This article is a special add-on the Jan/Feb 2014 issue of The Carlat Addiction Treatment Report. This article is not part of the continuing education content of that issue.

In addiction treatment, one of the biggest challenges that clinicians face is helping clients recognize that they are their own experts for making positive behavior changes. Here’s a case in point: I was having some difficulty maintaining a healthy diet, so I decided to sit down and have a conversation with the world’s leading authority in my behaviors—me.

D. Kuhl: I appreciate you taking time out of your busy schedule to talk.

Don K.: My pleasure.

D. Kuhl: So I have to ask, why haven’t you done anything yet to improve your eating habits? You’re still sneaking handfuls of M&Ms every night. You still munch on donuts in the break room. Don’t you want to change?

Don K.: Hey, we’re having this conversation, aren’t we?

What is Change?

Often, when I’m conducting one of my self-interviews, I have to work to remember what change is all about. My tendency is to focus on the tangible results. In this case, I grill myself about caloric intake, the degree of variance from baseline, the number of inches around my waist. If I can’t see a measurable improvement, I assume no change has occurred yet.

But this particular self-interview raises a good point. At least I was talking to myself about changing. At least I was thinking about what that might look like. Ambivalence can be a good thing. As the psychologist William R. Miller, PhD, says in talking about patients, “They want to change and they don’t want to, all at the same time.” (Miller WR, Rollnick S. Motivational Interviewing, 3rd ed. New York, NY: The Guilford Press; 2013:6). That’s a pretty good start.

For most people in treatment, just showing up really means something. Actually contemplating a change can mean even more. Fewer than 20% of people engaging in high-risk behaviors are ready to take action to change those behaviors. And a vast majority of treatment programs, up to 90%, are designed to target only the action stage of change, which usually shows the most overt modifications in behavior (Prochaska JO et al. Changing for Good. New York, NY: William Morrow & Co; 1994:15).

Does that mean the other 80% of at-risk people aren’t doing any work? Or does it mean we need to expand the way we measure and manage change?

D. Kuhl: So, what you’re telling me is that I should give you credit for showing up and being willing to talk.

Don K.: Would it kill you if you did? I mean, a month ago, I didn’t think there was anything wrong with the way I ate. I never counted the number of popsicle sticks lined up on my bedside table. Now, they’re the first thing I see when I wake up.

Change is not entirely defined by external actions. While actual behavior modification plays a key role, change can also be gauged by one’s awareness of an issue, one’s willingness to address it, even an increase in one’s perceived ability to change. I knew I could eat better if I wanted to. I’ve been successful in changing this behavior in the past. Recognizing and reflecting this ability is what builds motivation and lays the foundation for more outward behavior modifications in the future.

Preventing Change

D. Kuhl: Don, we’ve argued about this issue before. You’re putting yourself in danger. You need to cut back on the fats and the sweets if you want to continue staying active.

Don K.: I disagree. Besides, who said I wanted to be so active? Maybe I want to stay in more often. Basketball season is in full swing and March Madness isn’t going to watch itself.

D. Kuhl: But your cholesterol is above the medically recommended limit!

Don K.: Actually, I heard cholesterol measurements aren’t that important in determining overall health. A friend of a friend of mine knows a doctor who said so herself.

You would think that having objective data on your side would make for easier counseling. In fact, one of the early processes of change recognized in the Transtheoretical Model (TTM) is called “consciousness-raising” (Prochaska JO et al, op.cit).

What better way to raise someone’s consciousness than with cold, hard facts? Unfortunately, throwing facts, judgments, and expert diagnoses at a client has a unique effect. As one voice moves toward one side of the argument—the reasons to change—the other voice naturally picks up the opposite side—the reasons to stay the same.

This is a natural byproduct of argument and debate. “Argue for one side and the ambivalent person is likely to take up and defend the opposite” says Dr. Miller (Miller WR, op.cit). And in a treatment setting, who do you think that ambivalent person is going to listen to more: your arguments or his own?

Promoting Change

My self-interview was going downhill fast. I decided to turn to a more lighthearted subject: pets.

D. Kuhl: So I hear there were some recent additions to the family.

Don K.: That’s right. We just got two new puppies, named Amy Beth Baker and Benny Bean Baker. They’re hard to catch up with, but I feel like they’re keeping me young.

D. Kuhl: You enjoy running around with your new pups.

Don K.: Absolutely! I wish I could spend the whole day romping with them in the yard, but I get tired before they do.

D. Kuhl: You want to be able to spend more time playing, but are feeling slowed down by your body.

Don K.: Yeah. I can keep up for an hour or so, but I should be able to last longer. You don’t think that’s because of my eating, do you?

For some strange reason, this part of the conversation was much more enjoyable. The tension disappeared, and my resistant inner voice actually seemed interested in learning more about the issue at hand. Rather than spouting off all the objective, medical reasons why it was crucial to change, we were talking about what was personally important.

Dr. Miller refers to this clinical response as reflecting a client’s “preparatory change talk” (Miller WR, ibid). This kind of client response is further classified into the four subcategories of desires, abilities, reasons, and needs. When my internal monologue mentioned wanting to spend more time playing with the puppies, that was “desire” talk in action. When it mentioned being able to keep up for an hour or so, that was a stated “ability.” Continuing this discussion could easily have revealed “reasons,” such as maintaining a sense of camaraderie with the dogs, and “needs,” such as the need to be a healthy leader of the pack.

Reflecting a client’s “change talk” can be an effective tool in building motivation and self-efficacy, regardless of where one is in the change process. Part of me couldn’t understand how puppies were somehow proving more effective motivators than quantified medical data. Nevertheless, that seemed to be the case.

A Three-Person Conversation

I have interviews with myself on a regular basis. I listen to the different voices arguing in my head about what they might want to change, and do my best to keep from over-directing the conversation.

These “self-talk” conversations exemplify what most ambivalent clients are going through as they contemplate making a change. As counselors, it’s important to remember that ambivalent clients are coming in with both of these voices already arguing in their head at full-volume.

Professionals who show up only wanting to listen to the “rational” or agreeable side of this internal conversation can risk missing some of the client’s main desires, abilities, reasons, or needs. The catalyst for change may not be found in the “facts,” but rather a personal vision for the future, such as wanting to be able to spend more time with one’s family. A client who wonders if alcohol or drug use might be getting in the way of a family relationship is sharing a part of their own internal debate. Oftentimes, having productive conversations with still-contemplating clients simply means allowing both of these internal voices to be heard, rather than trying to make it two-against-one. It becomes less about “managing” the conversation and more about going along for the ride.