FOCUSupplementFOCUSupplementOn HIV Antibody Test Counseling

Volume 12 Number 4 March 1997

Helping clients to change unsafe behav-iors is a significant part of an HIV test coun-selor’s work. The Stages of Behavior ChangeModel is the most powerful tool the HIVcounselor has when approaching this chal-lenge. But, the model is inadequate to thistask without the additional understandingof how change occurs at each stage andhow counselors can target interventions tohelp clients advance in this process.

Assessing the Client’s StageThe first step in counseling after

assessing a client’s risk behaviors is todetermine the client’s current stage foreach particular behavior. The five stagesare: pre-contemplation, contemplation,ready for action, action, and maintenance.Counselors identify a client’s stage byasking questions to discover how a clientviews a particular behavior, such as injec-tion drug use or unsafe sex, and what rolethis behavior has in his or her life, and bylistening to the language the client uses todescribe thoughts and past actions. Forexample, questions might include: how isdrug use important in a client’s life? Doesthe client see a downside to using drugs?If so, is drug use a behavior he or she hasever thought of changing or tried tochange in any way?

A successful test counseling sessiondoes not depend on a client achieving thenext stage of change. Instead, an interven-tion is valuable if, at the end of the coun-seling session, a client seems to bemoving toward this next stage or if thecounselor senses that he or she hashelped a client gain greater awarenessabout a particular subject.

The process of change—and the appro-priate counseling intervention—is differ-ent at each stage of change. For instance,educating a client about HIV-related risks

may be a valuable intervention at the pre-contemplation stage, but presenting thisinformation is usually unnecessary andoften counterproductive if a client isready to change but has some apprehen-sion about doing so.

Throughout an intervention, listen andfollow the client’s process in order toformulate how to respond. Remember thatassessment continues throughout thecounseling session and that plans to pur-sue particular intervention strategiesmust be flexible and depend upon theclient’s responsiveness to them.

Stage-Specific Interventions During the pre-contemplation stage,

many factors may induce risk-taking.Among these factors are: lack of informa-tion, denial about risks, resistance tochange, and ambivalence about change.Clients at this stage generally have littleconsciousness about HIV-related risks.Often this results from a lack of informa-tion. Providing information and answeringquestions often raises a subject to a moreconscious level. This can help clientsunderstand the relevance of change forthemselves.

In some cases, clients may be informed,but may deny the significance of thisinformation to their own behaviors. Aclient may reveal denial through state-ments such as, “Getting infected won’thappen to me.” In response, a counselorcan point out the inconsistency betweenthis statement and the client’s stateddesire, for example, to avoid HIV infection.This type of response provides a founda-tion for the client’s future thinking and anopportunity to break through denial.

Assess whether clients at the pre-contem-plation stage are resistant or unwilling toconsider the issue of change. Explore theirwillingness to consider this subject, sincethis response will obviously affect thedirection of the counseling session. “Reflectback” to clients the feelings and actions

Responding to the Stages of ChangeJD Benson, MFCC and John Tighe

they report, and explore and validate theprocess they have used to make decisions.Suggest that feelings and attitudes maychange for various reasons, for instance, inlight of new information about HIV risks.

At the point at which clients think aboutchange—the contemplation stage—lack ofinformation is no longer the primary issue.At this stage, appropriate interventionsfocus on helping clients gain greater insightinto their perceived need or desire tochange. Ambivalenceat the contemplationstage presents anopportunity for thecounselor to makereflective commentsthat permit the clientto gain greaterawareness of his orher mixed feelings.At this point, thecounselor’s task is tofocus on and learnmore about theclient’s ambivalencein order to help himor her make deci-sions about movingforward.

Reflect back to clients examples of theirambivalence. For instance, the possibilityof initiating condom use may make aclient feel he or she is doing the rightthing to take care of him or herself, butmay also represent a significant andunwanted loss. If a client expresses con-flicted feelings about starting to use con-doms, reflect back the client’s concernsand validate the power of both the “pro”and “con” positions.

