Moving to Maybe

What to Do with Patients in the Contemplation or Thinking Phase

We are continuing our series on how to assess a patient's readiness to change and how to guide a quick conversation for each stage of readiness.  The first article in the series is named The First Rule for Successful Lifestyle Conversations is to start with Readiness.  This discusses the use of the Readiness Scale or Ruler to determine readiness.  

The second, is Rolling with Resistance. This discusses conversation strategies to deal with the Pre-Contemplation, Not Ready or “I can’t or I won’t” group that score a 0-3/10 on the Readiness Scale.  We now move on in this series to patients that score a 3-5/10, and are typically in the Contemplation Phase of change or “Thinking” about changing.

The Contemplation Phase

Patients in this phase are thinking about changing unhealthy behaviors in the future due to decreased satisfaction with their current health status.  They will often express how difficult change will be and this can keep them stuck in this phase for a long time.  I am sure you can think of something in your life that puts you in the chronic contemplators club.  Pros and cons for change feel pretty even to them.  This is why having this conversation can be so impactful.  Your ability to tip the balance to the “Pros” side is more persuasive than you believe. 

Avoid the Righting Reflex

Providers are natural problem-solvers, but this can backfire. The "Righting Reflex", the immediate urge to fix a patient's problem, often triggers defensiveness when a patient is in the Contemplation phase. When you feel that urge to jump in with advice, pause. Your goal isn't to "right" them; it's to listen. Often, simply holding space and validating their struggle (rather than fixing it) reduces their resistance and allows them to move forward on their own terms.

It can be helpful to ask a couple of open-ended questions like: 

(Open-ended questions can feel scary because you are worried about going over in your short office visit, but this could actually be quicker due to evoking less friction.  You stop trying to convince a resistant patient.  It may actually save time, shorten the visit, and be less emotionally draining for you as it gives you permission to stop trying to fix them.)

“Sounds like you’re thinking about it.  Would you like more time, or do you feel ready to take a first step?”

If they need more “Thinking” time, this is when you can ask to share your knowledge and answer any questions they have. 

This is how a conversation might go:

Your patient scores a 5/10 when you ask them how ready they are to quit smoking. 

Provider: “So you would say you are a 5/10 as far as your readiness level is to quit smoking.”

Patient: “I have been thinking about it for a while, I know it is bad for me, but I just am not sure I can do it. I can’t afford to gain any more weight.”

Provider: “OK, you have spent some time considering it. I can appreciate how hard it is to quit something that is addictive and such a habit.”

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Provider: “Would you like more time to think about it, or do you feel ready to talk about a plan to help you?”

Patient: “I think I am ready to talk about a plan.  What do you think is the best way to go about this?”

Provider: “Have you thought about what might be easiest for you?”

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This conversation has moved the patient to the Planning Phase. They still might not have an action step, but the goal would be using your conversation and written/verbally given information, if requested to create a Planning goal.  You never know, this conversation could end up with a small action goal, like cutting down the number of cigarettes per day or downloading an app that tracks a non-smoking streak or amount of money that has been saved. 

Or, if they need more time to think about it..

Patient: “I don’t think I am ready to talk about a plan yet.  It seems too hard for me with all I have going on at the moment.”

Provider: “The good news is that you are thinking about change, even if it is not the right time to make the change.  What will have to happen in your life for you to have the bandwidth to start planning to give up cigarettes?”

Patient: “I have to finish helping my mother sell her house.” 

Provider: “If it is ok with you, I would like to bring up this conversation again to see if you are ready to put a plan in place. If you would like some information about quitting options to help you think about a plan, I can give those to you now or we can wait til the next visit.”

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As part of our HealthyChange Scripts Kit, we developed a specific script called Are You Ready? It has a series of motivational interview questions that help the patient weigh out the pros and cons of change for the patient in the Not Ready or Thinking change phases.  Our Smoking Cessation script is for those in the Planning Phase with questions more appropriate for taking a small step: thinking, planning or action. In the kit, there are a total of 12 scripts and an accompanying self-coaching workbook that cover all the lifestyle pillars that the patient might be ready to tackle. The prescriptions can be used as a “script” for a provider to guide this meaningful conversation, reducing the cognitive overload, keeping the conversation on a short leash and knowing that you are getting this conversation “right”.  

In Summary

As a provider, you hold a powerful role in tipping the scales for your patients. By grounding your approach in proven behavior change research—using empathy, curiosity, and non-judgmental questioning—you can effectively bridge the gap between "thinking" and "planning." Even within the constraints of a short office visit, these brief but meaningful interactions empower your patients to move through the contemplation phase and take their first meaningful steps toward lasting health changes. It may not happen in a single visit, or the next, but each conversation adds weight to the “pro” side of the change scale. 

We would love to hear how a change in your approach of a lifestyle change conversation changed the way you felt.  Please leave a comment!

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Reference: 

Moore, M., Jackson, E., & Tschannen-Moran, B. (2016). Coaching Psychology Manual (2nd ed.). Wolters Kluwer.