Young people in the contemplation stage continue to focus on what for them are the benefits of substance use; what they like about it. However, contemplators have also experienced and give weight to the adverse consequences; the things that they don’t like about substance use.
People who are contemplators may also be considering the benefits associated with changing but are likely to be acutely aware of what it will cost them in effort, energy and loss. This balance between consideration of the costs and benefits of changing can produce profound ambivalence that can keep young people.
As with those young people who are not interested in change, contemplators might also mask their true state of mind. Again there is potentially a developmental component stemming from young people’s:
- Acute need for privacy and reluctance to share personal details about themselves until trust and regard has been built with another
- Sensitivity regarding the image they project, with both young men and women often feeling it necessary to hide vulnerability
- Inexperience and being either uninformed, under-informed or ill-informed
Young people in the contemplation stage have not yet given consent for, or made a commitment to participate in, focused interventions targeting behaviour change around AOD use. Thus interventions focus on the task of further engaging the young person and creating the conditions where the idea of making change can be considered. Young people who are contemplators require the space and support to work through ambivalence and make decisions about their substance use. Any approach from practitioners and/or significant others that closes down communication is likely to be detrimental at a time when guidance and support is needed.
The aim with young people in contemplation is to assist them to make their own decision to change. Young people in this stage perceive and give weight to the downside to their substance using behaviour but continue to give equal or more weight to the upside.
Young people contemplating change can benefit from exploring the pros and cons of substance use, and considering them in the context of the pros and cons of change.
As with pre-contemplators, contemplators will often respond well to being asked what they like about their substance use before being asked what they don’t like. Sequencing questioning in this way maximises the potential for young people to investigate the negative aspects of substance use for them. Miller and Rollnick (2002) recognise the therapeutic value in young people being given the space to hear themselves discussing the downside of their substance use, in their own words. If clients believe that practitioners are biased toward change and are concentrating only on the problems associated with substance use, they will tend to argue the other side of the ‘decisional balance’ and hear themselves justifying why they should continue using substances. Once a client feels that their view about the pros and cons of continued use is understood and respected, they will be more ready to respond positively when practitioners seek their opinion regarding the pros and cons of change.
Intervention guide: Contemplation stage
The primary intentions at this stage are:
- Build a therapeutic relationship
- Provide space for the young person to discuss AOD use and change in the context of what is important to them
- Build motivation for investment in self care and a healthy lifestyle
- Risk assessment and harm reduction
- Address determinants of problematic AOD use
The key change process are:
- Self re-evaluation
- Environmental re-evaluation
The key therapeutic models are:
- Motivational interviewing
- Solutions focussed
- Narrative therapy
Motivational Interviewing is a useful therapeutic model for enacting relevant change processes. ‘Consciousness raising’ and ‘dramatic relief’ employed at the pre-contemplation stage can be extended and deepened to include processes such as self and environmental re-evaluation. This can involve:
- Building the therapeutic relationship and minimising resistance by acknowledging that the choice to change is theirs to make (emphasising personal control), even if they are under coercion from others;
- Strengthening cognitive understanding and connecting emotionally to the impact substance use has had in their lives and the lives of others
- Exploring the ambivalence and consequent dissonance felt by young people in the contemplation stage
Elements From Motivational Interviewing
A3. Evoking and working with the client's own views and experiences of change
A5. Developing awareness of discrepancy
A6. Eliciting and exploring ambivalence about change
Solutions Focused Therapy
Effective use of SFT does not presume that the client is already engaged and committed to a project of change. Turning the focus towards solutions rather than elaborating problems offers hope and optimism at times when clients feel overwhelmed, hopeless, or have become ‘stuck’. Even so, young people value being listened to and feeling understood. Speedy movement towards a focus on solutions can be inappropriate for clients who do want to spend some time exploring and coming to terms with problems. An excessively proactive shift to solutions may risk alienating young people who are not yet ready.
Solutions Focused elements
B7. Competence seeking / Looking for strengths
Narrative Therapy is also ideally suited to “self-focused re-evaluation’. Further, Narrative Therapy techniques can be used to:
- Establish a relationship based on trust by demonstrating active listening, respect, and genuine concern to understand the young persons’ world view
- Develop a shared or common language for talking about problems and strengths
- Enable the client to externalise key problem/s and put them in their proper context
- Enable a client to identify and separate themselves from problem saturated narratives that are self defeating and serve to perpetuate substance using behaviour
- Develop with the client a narrative based on a realistic appraisal of his or her strengths, limitations and life opportunities
Elements from Narrative Therapy
