This document discusses strategies for engaging with and working with precontemplative individuals regarding behavior change. It notes that most behavior change programs are designed for those ready to take action, but only 20% of people presenting for help are at that stage. Effective strategies must start where people are and accept their unique experiences. Fear-based interventions can reinforce the perception of threat. The document discusses focusing on developing competence in other areas like stress management. It also discusses the importance of emotional intelligence and connection in communication. Timing is important - desire and competence for change must occur together. The processes of change involve experiential and behavioral processes seen at different stages. For precontemplation, it's important to raise consciousness and provide alternatives.

1. ALL IN THE TIMING:
CREATIVE STRATEGIES FOR
ENGAGING AND WORKING
WITH THE
PRECONTEMPLATIVE PERSON
Association for Medical Education and Research
in Substance Abuse Annual Conference
Lifestage, Inc.
www,lifestage.org

2. “TIMING HAS A LOT TO DO WITH THE
OUTCOME OF A RAIN DANCE”
OLD WEST WISDOM
The “action” paradigm of behavior change is a model that
enrolled clients in relatively brief programs designed to
conquer smoking, weight, alcohol, spending or other
problematic behavior and expected them to take action within
weeks. Failure to maintain the action is attributed to the
clients‟ lack of will power or motivation.
90% of behavior change programs are designed for people
who are ready to take action and change their behavior.
20% of people who present for help are ready to take action or
change their behavior.
Prochaska, Norcross & Clemente, Changing For Good, HarperCollins Books, 2006.

3. “REALIT Y IS THAT WHICH,
WHEN YOU STOP BELIEVING IN IT,
DOESN‟T GO AWAY.” P H I L L I P K . D I C K
 “The popular concept among behavioral therapists is that no
time is better than the present to take action against an
addictive habit. In theory, it sounds right. But the cold light of
reality presents a dif ferent picture. I am convinced that there
is a tremendous advantage in a well -prepared, pre-emptive
attack against the smoking habit.” D r. B a l a s a P r a s a d S to p S m o k i n g Fo r
Good

4. “THERE IS A TIDE IN THE AFFAIRS OF MEN
WHICH, TAKEN AT THE FLOOD,
LEADS ON TO FORTUNE;
OMITTED, ALL THE VOYAGE OF THEIR LIFE
IS BOUND IN SHALLOWS AND IN MISERIES.
ON SUCH A FULL SEA ARE WE NOW AFLOAT,
AND WE MUST TAKE THE CURRENT WHEN IT
SERVES,
OR LOSE OUR VENTURES.”
W M S H A K E S P E A RE , J U L I U S C E S E AR , AC T 4 , S C E N E 3 , 21 8 - 2 24 .

5. CHANGE IS A PROCESS THAT PROCEEDS
IN STAGES OR STEPS
But change is not a lateral process.

7. ADDICTION AND
CHANGE:
Understanding
and Intervening
in the Process
Carlo
C.DiClemente,
Ph.D. ABPP
UMBC
Psychology
www.umbc.edu/
psych/habits

8. THE PREPARED MIND
 “At certain moments in history, there are individuals whose
minds are prepared to recognize the importance of things that
unprepared minds ignore or throw away.” P r o c h a s k a , N o r c r o s s & C l e m e n t e ,
Changing For Good, HarperCollins Books, 2006: 17
 With pre-contemplative people, information about addictive
behavior – or any other health-threatening behavior pattern –
has to transcend the psychological barriers that allow the
behavior to continue despite its negative consequences.

9. INTERVENTIONS THAT DO NOT
MATCH THE PERSON'S
READINESS ARE LIKELY TO:
DAMAGE RAPPORT
BLOCK RECEPTIVITY TO THE
MESSAGE
IMPEDE CHANGE
“ M O T I VAT I O N A L I N T E R V I E W I N G A N D T H E S TA G E S O F C H A N G E ”
S U B S TA N C E A B U S E A N D M E N TA L H E A LT H S E R V I C E S A D M I N I S T R AT I O N ,
W W W. S A M H S A . G O V / C O - O C C U R R I N G / T O P I C S / T R A I N I N G / C H A N G E . A S P X

10. THE PRECONTEMPLATIVE PERSON
 The precontemplative
mind set is operating
from a protective
network of defenses.
These defenses
inhibit cognitive
awareness of
consequences to
behavior and block
the capacity to absorb
information about it.