Help clients prioritize from their ownperspective the motivations and outcomesthat are most important to them. Duringthis process, it may be appropriate toexamine the consequences of making achange and to compare these results tothe possible results of not making achange. It is also helpful to assess aclient’s overall sense of “self-efficacy,” thebelief that an individual can actuallyachieve change. This can be done whenthe counselor underscores areas in theclient’s life in which he or she has alreadymade some kind of successful change.

Beyond this, in both the pre-contempla-tion and contemplation stages, identify andreinforce the client’s motivation. Reflectingback statements that reveal motivation tomake a change can help clients understandand take ownership of those things that aremost important to them. Addressing con-

tradictions that may exist between what aclient says is important and what a clientdoes can help him or her move toward aposition of being ready to change. Feelingsthat may arise during this process—relief,joy, sadness, or anger—can be helpful tothe counseling process. When discussingcontradictions, it is especially important toremain neutral, demonstrate care andconcern, and be willing to move on toother issues if the client is not willing to go

further with dis-cussing a particularissue. In general, thecounselor risksalienating the clientonly if the counseloris working from hisor her own agendaand not the client’s.

A client at the“ready for action”stage has informa-tion about a riskybehavior and itsconsequences, andthe insight that thebehavior is one he orshe wants to change.At this stage, coun-

selors can focus on interventions relatedto planning and taking action. Respond toany ambivalence about taking action anddoubts about being able to achieve change,support this client’s resolve, validate con-cerns, strategize solutions, and make acareful, achievable plan that outlines thesteps necessary to take action.

Troubleshoot any challenges this clientmay face in moving to the action stage ofchange, and explore how he or she mightavoid or resolve such problems.Challenges may be related to a client’ssocial support, current living situation,economic factors, cultural influences,health matters, or self-esteem.

When clients reach the action stage ofchange, counselors should use interven-tions that demonstrate support for clients’original decisions to make a change, pro-vide positive reinforcement for changesmade so far, and highlight successes.Positive reinforcement, validation, anddiscussion of contradictions may continueto be appropriate at this stage. However, atthe action or maintenance stage, counselorsshould encourage clients to share strategiesto prevent lapses and specific behavioralsteps that clients need to initiate or contin-ue toward overall behavior change goals.

At the maintenance stage, counselorsshould apply strategies similar to those they

2 Mar 97FOCUSupplement

References1. Prochaska JO,DiClemente CC,Norcross JC. In searchof how people change:applications to addic-tive behaviors. Ameri-can Psychologist.1992; (47)9: 1102-1114.

2. UCSF AIDS HealthProject. Behaviorchange and HIV risks.HIV Counselor PER-SPECTIVES. 1996;5(2): 1-8.

AuthorsJD Benson, MFCC isContributing ClinicalEditor of the FOCUSSupplement for HIVAntibody Test Coun-selors, a SeniorTrainer at the UCSFAIDS Health Project,and a psychotherapistin private practice inOakland, Calif.

John Tighe isAssociate Editor of theFOCUS Supplementand Writer and Editorof HIV CounselorPERSPECTIVES.

Making the transitionfrom a health

education approach toa client-centered

model is a process notunlike that of changingfrom risky behaviors to

safer sex techniques.

3 Mar 97FOCUSupplement

used in the action stage, while helping clientsanticipate or respond to typical emotional orphysical changes that they may be experienc-ing or expect to experience.

Shifting from Health EducationFor many counselors, formulating inter-

ventions based on the concept of changeand using a client-centered model in theways described in this article represents asignificant shift in approach. Making thetransition from a health educationapproach to a client-centered model is aprocess not unlike that of changing fromrisky behaviors to safer sex techniques.Both challenges raise similar questions.For instance, is the counselor open to thepossibility that new counseling approach-es may be more effective? Does he or she

feel capable of changing approaches? Is heor she willing to take steps toward makingchange? Finally, what support does thecounselor need to be able to consider oradopt this approach?

