Working With Ambivalence: Using the Stages of Change in Session

The stages of change model is useful in session for one reason: it tells you what kind of intervention fits where the client actually is. Most stalled therapy is a stage mismatch — a clinician doing action-stage work, with plans and homework and goal-setting, for a client who is still in contemplation and hasn't decided anything yet. Match the intervention to the stage and the stall usually resolves without any new technique.

You know the client. They agree with everything you say. They nod at the formulation, call it helpful, thank you warmly on the way out, and change nothing. Week after week. "No, that really makes sense. I've just had a lot on." That isn't resistance and it isn't failure on either side. It's almost always contemplation being treated as action.

The Model, Briefly

James Prochaska and Carlo DiClemente developed the transtheoretical model in the late 1970s and early 1980s, initially from studying how people quit smoking — including the many who quit with no treatment at all. What they described was a sequence people move through, and the finding that different processes matter at different points.

Six stages: precontemplation (no intention to change; often doesn't see a problem), contemplation (aware of it, deeply ambivalent, not committed), preparation (intending to act soon, some steps taken), action (actively modifying behavior), maintenance (sustaining the change), and recurrence — a return to earlier behavior, which the model treats as part of the cycle rather than an exit from it.

That last point matters. Recurrence is expected. It's built into the shape of the thing, not an interruption of it.

What Each Stage Needs From You

Precontemplation

Needs information and rapport. Not a plan. Hand a change plan to someone in precontemplation and they learn you weren't listening. Offer information without a recommendation attached, be curious about how they see it, and ask permission before saying anything that sounds like advice. The mismatch: proposing goals to someone who hasn't agreed there's a problem.

Contemplation

Needs the ambivalence explored on both sides — including the real, non-trivial reasons not to change. This is where most therapy stalls, and it stalls because the clinician spends the hour arguing the change side while the client silently keeps custody of the other. The mismatch: action-planning with someone who hasn't decided. Contemplation can last years. Rushing it extends it.

Preparation

Needs concrete planning and obstacle-anticipation. What specifically, when, where, and what will get in the way. This is where goals that actually hold belong — the specificity that feels premature in contemplation is exactly right here. The mismatch: more exploration. Continuing to explore ambivalence with a client who is ready to plan reads as the therapist stalling.

Action

Needs reinforcement and troubleshooting. Notice what they did, out loud and specifically. Then problem-solve what didn't work without treating it as evidence the whole thing is failing. The mismatch: reopening the decision. Asking "are you sure this is what you want?" in week three of action is destabilizing rather than thorough.

Maintenance

Needs relapse planning made before it's needed, while things are going well and nobody feels like doing it. Name the high-risk situations, the early warning signs, and the specific plan. Do this at the point of most confidence, because that's when it can be thought about clearly. The mismatch: terminating early because the presenting problem has resolved.

Recurrence

Needs normalizing and a return to the cycle — not a restart. The clinical task is to protect what was learned: "You did four months. That happened. What do we know now that we didn't in January?" The mismatch: treating it as failure, which is the fastest route to a client who stops coming out of shame rather than disagreement.

The Stages of Change Workbook gives clients a way to locate themselves in the cycle and work the stage they're actually in — often more persuasive in their own handwriting than in your formulation. When a client is ready to move but exploring has become the habit, the Solution-Focused Brief Therapy Question and Intervention Guide supplies the forward-facing questions — exceptions, scaling, preferred future — that shift the room out of analysis.

Decisional Balance, and Why It Isn't Collusion

The intervention for contemplation is decisional balance: mapping the costs and benefits of changing and the costs and benefits of staying the same. All four quadrants. The one clinicians flinch at is the benefits of not changing.

Exploring that quadrant is not agreeing with it. It's the only way to find out what the behavior is doing for this person, and it's always doing something — the drinking that ends the day, the avoidance that prevents a humiliation, the job they hate that their family is proud of. Until that's on the table you're negotiating with half the client.

This comes out of William Miller and Stephen Rollnick's work on motivational interviewing, and their central reframe is worth stating exactly. Resistance is not a client trait. It's a signal about the interaction — about what just happened between the two of you. If a client argues against change, look at what preceded it.

Usually what preceded it was the righting reflex: the clinician's well-meant urge to fix, correct, and advocate for the healthy option. The result is predictable. You take the change side, and the client, preserving their own ambivalence, takes the other — then argues themselves back into staying the same, out loud, in your office. People are persuaded by what they hear themselves say. Argue for change and you hand them the other role.

The discipline: when you feel the urge to make the case, that's the cue to ask a question instead. The open-ended questions that open a first session work the same way here.

The Honest Limitation

The transtheoretical model has been meaningfully criticized, and clinicians should know it rather than presenting the diagram as settled science.

The stages aren't as discrete as the wheel makes them look. People move non-linearly, occupy two stages at once, and sit in different stages for different behaviors — contemplating the drinking while in solid maintenance on the exercise. The time-based cutoffs separating stages are essentially arbitrary. And the evidence for stage-matched interventions is mixed rather than settled: reviews of stage-based work, particularly in smoking cessation, have repeatedly failed to show clear advantage over non-staged approaches. Robert West's 2005 paper in Addiction argued the model should be retired outright — a serious critique from inside the addictions field, worth reading rather than dismissing.

So what's it for. Its value in practice is as a formulation heuristic, not a staging instrument. You are not diagnosing a stage. You are asking one clinically useful question — has this person decided anything yet? — and letting the answer determine whether the next hour is exploration or planning. That question prevents a specific, common, expensive error, which is why the model has survived criticism it hasn't fully answered.

Don't tell a client what stage they're in. It lands as a grade.

For clients: the client-facing version of this is the stages of change model and where you are in the cycle, written to be handed to someone directly. Clients often locate themselves accurately when the model is explained plainly, and it takes the moral charge out of not being ready yet.

The Bottom Line

Use the stages of change as a check on your own intervention rather than a label for the client. If therapy is stalling — pleasant sessions, warm agreement, nothing moving — the likeliest explanation is action-stage work with a contemplation-stage client. Explore both sides of the ambivalence, including the good reasons to stay the same, and stop arguing the case for change.

It's also the first thing to check when between-session tasks keep not happening. Of the several reasons clients don't do therapy homework, stage mismatch is the one clinicians look at last.

— Nina-Lucia Rodriguez, LMHC

This article is written for clinicians and is offered as general professional education. It doesn't replace your own clinical judgment, your supervision, or the limits of your scope of practice with any particular client.