11. tread
lightly
or
SELF-PROTECTION IS they
HEIGHTENED FOR THE will
PRE-CONTEMPLATIVE run
the
PERSON. other
way

12. TO AN ACTIVE SMOKER, E.G., SMOKING IS
A FORM OF SELF-CARE
All effective “There must be
strategies must really pragmatic acceptance
start where people that people are where
are, with their unique, they are, as well as
complex, subjective compassion for any
experience. struggles and
suffering linked to the
problem behavior.”
The Smoke -Free Smoke Brea k: Stop Smoking
Now With Mindfulness & Acceptance , Pavel
Somov, PhD & Marla Somova , PhD

13. CHANGE CAN BE PERCEIVED AS A
THREAT AND TRIGGER THE “STRESS
RESPONSE” --

14. FEAR-BASED INTERVENTIONS REINFORCE THE
SUBCONSCIOUS PERCEPTION OF THREAT

15. PSYCHOLOGICAL BARRIERS TO
COMMUNICATION IN PRE-CONTEMPLATION
 All information about the addictive behavior and its
consequences is communicated over some kind of barrier, like
speaking to someone through a closed door.
These defenses include:
 Denial: “I don‟t see anything wrong here.”
 Rationalization: “I know that what I‟m doing might be bad for
me but I couldn‟t handle my stress without it.”
 Projection: “You‟re not so perfect. You are judgmental. You have
no right to criticize me.”
 Blame: “Ever y time I try to quit my spouse sabotages me.”
 Internalization: I feel guilty and shameful about doing this, so
that‟s something….”

16. THE
NEUROSCIENCE
OF BONDING

17. REWIRING ONE‟S BRAIN
IS UNCOMFORTABLE,
ANXIETY-INDUCING AND
REQUIRES TIME AND
PERSISTENCE,

18. SUCCESSFUL SUSTAINED BEHAVIOR
CHANGE: ALL IN THE TIMING
The will to change and the skills/tools to navigate change must
occur at the same time.
Desire: “I want ” – necessary for change to occur; but
without the tools and skills needed to achieve some degree of
success leads to repeated, frustrating attempts that do not
succeed and produce more shame, anxiety and
demoralization.
Competence: “I can”- tools, skills and knowledge are
key to making a behavior change; but desire ignites the
energy to use them.

19. DESIRE AND COMPETENCE
When a person has
the desire to change
and at the same
time the tools, skills
and knowledge to
get through the
tensions of change
action is possible.

20. PROCESSES OF CHANGE
Experiential Processes
 Concern the person‟s thought processes
 Generally seen in the early Stages of Change
Behavioral Processes
 Action oriented
 Usually seen in the later Stages of Change
A D D I CT I ON A N D C H A N G E : U n d e r s t a n d i n g a n d I n te r ve n i n g i n t h e P r o c e s s
C a r l o C . D i C le m e n te , P h . D . A B P P U M B C P s yc h o lo g y
w w w. umb c . e d u/ p s yc h / h a b i t s

21. PRECONTEMPLATION AND THE
PROCESSES OF CHANGE
 Consciousness-raising  Counter-conditioning -
– reframe problems to provide alternatives for
integrate new the behavior that provide
information with the something that
person‟s stated approaches it‟s perceived
perspective, e.g. “when benefits, e.g. medication,
I take a smoke break I relaxation, emotional
am breathing deeply intelligence skills,
and taking care of mindfulness,
myself – what happens
if I take the break and
breathe without the  Cancer Prevention Research Center
Transtheoretical Model,
smoke?” http://www.uri.edu/research/cprc/TTM/Processe
sOfChange.htm

22. MORE PROCESSES OF CHANGE
Environmental re- Helping
evaluation – “My kids relationships –
are upset that I smoke Encourage social
and are always on me
to quit” and interpersonal
 “It is very inconvenient
relationships with
to take a smoke break people who do not
now that we have to go smoke – educate
so far from the about the role of
building” social networks in
health behavior
change;

