (Norcross, et al, 2011, p. 144).

Second Hand Observation

According to Prochaska’s Transtheoretical model of change, individuals here are unaware of their problem and are reluctant to discuss matters in detail.  Rogers, (2012), notes an “unwillingness to communicate [about] oneself…communication is [instead] about externals…feelings are neither recognized or owned.  Personal constructs…are extremely rigid” (p. 133).  Feelings are managed with a goal of repression, in order to maintain a sense of security thru avoidance.  Unwilling to seek help independently, clients often enter counseling at the insistence of someone else.

First Hand Experience: “The ‘IT’ years…”

First Year of College…

“There is no need to talk about it: it won’t change a thing,” (Fraser, et al, 2001, 214).  This was my attitude in the first year of our relationship.  I felt a sense of complete hopelessness and lived in denial of the problem.  It was my first serious relationship and introduction to the dating world.  I was in my second year of college when we met, although not your “typical young adult”.   He was my first serious relationship:  prior to him I hadn’t even so much as even kissed a boy before.   I had just left high school that previous year, with a huge chip on my shoulder.  I was a bullied child with a well of unresolved hurt.  Since my best friend, Ruby Stricker moved in sixth grade, I hadn’t experienced a feeling of acceptance or belonging amongst peers.  I was the girl with the cooties that got picked last in P.E., and sat alone at the lunch table.  By the time I reached high school, I would go weeks without speaking more than a few words to people.  These exchanges included “pass the salt” (at home), or “can I use the bathroom” (at school).  This left me with six full years of stagnation in the area of social development.  While I was eighteen chronologically, an insecure sixth grader still lurked within.  As a result, I had huge expectations for my freshman year.  I hoped to make friends & wanted nothing more than to be accepted.  As you might expect, reality didn’t live up to expectations.

While I did experience some companionship with fellow dorm residents, a cavernous divide separated us.  They were your typical college freshmen, and I was  “different”.   Conversations with fellow dorm mates provide a unique window into this divide and my “burgeoning issues”.  Concerned for my level of naivety, the developmental divide between us made it difficult for me to be regarded as an equal.  I recall being very frustrated by this: their parental concern angered me.  Today, I realize I had misperceived it as a demeaning insult.  I wanted nothing more than to be like them, but had no idea of how to make up for “lost time”.  I finished that first year with very few friends and still had yet to go on my first date.

As I entered my sophomore year, I was still completely ignorant of my “issues”.  The consequences of my own chosen methods of adaptation to bullying continued to play out.  The self-imposed isolation throughout teens, now made it difficult to relate to those my own age.   Desperate to solve the problem, I was eager to to take the first “zero-to-sixty” route to maturity I could find.  Little did I know, I was to meet a guy who would deliver just that “and more”.

Meeting “IT”

(((FYI – in conversations with my family about this time of my life, my mother has requested we not mention “that name” .   In time we’ve adopted the nickname “IT” to refer to him.  I use this in reference to this individual throughout the post))) 

…From the moment we met, we were like moths to a flame, drawn to each other for all the wrong reasons.  We were the other’s “quick fix” solution to unresolved hurt.  His involved a complicated relationship with a “domineering” mother.  Mine involved a chip-on-your-shoulder mentality in the aftermath of prolonged bullying and emotional neglect.    We never did have that “honeymoon period” common in most “unhealthy relationships” (Burman, 2003; Fraser, et al, 2001).  Instead, I would describe our relationship from the start as a “boot camp” in which IT made the development of a traumatic bond, his priority.  I lost my virginity very early.   It happened so fast, I remember it in retrospect as an unreal “out-of-body” experience.  It was only when he crawled on top, that it dawned on me what was happening .  My head spun: it was over almost as suddenly as it began.

He immediately set a plan in motion, to turn my insecurities into a certain self-perceived fact that I was totally worthless and helpless without him.  Reading me like an open book, he berated me for my inability to fit in.  I was ugly and stupid.  He told me there was no way any other guy would want me.  I believed him, (based on past experience, it appeared a logical conclusion at the time).  This resulted in the gradual reinforcement of learned helplessness (Burman, 2003; Fraser et al, 2001).  He would push the boundaries of what I would put up with, by using my naivety to his advantage.  He dangled “girlfriend” status in front of me like a carrot on a stick.  Achieving this status meant doing what he said, no matter how crazy, willingly and without complaint.  If not, I was to receive anger and rejection.  This was an unthinkable horror I intended to avoid at all cost.  I “NEEDED” him.  Before long, I was his personal slave –  the sole reason for my existence was to do his bidding.