Counselors who feel frustration becausethey believe they have not helped clientsto change or that HIV counseling cannotcontribute to change, may find that apply-ing stage-specific interventions will bemore beneficial for clients. Such strategiesare more likely to lead to visible changesin attitude by clients. In addition, under-standing that change happens incremen-tally—moving from stage to stage andsometimes backward before progressing—highlights the fact that change is a pro-cess and that a counselor’s contribution tothis process is an important one.

Getting beyond Pre-ContemplationRobert is a 35-year-old White man who

identifies as gay. He is seeking HIV testingbecause he considers himself to be at riskfor infection. He states that he has recent-ly learned that a man he had been in arelationship with has HIV disease. Duringthe risk assessment session, Robertreports that he injects drugs and that henever uses condoms during sex.

Robert says he understands that he hasbeen at risk for infection through sex, butthat his error was in choosing the wrongpartner, not in failing to use a condom. Hesays that he will stay away from “unclean”partners in the future. When Caroline, histest counselor, talks with Robert aboutsafer needle practices, Robert resists: “Icame for a test, not a lecture about drugs.”Robert is satisfied in the knowledge thatonce he learns his test result he’ll be “inthe clear,” and will not have reason forconcern about future infection.

While Robert reports his risks, says heunderstands them, and intends to avoidthem—a response that often indicatessomeone is contemplating change—hisplan for reducing risks is a rationalizationand not an effective risk-reduction strate-gy. Caroline accurately assesses thatRobert is at a pre-contemplation stage ofchange related to both sexual and injec-tion drug risks. She detects, from hisacknowledgment that he could get HIVfrom sex, some willingness by Robert to

talk further about his sexual practices andchooses an intervention to respond tothis. Caroline reviews risk informationwith Robert and reflects back what he sayshe will do to ensure his safety, namely,not having sex with men who are“unclean.” Caroline asks Robert what hemeans by this term and asks him todescribe how he will determine who is oris not “risky.” Robert is clear that he canprotect himself from infection in thefuture by having sex only with men whoare introduced to him by a friend.Caroline responds by saying, “I wonderhow this will assure you that someone isnot infected with HIV or, for that matter,another sexually transmitted disease?”

Robert responds, “I trust my friends to setme up with someone who’s okay, and any-way you can tell by looking at a person.”Caroline asks Robert, “Didn’t you trust yourHIV-infected partner to tell him he wasinfected?” Robert shrugs and starts toprotest, “But maybe he didn’t know...” beforestopping mid-sentence. Caroline gentlysays, “Yes, it is likely that he didn’t know;but how can you expect to judge whethersomeone is clean, if they can’t even judge itthemselves?” Robert looks away, and says,under his breath, “You don’t understand.”

By gently confronting his reasoning andrationalization, Caroline helps Robertbegin to move toward contemplatingchange, a process that will not completeitself during the session, but which islikely to continue after the session asRobert thinks about his talk with Caroline.While Caroline does sense that the sessionmay have changed Robert’s perspective,the progression of moving from one stage

Case Examples: Interventions at Two Stages of Change

to another may occur without her recog-nizing that this is occurring.

After this brief intervention, Carolinedecides she cannot go any further on thistopic without raising more resistance fromRobert than can beresolved in the session.Sensing on some levelthat their talk hasmoved Robert closer tocontemplation, sheoffers him literature onHIV transmission andsafer sex, saying,“Maybe I don’t under-stand, and maybe thispamphlet speaks moreclearly to your con-cerns.” She then pro-ceeds to anintervention that willbegin to addressRobert’s injection drug-using risks.

Contemplating Change Jo is a 40-year-old Black woman who

identifies as heterosexual. She seeks anHIV test because she had unprotected sexwith a man she met in a bar. She and herhusband recently separated after a 12-year marriage. Jo has a 7-year-old daugh-ter who is living with her husband, andshe says this will continue until she getssettled into a new apartment.

Upon further exploration, Jo revealsthat she drinks regularly to deal withemotional stress. She works 50-hourweeks as a production manager and hasbeen “practically a single parent” since herdaughter was born. Sam, her test coun-selor, asks Jo more about her alcohol useand how alcohol works and does not workin her life. Jo responds by saying thatalcohol is great for relieving tension. Shesays she regularly has a few drinks afterwork, she sometimes drinks from herflask in the middle of the workday, andshe drinks when she goes out on a date.