23. SOCIAL NETWORKS INFLUENCE
BEHAVIOR CHANGE
Every facet of health examined so far
appears to “spread” from person to person.
The strength of a network effect
depends on the strength of a friendship.
“Friendship as a health factor” Science, Volume 323 23 January
2009, www.sciencemag.org

24. EMOTIONAL INTELLIGENCE IS THE
FOUNDATION FOR EFFECTIVE
COMMUNICATION
 Self- Awareness and Self-Control – an accurate understanding of
how one‟s behavior and words affect others
 Emotional and inner awareness – an accurate understanding of
how one‟s emotions and thoughts affect behaviors
 Accurate self-assessment of skills and abilities – an honest
assessment of strengths and weaknesses
 Conscious planning of communication – the ability to plan the
tone of a conversation to achieve the best results
 Respectful listening – listen deeply and seek to understand what
others are saying
 Creativity and sense of play – the ability to take one self lightly
and engage with serious situations in a creative way
D a n G o l e m a n , E m o t i o n a l I n te l l i g e n c e , B a n t a m D e l l , 2 0 0 6

25. EMOTIONAL INTELLIGENCE: AN EXPRESSION
OF THE RICH INTERPLAY OF CONSCIOUS FEELINGS,
THOUGHT- ACTION REPERTOIRES, AND ATTITUDES
“Emotional Intelligence
(EI): Our ability to
engage our emotionality
in effective ways in
order to facilitate
positive outcomes in our
relationships.”
D r. M i c h a el E . Ro c k . o n e o f a few
s pe c i alist s i n t h e wo rl d c urre n t l y
l i c ensed to c e r t i fy pro fe s s ion als i n t h e
un de r s t a nding o f, t h e s t a t i st ic al
re s e arc h ba c k g ro un d i n , a n d t h e
i n te rpret a t ion a n d us e o f t h e B a rOn
E Q- i

26. EMBRACE THE “WOBBLE”
The first rule of intervention in a behavior change process is the
same as the first rule in improvisation:
 Accept what is;
 Accept people as they are;
 Listen;
 Take in what is being expressed and build on it;
 Notice the facts – both spoken and unspoken;
“Improvising has much in common with riding a bicycle, surfing or
skiing. Things are not stable, linear, or predictable. The situation is
always in flux. Our footing keeps changing. This approach may be
uncomfortable or unsettling at first, and it is natural to seek out
security. ..We can stop trying to flee from the wobble.”
Patricia Ryan Madson, Improv Wisdom, Crown Publishing Books, 2005: 82 .

27. EMBRACING THE “WOBBLE” IN A
WORKPLACE SMOKING CESSATION
PROGRAM
What is: Employees who smoke
A workplace wellness must take all the
program in which classes other
employees earn points employees take plus a
that reduce their series of 6 90-minute
medical deductible by smoking cessation
increasing amounts classes.
based on their
completion of All classes and
requirements. exercises hours must
take place on
employees‟ own time.

28. WHO WANTS WHAT
The employer‟s The employees‟
objectives : objectives:
 Reduce the number of
employees who smoke;
 Reduce insurance co-
 Reduce health care pays;
costs related to
 In most cases, continue
smoking;
to smoke while
 Provide tools and fulfilling the employer‟s
knowledge to help mandate to attend
employees who smoke smoking cessation
achieve cessation. classes;

29. EMPLOYEES ACHIEVE THEIR OBJECTIVE BY
ATTENDING SMOKING CESSATION CLASSES.
CHANGES IN SMOKING BEHAVIOR
CANNOT BE MANDATED.

