by Maria E. Zuluaga, LCSW-R
Hello, social work students! No matter where you are conducting your field placement, you are meeting clients facing an array of issues. A working relationship is forming, and as it forms, many questions, feelings, emotions, and concerns are surfacing. One of the recurring issues that have been brought to my attention by students just like you is the hardship they face when they realize that the rate of client change is slow. In the section below are some reflections of former interns depicting their feelings associated with the slow rate of client change. I am certain that you will be able to relate!
Reflections of a Former MSW Intern—Alexandra Sapera, MSW Graduate, 2015
As a student when you start your field placement, you have the idea that you are coming into this new place with a fresh perspective and you are going to make a difference and see change. Then you start meeting with patients and realize that change is slow. As a student being in a placement for as short a time as eight months, I worked with patients who have been in programs for years and have gone through a number of workers. Part of the biggest learning experience for me was to change the way I measure success. I would take it personally when a patient would relapse, but part of educating the population included educating myself and realizing that for any step forward, there may be two steps backwards, and that is okay. I felt overwhelmed when I started working with substance abuse, but through supervision and continued education, I found it so rewarding that it is now the population I work with. This really is how I feel. I was so nervous starting my field placement and if you had told me two years ago this was the population I would have chosen to work with out of school, I would have said no way! Meanwhile, I love my job!
Reflections of a Former MSW Intern—Jonathan Belolo, MSW Graduate, 2014
To best explain my experience with the population of addiction, I have to bring in a client that I worked with for the majority of my experience at my field placement. The client was a mid-20s, Caucasian male who was struggling with a severe opioid and cocaine use disorder. He comes from an affluent family, and as a result of his substance use has been alienated from his family and accustomed lifestyle.
My supervisor noticed that a rapport was being built between the client and me, and she assigned him as a “case” that I would work on. Excited to work on my “first case” (as I called it back then), I looked forward to meeting him for individual sessions and helping him maintain sobriety, as he was to have a new therapist whom he thought could understand his perspective. After two successful sessions, I began to notice that the client was returning to old behaviors, both with his substance use and self-defeating beliefs. As this was happening. I became more frustrated and disappointed at my ability to “promote the positive change” that I was so desperately seeking. These thoughts only worsened when listening to other clients discuss the hopelessness and helplessness they felt related to the disease of addiction.
I spoke to my supervisor about my struggle with my ability to facilitate change in others and started blaming myself for the client’s failures. She immediately (almost instinctually) responded with the concept of “meeting the clients where they are,” explaining to me that not everyone is ready to change and that I have to first recognize what the clients’ current goals are. I've learned that when you do that, you can start seeing the small successes in the client’s progress rather than focusing on the overall objective. As I continued to process these feelings through supervision (and still do today), I realized that sometimes I, too, strive for immediate gratification like the client. The reality that I have come to accept is that by treating the client, we—as social workers—are having an impact in their recovery, no matter how small or how large and whether the change happens immediately or years later.
Stages of Change Framework
Stages of Change
Stages of Change Framework (Prochaska & DiClemente, 1982)
Prochaska and DiClementes’ (1982) Stages of Change is a trans-theoretical framework that allows clinicians to meet clients where they are in relation to their readiness to change. The authors caution that change should not be looked at as a linear process, but rather as a process that happens along a cyclical continuum. This is a valuable framework for social work students and recent graduates to learn, because it can be used in any social work setting and can be applied to all clients no matter where they are in the process of change. This user-friendly clinical tool can be learned by students at all levels. It will allow you to identify where your client is in relation to readiness for change. Identifying the stage of change your client is in is invaluable, as it will allow you and your client to select interventions that are compatible with that particular stage of change. Another instrumental aspect of this model is that you can teach it to your clients, so they can become empowered in their own treatment! Once you become familiar with this model, you will use it during your entire field placement experience and throughout your professional career.
This framework will allow you to meet clients where they are, thus empowering them. It will also encourage you to work from a strengths perspective. In addition, it will permit you to honor the clients’ autonomy by allowing clients to move toward positive change at their own pace. Finally, it will deter you from feeling responsible for your clients’ failures and successes.
Overview of the Stages of Change Model
- During the Pre-Contemplation stage of change, individuals have no intention to change, because they are not aware that they have a problem.
- During the Contemplation stage of change, individuals are aware of their problem and are thinking about ceasing the behaviors that have caused the problem, but they are not yet fully dedicated to taking action. Individuals can dwell in the contemplation stage of change for long periods of time.
- The Preparation stage of change marks the beginning of “small” changes that indicate the individual’s desire to change behaviors that have led to identified problems.
- The Action stage of change is defined by behavior, experiential, and environmental modification. The individual is ready to change those aspect(s) of life that are contributing to the undesired situation or problem.
- In the Maintenance stage of change, individuals carry out adaptive behaviors that can help strengthen their resolve. An individual can stay in this stage an entire lifetime if dedicated to maintaining change.