Because Jo reports only positive aspectsof her drinking, Sam validates this view,underscoring these positive aspects andgently inquiring about drawbacks, if any,to her alcohol use. Jo protests that thereare no drawbacks. She says the only prob-lem is that her husband, who is seekingcustody of their child, is making herdrinking an issue. Jo goes on to criticizeher husband’s absence and irresponsibili-ty during the marriage. She is also clearthat her daughter “is the best thing thatever happened” in her life.

Sam listens carefully, and validates Jo’sexperience: “It sounds like you feel strong-ly about your husband’s failure to be therefor you when you were married.” By vali-dating Jo’s feelings rather than challeng-

ing her, the counselormakes room for Jo to beless defensive. Jo beginsto cry, feeling some reliefthat someone is listeningto her and understandingthe “hopelessness” of hersituation.

Sam asks again if Jothinks her drinking has adown side. Trusting Sammore after his display ofsupport and understand-ing, Jo does not immediate-ly deny that drinking mighthave negative effects. Afteridentifying Jo’s strongfeelings for her daughter,Sam wonders aloud if Jocan envision any adverse

effects of her drinking on her interactionswith her daughter. Sam is careful not topresent himself as an ally of the absenthusband, but rather as someone who recog-nizes Jo’s attachment to her daughter andvalidates her motivation to continue being agood parent.

Sam is genuine and respectful of Jo as hesays “I’m sure that if you ever felt yourdrinking might have even the slightestnegative effect on your child, you’d be thefirst to acknowledge it and do anythingpossible to protect her and your relation-ship with her.” By helping Jo express herinitial defensiveness and with more gentlecoaxing, Sam evokes the trust necessary forJo to explore her mixed feelings aboutalcohol. Jo identifies some of the importantaspects in her life—her relationship withher daughter, her performance at work, andher ability to relate to friends and co-work-ers—admitting that drinking might interferewith these. With this tentative admission, Jobegins to contemplate change.

Keeping in mind the limited role of thecounselor and limited time of the session,Sam asks Jo if she’d be willing to continuethis sorting process with a counselor whois knowledgeable about alcohol use. Josays she appreciates that Sam isn’t beatingup on her for drinking and asks if thereferral counselor will be as understanding.Sam, who has worked with his co-workersto develop a comprehensive list of referralsfor a range of client concerns, assures herthat he knows this counselor will not judgeJo. Jo agrees to take a referral.

4 Mar 97FOCUSupplement

Executive Editor; Director,AIDS Health ProjectJames W. Dilley, MD

EditorRobert Marks

Associate EditorJohn Tighe

Founding Editor; AdvisorMichael Helquist

Medical AdvisorStephen Follansbee, MD

DesignSaul Rosenfield

ProductionShauna O’DonnellSaul Rosenfield

CirculationSandra Kriletich

InternsCathy HultinSari KasperCandice Meng

FOCUS Supplement OnHIV Antibody TestCounseling is a quarterlysupplement to FOCUS: AGuide to AIDS Researchand Counseling, bothpublished by the AIDSHealth Project, which isaffiliated with theUniversity of CaliforniaSan Francisco.

The Supplement is pub-lished under a grant fromthe California Departmentof Health Services, Officeof AIDS, and is distributedto HIV antibody test sites.Permission to reprint anypart of the Supplement isgranted, provided acknowl-edgement of FOCUS andthe California Departmentof Health Services isincluded. FOCUS itself iscopyrighted by the UCRegents, which reservesall rights.

Address correspondenceto: FOCUS, UCSF AIDSHealth Project, Box 0884,San Francisco, CA 94143-0884; (415) 476-6430.

ISSN 1047-0719

FOCUSSupplement

On HIV Antibody Test Counseling

By helping Joexpress her

defensiveness,Sam evokes the

trust necessary forher to explore her

mixed feelingsabout alcohol.

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