1 Sense of necessity for change

This isn't just saying you need to make changes, but having a clear emotion about the need to change – a sense of pressure that things can not continue as they have been and some anxiety or fear if they do. This leads to a cognitive reorganization, with new priorities and ideas for change.

You can look for this by asking the client, listening for a tone and demeanor of urgency, watching for an attentive and alert orientation to clinical work, a clearly stated desire for change, and clear areas in their life they know need to change.

When missing, the client may imply or say change is not needed, and that exploring some topics is a waste of time. They are less attentive to therapy, maybe arriving late, not engaging, and forgetting homework assignments. There is no urgency to their need for therapy.

2 Readiness to experience the anxiety change requires


This is the opposite of defensiveness, and entails feeling responsibility for change and being ready to suffer through the hard work to accomplish change. Fears, anxieties, losses, are discussed openly, and the client doesn't shy away from them. Hanna offers it's like making a mess during spring cleaning – ultimately is cleaner but it may not appear so in the short run.

You can ask clients about this, as well as watch for an eagerness to "dive in" to problems, a cooperativeness in session work despite the fear this may stir, and a sense that they have to take some risks and stand their ground.

When missing, clients can be late and uninterested, become remote when discussing emotions, "talk the talk" in a false way, deny a problem ("I an quit whenever I want"), resist probing and honest discussion, and blame the therapist with how therapy makes them more uncomfortable.

3 Awareness or clarity about the problem


This is the opposite of denial, and gets to one's ability to define the problem in terms of details that can be addressed. They recognize it is happening, and can step back somewhat to look at it so their ego can offer some insights.

When present, the client can specify some problem and its ramifications with some confidence, recall details of it in an organized and detailed way, and can avoid getting lost in the emotions recalling it brings.

When missing, clients are vague and unforced, offer "I don't know" a lot, and may minimize some issues and be totally blind to others.

4 Confronting the problem with sustained awareness of it


This gets to holding in consciousness the awareness of the problem in its details and importance to confront it. It is sort of like readiness and awareness combined for periods of time, which lead to some simplification of the problem into a reality-based synopsis that brings a sense of the problem as solvable or manageable as opposed to big and scary. Hanna likens it to an inoculation – you face the strong problem in a weakened state and fight it to build some resistance to it.

When present, this can be seen in a client's perseverance to work at issues, ability to accept feedback, and confidence that they can resolve matters. They can maintain some observing ego, or awareness of what happens as it happens, and reflect on events later.

When absent, clients avoid holding their awareness on the problem, and see it as unneeded or overwhelming. It takes a great deal of encouragement to do small things, and the client seldom gains closure because they avoid that kind of assertion. They may "talk the talk" and turn to rationalizing and intellectualizing.

5 Effort or will to change


This gets to an ease in relating to the therapist and therapy, followed by action toward self-improvement and change. It is not just talking, but making choices, being committed to one's defined goals, and acting to reach them. It's the difference between joining the gym, and going weekly.

When present, clients see they have some choice in their problems and act to resolve them. They actively work with the therapist to understand and resolve the problem, are eager to try out exercises and homework, and show self-determination.

When absent, the client procrastinates, makes little effort, and "didn't get around to it." They may talk a good game, but never implement suggestions. Or they play the "I tried it, but it didn't work" game of doing what the therapist suggests, but sabotaging it and making a huge deal of how it failed for reasons they just don't understand.

6 Hope for change


This is not blind optimism, but rather realistic focus on the good things the future could bring, and a sense of welcoming the future into life. It is the basis of placebo effects, and is based on self-efficacy and a belief in a positive payoff for acting. It helps to overcome apathy, and combat a sense of resignation to problems.

When present, clients see change as obtainable, are thankful for lessons learned even in learned the hard way, and may not know the answer but know they will figure one out. They may also be able to laugh about a problem sometimes.

When missing, clients show a palpable despondency, self-pity, and discouragement with their life, coupled with a certainty nothing can change it. Humor can arise in a sarcastic self-depreciating way. Passive suicidal ideation is also possible.

7 Social Support


Social support can intensify and bolster other precursors for change, or work against them. Consider a family supporting a person in overcoming their substance abuse, but fellow gang members pressuring the person to remain in the gang and continue using and selling. It can be a reinforcer, and can provide additional resources and a sense of belonging and acceptance that are therapeutic. Hanna makes a point that failing to acknowledge discrimination, and how it impacts social support networks, can be a crucial mistake in forming the therapeutic relationship.

When present, you can ask clients whether they feel they have social support, and gage the trust they report being present, the number of friends they report being able to confide in, and what they have in common (e.g., hobbies and interests, religion, family…). They are also likely to build a relationship with the therapist far faster and easier.

When missing, the client may complain of loneliness or may not say much about social connections at all. Vague comments like "there's so few understanding people in the world today" can be ways to ask about their views of relationships.

Resources

Freeman, A., and Dolan, M. (2001). Revisiting Prochaska and DiClemente's Stages of Change Theory: An Expansion and Specification to Aid in Treatment Planning and Outcome Evaluation. Cognitive and Behavioral Practice, 8, 224-234.Hanna, F. J. (2001). Therapy With Difficult Clients: Using the Precursors Model to Awaken Change. American Psychological Association.