Ready for Change?

At a private practice meet-up recently we were discussing the difference between people going to community mental health and those seeking treatment in a private practice. The first point someone brought up was a difference in payment. This person felt that in community mental health most clients aren’t paying for a service so they may not be as invested while in private practice there can be things like co-pays and deductibles. I think this is a valid point considering so many people going to CMHCs are on Medicaid and do not have to pay for services. To be clear, I don’t think paying for a service automatically makes a person more invested, but I do think for some it does.

When going to a CMHC, a lot of people have a lot of psychosocial issues or issues around the social determinants of health. Housing, employment, transportation, childcare, the list can go on and on about the challenges people face daily. These issues can present obstacles for people to engage in treatment.

We are familiar with the stages of change model. Here is a quick reference and a visual if you are unfamiliar.

It appears to me that we tend to believe that clients who come into a community mental health center are at that action stage of change. Why would someone make an appointment and then show up to an appointment if they are not ready for change? It seems logical, but that may only be from our frame of reference. A client coming into an agency may still be in the preparation stage. The task in the preparation stage (I’ve seen places call it determination) is to find appropriate strategies to help make the change. Looking at a website on an agency or research information on treatment is definitely part of that preparation stage, but I would argue that making an appointment and keeping that appointment is also part of the stage.

When I worked in psychiatric crisis, I would educate patients and families on the art and science of therapy. While it is based on science, we naturally do not “click” with everyone. If a therapist is assigned that doesn’t mean they are the best fit. It’s ok to change the agency and the treatment provider. From my perspective, an individual finding treatment provider they can work with is all part of the preparation stage.

If a client comes to you seeking services it may be that they are ready, but they may not be ready. This really speaks to the need to develop motivational interviewing skills for all staff. Reception and intake staff can start to recognize change talk and help enhance motivation. We need to do better at meeting clients where they are. That includes fully recognizing where they are in the stages of change.