You have to use stage matched interventions.

A common experience for therapists is having clients agree to do homework but then not actually following through on it. A leading cause for this is a mismatch between the client’s stage of change and the therapist’s approach. 

“Meeting the client where they’re at” is vague, perennial advice for therapists that applies to a surprising number of problems or sessions that didn’t go well, even for seasoned therapists. People will only make sustained change if they think they need to and they’re willing/able to put in the work of changing. 

Prochaska and DiClemente came up with the transtheoretical model (TTM) of change in the 1980s, usefully dividing motivation into 5 stages: 

Pre-contemplative: possibly unaware of need for themselves to change, not going to do the work (e.g., complaining, blaming, minimizing, helpless victim stance)
Contemplative:  less ambivalence, may start action in next 6 months
Preparation: Taking small steps, maybe sharing about it, acting in next 30 days
Action: working to enact the change
Maintenance: working to maintain the change over time

It’s crucial to utilize stage-matched interventions—taking us back to people not doing their homework between sessions. When therapists are working at a different stage than clients, people can feel misunderstood, lazy, stupid, not good enough, judged, etc—and while many people are polite and may verbally agree to tasks during the session, they are unlikely to follow through.

This is part of why you can’t just have a list of skills and how-tos in the waiting room that people read on their own, then leave without seeing you. It’s also part of why self-help books can’t put therapists out of business. People overcome difficult problems in their lives frequently (without therapy!), and being highly motivated is often key to that success.

Newer therapists can have a bias to slide into problem solving too quickly; we have so many fancy interventions from all our education and trainings we want to use (plus their structure reassures us and we get to feel like an expert in a field where we mostly feel uncertainty)—but this is only useful when the timing is right. A comment I frequently make to someone in a couple who likes to jump to solving problems that also applies here is “yes, there is a problem and you can fix it. The problem is that your partner doesn’t FEEL heard and understood, and you can fix it by listening to them effectively” (which hopefully they agree to learn and practice).

I find early career therapists are often already good at working in the latter stages of change, so here I’ll focus more on the earlier ones. The TTM article on wikipedia is useful, but in short: you should master motivational interviewing (MI).

Interventions by stage: 

Pre-contemplative: 

• Simply hear the story, build rapport, use active listening and validation

• Subtly start to add in MI to focus on what they can control, not what merely happens nearby them, “is there anything about this situation that you want to be different?”

• When they describe an action they’ve taken often or pattern they have, I ask “How’s that working for you?” (Suit your personality, I usually ask it sincerely and curiously, but at times we both sort of laugh). 

• Deepen on client emotions with process and EFT questions “what’s it like for you when [eg your wife keeps fighting with your? Or to realize your family tried to shame you? etc]”. Frankly, I like to get people crying here, which is often a sign they’re being honest with themselves and recognizing that the current situation isn’t working out. Processing emotions in therapy like this removes some barriers and then action is easier to initiate.

• “It seems like you keep trying the same thing and you already told me it’s not working. Where does that leave us?” And some time shortly after “Maybe it’s time to try something else?”

• I try to keep with these kinds of consciousness raising strategies, maybe getting a bit more into pros of changing etc, until they invite me to help them change, or ideally, they’re convincing me they should change. Some therapists like to play devil’s advocate here (not usually my style)

• Building the client’s safety with you, awareness of the impact of the problem, and the impact of them choosing not to act is key to this step

Contemplative: help them start to take responsibility for their actions and health. More MI, more awareness, perhaps sharing or co-creating more specific language, ideas, imagery, metaphors etc to help them understand nuances of their situation or feelings

Preparation: building self-efficacy, finding positive exceptions from their past to adapt to the present, identifying skill deficits to work on

Action: they use whatever intervention/change you both worked out

Maintenance: organize a plan for how they’ll keep these changes up over time: How were you able to make that change? How can we make sure you can maintain it? What systems or reminders might help you? What might give you a ‘run for your money’ in 3 or 6 months, and how can you prepare ahead of time for it?

Regarding structure, people need to feel understood and safe, and then they’re more willing to process the emotions and evaluate the need for change. Once clients are more ready to act, don’t miss the step of “buy in”, as in conceptually connecting their worldview and problem to a cogent path forward. You’ll know you did this well when both you and the client are 100% clear on why each skill or intervention is being taught and how that step fits into their larger picture. Once these things are set up thoroughly, taking the steps to change is usually the easy/fun part. Or at least change has a chance of happening.

Some clients are mandated: socially or legally. I address this more later, but generally this all still applies, with a particular focus on the first few stages. Remember that people will show up to therapy at various stages of change; most new therapists persistently act like every client shows up in the action phase, but don’t now assume everyone’s pre-contemplative either.

For more info, google: “the 4 Processes in Motivational Interviewing” and see the wikipedia article on TTM, it gets very specific with 10 processes of change, and later researchers added 21 more.

Return to Article overview