Evidence-Based Reviews

Engage resistant patients in collaborative treatment

Current Psychiatry. 2007 January;6(1):47-61

References

1. Horvath AO, Bedi RP. The alliance. In: Norcross JC, ed. Psychotherapy relationships that work: therapist contributions and responsiveness to patients. New York: Oxford University Press; 2002.

2. Mee-Lee D. Treatment planning for dual disorders. Psychiatr Rehabil Skills 2001;5(1):52-79.

3. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. Am Psychol 1992;47:1102-14.

4. Prochaska JO, Norcross JC, DiClemente CC. Changing for good. New York: Avon Books; 1994:54.

5. DiClemente CC. Conceptual models and applied research: the ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12.

6. Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford Press; 1991:18.

Table 3

Strategies and interventions to motivate patients at each stage of change

Stage of change	*Most useful processes of change (see Table 2)*	Goal of treatment	Strategies and interventions
Precontemplation	Consciousness-raising Social liberation	To raise doubt	Establish a relationship and identify treatment contract Develop discrepancy between patient’s goals and behavior Use leverage to create incentives to change
Contemplation	Consciousness-raising Social liberation Emotional arousal Self-reevaluation	To tip the balance	Allow and explore ambivalence Decisional balance (pros and cons, costs and benefits) Elicit self-motivational statements
Preparation	Social liberation Emotional arousal Self-reevaluation Commitment	To determine best course	Clarify and reinforce patient’s goals and strategies Identify obstacles to follow through Declare plans to change to others
Action	Social liberation Commitment Reward Countering Environment control Helping relationships	To take steps to change	Strategize on how to reach patient’s goals, and start behaviors and changes in thinking Identify what is working and do more of that (solution-focused) Establish support network and coping skills
Maintenance	Commitment Countering Environment control Helping relationships	To prevent relapse	Strengthen and support lifestyle changes Celebrate successes and rewards of change Identify relapse triggers and develop plan to avoid or deal with relapse
Relapse/recycling	Depends on stage to which patient returned	To renew processes of change	Reinforce patient’s honesty to admit relapse and his/her return for help Identify to which stage patient returned Examine where patient got “off track” and what needs to change to resume recovery

Related resources

Scott D. Miller, PhD. Institute for the Study of Therapeutic Change, Chicago, IL. (773) 404-5130; www.talkingcure.com.
Miller WR, Rollnick S, Moyers TB. Motivational interviewing: professional training videotape series. Albuquerque, NM: University of New Mexico, 1998. Six videotapes (about $130 total); (505) 768-0279 or 0100.
Miller WR, consensus panel chair. Treatment improvement protocol. Enhancing motivation for change in substance abuse treatment. Rockville, MD; Center for Substance Abuse Treatment, 1999. DHHS Publication 99-3354. Available from the National Clearinghouse for Alcohol/Drug Information, Rockville, MD; (800) 729-6686.

Acknowledgment

Dr. Mee-Lee is a board-certified psychiatrist and is certified by examination of the American Society of Addiction Medicine (ASAM). He is based in Davis, CA, and is involved in full-time training and consulting. For information, visit www.DMLMD.com.

Engage resistant patients in collaborative treatment

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