Now under his “complete control”, the next phase of his plan was set into motion.  He started to isolate me from others, insisting I move to another dorm and take a single room.  Away from my friends, I was alone again, just like high school.  Old insecurities re-emerged and with it, crippling depression.   I only wanted love and acceptance. He utilized these urgent needs to his favor.  He was very possessive and insisted I never leave his sight without his say.  However, he cheated on me constantly – openly and without apology.  In fact, he would share intimate details of his “trysts”.  He insisted I listen attentively without complaint so he could drive home the idea that I was lucky to have him.  Fearful of rejection, I complied as instructed.  At first, it was difficult to conceal my feelings.  I would sob uncontrollably while he laughed and called me pathetic.  In time I learned to separate myself from my experiences, as if I were floating outside my body and witnessing the events like an observer.  He could do as he pleased – I felt nothing.

In time, he was my “sole source” of acceptance and love.  Desperate to have somebody in my corner, “losing him” was now a source of fear and panic.  I was “lucky” to have him and fell for his plan; hook, line and sinker…

Contemplation

image“Contemplation is the stage in which patients are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action.” (Norcross, et al, 2011, p144).

Second Hand Observation

In the contemplation stage, a growing ambivalence begins to emerge as individuals begin to struggle with their own self-evaluations of dysfunctional behavior, (Norcross, et al, 2010).  Aware that a problem exists, individuals often describe feeling “stuck”.  Concerned about the energy and risk involved in change, resistance prevents further action.  Stages two and three in Roger’s description of growth/change provide additional insight on the nature of this resistance.  In stage two, problems are acknowledged but externalized (Rogers, 2012).  Feelings start to ‘bubble up’ and are unacknowledged.  Emotions are used to assess what is of value to us.  In phase three, an emerging understanding develops of how emotions exist in reaction to events while also defining their nature.  With this realization, we begin to re-examination our perceptions and beliefs of the situation. “Is all as we perceived it to be?” Questions such as these produce a growing awareness of our problems.

First Hand Experience

The move to New York…

The burgeoning depression I felt as a result of his imposed isolation was now intermingled with a constant state anxiety and feelings of hoplessness.  My body was a jumble of nerves, I couldn’t keep food in me, my heart was pounding out of my chest.   This state of “near panic” was due to the unthinkable:  losing what I perceived was my only real chance at love and belonging.    The very idea of this terrified me.  While I didn’t have the courage to “hurt myself”,  the emotions were overwhelming enough, that this option was starting to become quite attractive.

As the semester came to a close, he began planning our next move.  By this time, I had managed to alienate myself from all the friends I made first year.  We were spending every minute together.  He refused to let me out of his sight.  During finals week he made an executive decision that we were to hop the next Greyhound to New York City – his hometown.  Plopping down two duffle bags in my room one day, he told me to fill them up and “leave the rest of your shit here”.  I did as I was told, and only informed my parents of our move after arriving in Staten Island, where his mother dropped us off at an apartment she found.  With only $1000.00 in our pocket, it was my job to figure out how to support both of us.  I got a job at a restaurant, and begged my parents to help and they relented.  However, I received an angry letter from my father shortly thereafter, demanding “how could I do this”.  He told me I made my mom cry in attempt to induce guilt.  In short: I was “disappointing them”.  My sister, then only 12, was incredulous at how stupid I was.  “I would never hurt mom and dad like that”, she exclaimed, and set forth a path toward “being perfect”, that involves always following the rules as the “good girl”.  I was angry, for their failure to be there when I needed.  Couldn’t they see how this was an end result of years of many years of bullying and torment?

It was when we arrived in New York, that a new phase of our relationship began –  10x worse than what I had experienced previously.  Every second of my day was lived in a “pins and needles” like environment.  Trying desperately to “hold my head above water” emotionally, my only concern was to please him.   This meant stressing over every little thing.  The food was too “salty”.  I forgot to “lay out his clothes”.  Every little misstep was intermingled with negative commentary about my ineptness.  He called me “pea-brain” because I was so stupid.

The control was also amped up by this point, since we lived together.  There wasn’t a single move throughout the day that I could make without his say so.  He controlled the money, so I couldn’t do anything without his permission.  I was only allowed to eat small amounts of food, including oatmeal and ramen noodles 1-2 times daily.  My weight plummeted to around 90, (at 5’8″).  I was anorexic looking.  Meanwhile he ate like a king and started gaining lots of weight.  I remember watching him consume food longingly while crying inside because the hunger was beyond bearable.  He did this intentionally because it drove me crazy.

