Determining Readiness to Change

When clinical screening indicates a potential substance use disorder, take steps to determine the patient’s willingness to accept the diagnosis and accept further exploration, intervention and referral for treatment. Prior to discussing treatment options, check patients’ readiness to change their behavior. Inquire directly about patients' interest in changing, and about their confidence in accomplishing change.   

Researchers have found that patients go through a series of predictable stages in the process of changing unhealthy behaviors. Stages of change include: precontemplation, contemplation, preparation, action, and maintenance. (20) It is important to understand what stage your patient is in, since your counseling will need to address the patient's particular needs and expectations relevant to that stage. Briefly, in Precontemplation, the patient is content with the behavior and doesn't see the need to change. In Contemplation, the patient understands that there are benefits of the behavior, but also risks and current negative consequences, and is thinking about changing the behavior. In Preparation, the patient has decided that it is best to change the behavior, begins to gather information on what it will take to change, and plans concrete actions necessary to change. In Action, the patient undertakes the necessary behavior, social, and environmental changes necessary. In Maintenance, the patient practices the many behaviors necessary to substitute for the previous unhealthy behaviors and to avoid restarting the previous behaviors. In Relapse, the patient restarts the previous unhealthy behaviors and usually returns to the contemplation stage.

Please click the buttons "Contemplation", "Action", and "Relapse" in the graphic on the left to play video examples showing interviews of Ms. Anderson in these stages. Below are videos of actual patients illustrating maintanance.


Reno George Cliff Please click the video buttons on the left to listen to Reno, George, and Cliff talk about how they remain in the stage of maintenance.

Asking two questions about patients' conviction and confidence helps you ascertain their motivational readiness.  Conviction assesses what patients believe about the importance of taking action, and confidence assesses what patients believe about their present ability to adopt or change a behavior (despite obstacles or barriers.)  The latter is often referred to as their degree of "self-efficacy."

Ask patients to help you understand where they stand by using a numerical rating scale.

"On a scale of 0–10, how convinced are you that quitting cocaine is important?"

Not only will patients' answers to readiness questions alert you to material not usually made explicit, but also many patients respond with more dialogue and useful information about the past and the present. This is true even when patients protest that they do not like to use number scales.

Usually, asking why the number the patient chose is not LOWER than the one the patient named proves a helpful continuation of the dialogue.  You may wish to incorporate this tactic in your Brief Intervention (below), perhaps saying,

"So you are at a “6” about thinking you need to quit cocaine; I'm wondering why you did not name a lower score?”

Asking about lower scores encourages patients to speak (and to hear themselves speak) about change in positive terms.  You can then move more smoothly to talking about next steps.

Frame your confidence question as follows:

"Let's suppose for a moment that you were a 10, completely convinced that you should cut down or quit; on a 0–10 scale, how confident are you that you would be able to entirely abstain for the next 4 weeks?"

If the patient chooses a low number, you might ask, "What would it take for you to get your confidence level higher, say to an 8?"  The patient may then suggest strategies that develop a greater sense of self-efficacy and hope.