30. PRE-CONTEMPLATIVE
PEOPLE IN A WORKPLACE
SETTING SPENDING THEIR
OWN TIME TO TALK ABOUT What
SOMETHING THEY DO NOT is
WANT TO TALK ABOUT

31. IF WHAT IS: LITTLE OR NO DESIRE TO
CHANGE SMOKING BEHAVIOR
 Talk around the closed
What works: doors by connecting
 Acceptance that the through open
defenses associated pathways:
with pre-
 Emotional connection
contemplation will
disrupt and distort  Empathy
messages that  Respect for a person‟s
directly challenge humanity, individuality
smoking behavior. and freedom to think
for him/herself

32. ASSERTIVE ENGAGEMENT:
IT‟S ALL IN THE TIMING
“This is not for the faint -hearted but nor is it for the indelicate
and insensitive. We are seeking to unbalance someone, to pull
the defensive carpet from under their feet. This is a role that in
any ideal scenario would sit with a skilled therapist in a
perfectly crafted environment. But as we‟ll say a thousand
times, assertive engagement is about working in an imperfect
environment and still seeking change. It is okay to challenge
defenses but be mindful that the client rarely is in a safe space
and even more rarely will return to a safe space after having
met with you. So we proceed with care but we proceed
nonetheless.”
“Precontemplation and Assertive Social Intervention” Assertive Engagement Resource

33. HOW TO “EMBRACE THE WOBBLE” BET WEEN
EMPLOYER AND EMPLOYEES‟ OBJECTIVES:
Focus on developing competence in other
areas that can impact health:
 Identify stressors at work and home;
 Teach about the stress response and its ef fects on health and
ability to cope with change;
 Identify and build on individual strengths, e.g. perseverance,
resourcefulness, humor, social skills;
 Cultivate competence in getting through stressful situations
and states of mind through the processes of change;

34. CHANGE CAN MAKE A PERSON FEEL LIKE A FISH OUT
OF WATER – IT HELPS TO UNDERSTAND THE TENSIONS
OF CHANGE AND OUR OWN APPROACH TO CHANGE

35. Reduce the
reactive,
INCREASE EMOTIONAL fear-based
“threat”
response to
RECEPTIVITY change.
Give only
THROUGH EMOTIONAL small bits of
information
that are
CONNECTIONS; easily
digested
and applied
FOCUS ON: WORKING THE
SOIL & PLANTING SEEDS

36. EXPLAIN THAT NICOTINE CHANGES THE BRAIN AND
IMPACTS THE FREEDOM TO THINK FOR OURSELVES
 3 Brain Regions are involved with nicotine dependence and cravings
 BLUE: the thalamus,
the brain region critical to
one's ability to calm down
when stressed.
 RED : the striatum, a region
implic ate d in the pleasure system of the brain.
 GREEN : the anterior cingulate cor tex,
a region vital to self -control and concentr ation.
Credit: Image courtesy of Duke University Medical Center

37. EXPERIENCES CHANGE THE BRAIN

38. YOGA BREATHING
MINDFULNESS
CHAIR YOGA
BREATH WORK Teach
Breath
Work and
Why It
Matters

39. SELF-KNOWLEDGE PROMOTES
EMOTIONAL INTELLIGENCE
Emotional
intelligence grows
through increasing
connections
between emotions
and higher cognitive
functions.

40. “Through increased self-
awareness, individuals are more
able to detach themselves from
events and regulate their
emotions in order to prevent
them from becoming „immersed
in‟ and „carried away‟ by
emotional reactiveness.”
Mark Slaski and Susan Cartwright, “Emotional intelligence
training and its implications for stress, health and
p e r f o r m a n c e ” S t r e s s a n d H e a l t h Vo l u m e 1 9 2 0 0 3

41. PROVIDER RELATIONSHIP SKILLS:
EMPATHY COMMUNICATION BOUNDARIES
• Everyone has blind spots – if we are open to seeing our own
ambivalence toward change we will be more open to
acceptance of others‟ ambivalence;
• Compassion and understanding toward self is the doorway to
empathy toward others;
• Recognize and respond to the ef fect that role hierarchies have
on perception and communication;
G o l e m a n , D a n i e l ( 1 9 9 8 ) Wo r k i n g w i t h E m o t i o n a l I n te l l i g e n c e , B a n t a m B o o k s

42. Training in effective approaches to working
with precontemplative clients is available for
your staff, organization or conference.
Jude
Treder-
Wolff,
LCSW,
RMT, CGP
Nicholas
Wolff,
496 SMITHTOWN BYPASS SUITE 202 LCSW,
SMITHTOWN, NY11787 BCD, TEP
631-366-4265
WWW.LIFESTAGE.ORG