The demeaning and controlling behaviors steadily increased as his demands became more and more insane.  I was to sleep on the floor next to his bed like a dog because this enforced my status in the relationship.  I only entered it when he wanted “to get him some”.  I spoke only when spoken to.  I was to refer to him as “Sir”.  I had to ask permission to take a “piss”.  I was allowed to bathe only once every week or two for minutes at a time or he would pour a bucket of ice water on me.   After months of this, I was dirty and smelly since I rarely bathed.  My hair was greasy and tangled since I rarely had an opportunity to groom.   My clothing was usually disheveled since I only had minutes to dress.  I now looked like a starving, homeless, crazy drug-addict.   People walking down the street would stare at me visibly in horror.

The return home…

After a year of this, he decided a move was in order.  He felt moving to my hometown was a good idea since it was more affordable.  He also discovered he could manipulate my parents into giving me money, due to their concern for my well being.  By this time, I felt stuck and totally helpless.  I was certainly sick and tired of his treatment, but felt there was no other option.   I did recognize by this time that our relationship was a repeat of my childhood.  I knew it wasn’t a coincidence, that old traumas and fears from then were  re-emerging.  He was my “band-aid”: used to conceal issues I hoped to avoid. Like an addict in need of a “fix”, he had me where he wanted.  There was nowhere I could go.   By admitting this to myself, I was able to examine how the past explained the present.   However, I was still not strong enough to process those old memories.   I preferred, instead, to box them up in the attic of my mind with all the other baggage.

Preparation

22039“Preparation is the stage in which individuals are intending to take action in the next month and are reporting some small behavioral changes” (Norcross, et al, 2011, p144)

Second Hand Observation

In the preparation stage, clients begin making “baby steps” towards lasting change (Norcross, et al, 2011, p. 144).  With a full awareness of one’s problems, clients in this stage are ready to begin taking action in the upcoming months.  In this stage our goal is to begin understanding our situation more fully as we prepare to institute some big life changes.  Emotions are expressed with greater intensity regarding current experiences and past events.  The client begins to understand the importance of accepting and claiming ownership of all emotional experiences (both good and bad).  However, especially hurtful and traumatic experiences are still met with resistance.  Underlying a desire for change “is a realization of concern about contradictions and incongruences between experience and self….Example: I’m not living up to what I am” (Roger, 2012, p. 138). 

First Hand Experience

Fast-forwarding a few years, we now live in my home town and are working on completing a bachelor’s degree.   The relationship – as described above –  is otherwise unchanged.  I learn to acclimatize through a state of (almost perpetual) dissociation and numbing.  I am much like a marathon runner, emotionally conditioned to the situation.  Gradually, I gain awareness of the patterns in our relationship.  I come to understand that the unresolved insecurities from childhood bullying are a core component.  A sense of incongruency develops when I recognize this emerging clarity isn’t reflected in my dysfunctional life choices.   I desperately desire to leave, but feel incapable and stuck.  There is no pond to jump to where acceptance and love lie.  The only other option is aloneness – which frightens me.  A series critical incidences occur during this time which force me to examine our relationship further…

The first incident occurs just before Christmas break….

We had just finished our first semester back at school after a move from New York City.   We were living in the dorms at that time and planned to move in my parent’s apartment house once a vacancy opened up.  As Christmas neared, my mother insisted I come home to spend time with the family.  Her parents had just moved into the house after immigrating from the Philippines and she wanted me to spend time with them.  I was happy to see my grandfather, and desired to see him more.  Our last visit was when I was nine and he spent the summer at our house.  I remember growing close to him and being sad when he left.  When my mom stopped by the dorms to pick me up, IT forbade me to go.  A shouting match occurred between them and before long they are each holding me by an arm, pulling me in opposite directions.  After what seemed like an eternity, my level-headed father tells us to get in the car so we could discuss this.  Once we climbed in the car I noticed IT was crying(!).  I was shocked in that moment to discover IT’s “iron clad” armor was actually just show.  In reality, he was a scared and insecure child inside.   The only compromise we could come to, was for IT to accompany me to their house during the day and sleep at his place at night.  Mind you, the dorms were closed and he had nowhere to stay.  The only spot he could find was a van with and extended cab, in the driveway of a university maintenance worker’s house.  It was cold, dirty, and smelled of gasoline.   I hated him for ruining my Christmas and returning all the presents so he could spend the money.  I hated him for the time he took away from my family.  I hated him for making me sleep in that disgusting van.  Still, I felt completely helpless….