- During Relapse, individuals revert to earlier stages. It is imperative to let individuals know that “relapse” is part of recovery and that it is a simple bump in the road that can be overcome with hard work (Prochaska & DiClemente, 1982).
Students! It is vital to understand that a “relapse” episode is not a reflection of your skills or of something you did or didn’t do. Relapse is a normal part of the change process. When a relapse or setback occurs during treatment, encourage your clients to get back up and “dust themselves off” and try again and again and again!
Why Should You Learn This Model?
When interns begin a new field placement, they are eager to serve, to learn, and to make a change in the world. After all, you are supposed to be “change agents,” right? The harsh reality begins to set in when faced with clients who are not quite ready to make changes. I am certain you are nodding your head right about now!
In my decade of providing field supervision in the addictions field of social work, students have brought an array of issues to my attention. No issue has been as recurring as the anxiety, struggle, and challenge students face when they come to the realization that change comes slowly. Students completing their field placements in addictions, as well as many other fields of social work, come face to face with patients in different stages of change. When a patient in the “action” stage is assigned to you, it is usually smooth sailing. Am I right? However, when you are assigned a client in the “pre-contemplation” stage and the “contemplation” stage, it is a different story. Agree? You begin to question your abilities and even question whether you have made the right career choice. These are normal feelings and questions, but hang in there—you will get through! The best case scenario is to address these uncertainties, fears, and concerns as soon as possible when writing your process recordings and during supervision.
Changes in behavior do not occur instantaneously. For example, students working in substance use fields need to understand that the disease of addiction compromises the ability for a person to make automatic behavioral changes. These changes are difficult, even for people facing the risk of losing their homes, employment, family, or children. As a student, you might find it almost incomprehensible that a person would risk these losses. The fact is that the disease of addiction is so overpowering that even if a doctor tells someone “you will die if you do not stop using alcohol,” the person will continue to consume alcohol if not ready to stop. This notion can be applied to clients struggling with all sorts of issues, such as gambling, tobacco use, and eating disorders.
This reality is difficult for the most seasoned social worker to grasp. So I can imagine what you, as a student, must go through when you come face-to-face with this fact. It is overwhelming, to say the least. The array of biopsychosocial issues your clients struggle with, coupled with the slow rate of client change, can increase your level of anxiety immensely. This becomes even more difficult to cope with when you know that you have to meet the field placement and school’s expectations.
Conceptualizing Change Differently
Conceptualizing change as a stage process can be helpful in many ways. First, you can begin to see change happening along a continuum. Second, becoming familiar with the Stages of Change Model will provide you with the opportunity to integrate evidence-based interventions that are compatible with each stage of change. Also, understanding your clients’ readiness and ability to change will allow them to move at their own pace—thus, honoring their autonomy. In addition, this model will provide you with a concrete and logical framework that can be used with any client, no matter what Stage of Change they are in. Finally, it will provide you with a way to track your client’s progress.
Keep in Mind
It is important to keep in mind that the stages of change are cyclical. In other words, clients can suffer setbacks. A client can take two steps backwards before being able to move forward again. Also, movement from stage to stage is not time-specific. Some clients can move from stage to stage much faster than others. Other clients can be stuck in the same stage of change for a long time. Do not become discouraged when this occurs. Instead, take this time to explore the discrepancies that are preventing your client from moving to the next stage of change. Also, use this time to explore with your client the pros and cons of making changes. Finally, this time can be used to educate your clients about the possible consequences that can come from not making changes in their lives. Exploring discrepancies, discussing the pros and cons of change, and educating your clients about the consequences associated with current behaviors will help your clients begin to move toward change.
It is imperative to understand that clients can be in different stages of change relative to different life areas. For example, a client can be in the Pre-Contemplation Stage of Change in relation to alcohol use and in the Contemplation stage in relation to establishing mental health services. It is important to carry out a comprehensive assessment of your clients’ needs in order to be able to determine their readiness and willingness to make changes in different areas of life.
Having a clear understanding of the Stages of Change model will help you explore appropriate interventions, identify possible barriers to change, and provide you with the opportunity to team up with your client to find ways to remove those barriers. Finally, and most importantly, recognizing your clients’ level of readiness to change will discourage you from personalizing their failures or triumphs. Instead, it will help you become your clients’ ally, cheering them on until they achieve CHANGE! Good luck in your field placements. Thank you so much for all the difference you are making.
References
Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19, 276-287.
Maria E. Zuluaga, LCSW-R, has worked in addictions and mental health for more than two decades. She received her bachelor’s in psychology and sociology, as well as her Master of Social Work, from Stony Brook University. In 2016, she received a Master’s in Addiction Counseling from the National Certification Commission for Addiction Professionals. She is pursuing a Ph.D. in social work research at Wurzweiler School of Social Work—Yeshiva University. Her research interests are addictions, mental health, and cultural competency. She has been a Supervisor in Field Instruction for 10 years.