The second series of incidents involves encounters between IT and my former classmates.

On one such occasion, he informs me of two new friends he’s made: former bullies of mine.  IT talks about the time they enjoyed hanging out and describes their conversation.  He makes sure to tell me they thought I was a loser and I should be dumped.  On another occasion, I discover he was cheating on me with the most popular girl in school.  Again his storytelling involved a detailed accounting of their times together.  After years of this same treatment, I began questioning these stories as part of his plan to brainwash me.  However, when this girl started following me around in her car whenever I went out, I thought maybe there was a grain of truth to his story.

With every incident like this, the chinks in his armor start to appear.

I come to realize in time that he is completely full of hot air.  Underlying a thin veneer of confidence and good showmanship, is a well of insecurity and ineptness.   Underlying his assertion that I’m a helpless idiot is the reality that I’m pulling all the weight.  I work hard to support the two of us, (he is unemployed and only receives tuition money from his parents).  I work hard to help him get good grades (while holding down a full schedule myself).  I wait on him hand and foot, (he does nothing).  My hopes for love and belonging are now shattered.  I am now completely numb to any and all emotions – like a robot.  He is an asshole and I despise him but feel stuck.

Inside my mind, an emotional equation functions much like a “scale of justice”.   On one side, are the emotional burdens associated with being in this relationship.  On the other side are insecurities, feelings of worthlessness, and traumas I hope to avoid.   As each day passes, a few pieces fall from one side of the equation to the other.  The options of staying and leaving play out in this manner as I weigh this decision.  It is only a matter of time before the scale finally falls in the opposite direction….

Action

 image“Action is the stage in which individuals modify their behavior to overcome their problems” (Norcross, et al, 2011, p144).

Second Hand Observation

The action stage is observed through changes in a client’s behavior with the commitment of time and resources to sustain such a change (Norcross, et al, 2011, p. 144).  Rogers, (2012), provides commentary regarding Stage Five of his own theoretical model in the following statement: “There is an increasing quality of acceptance of self-responsibility for the problems being faced, and a concern as to how he has contributed” (p. 142).  Client’s in this stage display a heightened emotional awareness expressed as a desire to gain clarity.  As a result, feelings are experienced in the present.  This is accompanied with a “desire to be the ‘real me’” (Rogers, 2012, p. 142).  This need for change is goaded by a desire for honesty and self-responsibility (Rogers, 2012).

First Hand Experience

My Grandfather’s Passing….

In my junior year, my grandparents decide to move in with my aunt who lives in Texas.  As Filipinos accustomed to a tropical climate, they disliked the South Dakota winters.  Sad to see them leave, I promised to myself that “someday” I wouldmake time for them.  However, later that summer, my grandfather is hit by a drunk driver while out enjoying a bike ride.  I packed quickly and traveled to Texas with my family for the funeral.  I was numb and quiet throughout the visit.  I got my first taste of “freedom” in four years at this time. I could eat whatever I wanted, I didn’t have to ask permission to piss, and took leisurely showers every morning.  After relaxing into these experiences, nagging thoughts began to enter my brain.  My grandfather would never get to see me “well”.  His last memories of me woud be in this state of “fuckedupness”.  Of all my grandparents, I felt closest to him.  Our only time meeting was during the summer before I turned nine.  I began reminiscing about that time and was saddened by the fact that I lost our final opportunity to spend time together.  The real “kick in the gut”:  I chose instead to focus on appeasing “that bastard” waiting at home.  I knew there was something I had to do.

The London Trip.

On the way home from our trip to Texas, my mother expressed her concern.  I was quieter than usual, and she didn’t understand “what was wrong”.  An overwhelming sense of dread washed over me as I admitted to her that I wasn’t looking forward to getting home.  I didn’t elaborate but she knew implicitly what I had meant.  “Serendipitously”, just weeks after that exchange, my mother arranged a two week family vacation to England.  She then called IT’s family back home in New York and encouraged them to fly him home, since IT would be alone during this period.  They do, and somehow, (despite “his” protestations), I have a two week vacation to look forward to.  While over there, I’m treated to another two weeks of complete freedom.   On our third night there, I confess to my mother I needed to leave and felt now was my only real “safe chance”.  She gave me a hug and promised to be there for “moral support” during this call.   Our conversation was very brief and I’m not sure what I said.  I only know my heart was exploding out of my chest and my hands shook uncontrollably.  After a quick “I can’t do this any more”, he says “okay whatever” and drops the phone.  IT’s father then gets on the line and says he has to retrieve his son, who is outside in the snow without shoes or a shirt on.  I’m bawling at this time, but grateful for the courage I’ve mustered.  My mother gets on the phone and exchanges pleasantries with his dad.   I’m shocked – it’s over as quickly as it started.

The rest of the vacation is a blur.  My mind is muddled and my emotions are up and down like a roller coaster.  No longer numbed and in a state of robotic dissociation, my thoughts and emotions run wild.  While grateful to be out of the relationship, years of emotional brainwashing still remain.  I am still that addict in need of her “drug of choice”.  The emotional withdrawal of going cold turkey is unbearable.  “White-knuckling” it inside, I do my best to give “good face”.  I am strangely fearful and anxious without him nearby, (knowing we will probably never see each other again).  While I was able to contextualize these fears as based on his “emotional conditiong”, they remained unabated.  Unable to enjoy the vacation, I tried my best for my mother’s sake.  From an observer’s perspective, this decision might seem courageous.  From my own, this decision amounted to me “yelling uncle”.   Emotionally, I just had the living crap beat out of me.  I left the relationship that day, an empty shell with nothing left to give, a shadow of my former self…

((In the video below, Gabriela Andersen-Schiess crosses the finish line completely exhausted, after running a marathon during the 1984 Olympics.  It visually depicts my emotional state during this time:))

Maintenance

24816“Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action” (Norcross, et al, 2011, p144).

Second Hand Observation

The maintenance stage can be observed as the sustained maintenance of behaviors incompatible with one’s problems for a sustained period of time (Norcross, et al, 2011).  Rogers, (2012), describes stage six of his model of change by stating: “Once an experience is fully in awareness, fully accepted, then it can be coped with effectively” (p. 145).  Where there was once stuckness there is now allowing.  Where there was once resistance there is now acceptance.  As a result, the client is able to handle the problem effectively.  Problems are not externalized as “somebody else’s fault” so we can play victim.  They are not taken inward with a sense of shame while we “beat ourselves up”.  Instead, “he is simply living some portion of it knowingly & acceptingly [one step at a time]” (Rogers, 2012, p.150).

First Hand Experience

The aftermath…

With IT out of my life, I was able to move forward.   I began to relax into the simplicity of daily life.  I redecorated my apartment, and removed anything that reminded me of him.  I enjoyed  the pleasures of complete freedom.  My grades and overall health improved and I got my emotional “sea-legs” back.  After graduation, I moved to be closer to my sister and found a job.  Still not “over” the effects of all these experiences, I tried my best to manage them.   In those early years, I began to focus upon healing and addressed the most raw wounds of that period.  The support groups I attended were a vital lifeline.

20-20 hindsight…

It is now over 20 years since I broke up with this guy.   I don’t know where to begin discussing this last stage of change.  It just might need to be the subject of another post, since this one is already much longer than I had intended.   I can, however, reassure you that in time even the deepest wounds heal.  It’s taken a long time to work through the effects of this experience and put it into perspective.  In fact the last reminants of baggage from that relationship have finally been put to rest in the last few years as I’ve worked in repairing the relationships in my family.  In case you are wondering, I’m happily married now to a loving man and enjoy a relationship that once seemed impossible.  Today, memories of this experience rarely come up. I can honestly say I hold no ill-will towards IT. Healing began as I examined those reasons for entering and staying in such a relation.  I took a DBT therapy skills group and started procrssing old traumas.

In time, I discovered that in order to move forward, I would need to forgive and begin healing.  Doing so has been essential to make room for the “good stuff” that has since followed.  In fact, this experience provided me a chance to grow.  Strangely, the relationship I enjoy now, stands on the shoulders of lessons learned during this time…

Over the years I’ve learned that guys like this follow their own fucked-up rule book.  Click here for insights on how to spot a guy like this…

References

Burman, S. (2003). Battered Women: Stages of Change and Other Treatment Models That Instigate and Sustain Leaving. Brief Treatment & Crisis Intervention. 3(1).
Brown, B. (2015). Rising Strong. Random House: New York
Frasier, P. Y., Slatt, L., Kowlowitz, V., & Glowa, P. T. (2001). Using the stages of change model to counsel victims of intimate partner violence. Patient education and counseling, 43(2), 211-217.
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of Clinical Psychology, 67(2), 143-154. doi:10.1002/jclp.20758
Rogers, C. (2012). On becoming a person: A therapist’s view of psychotherapy. Houghton Mifflin Harcourt.

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