CLIENT CENTERED MODEL

CLIENT-CENTERED COUNSELING
Client-centered counseling is an approach to working with clients that allows both the
provider and the client to focus and prioritize on small goals during each session.
Counseling in this context does not mean ongoing therapy. It is the totality of
communication, both verbal and non-verbal, made in the context of feelings. Counseling,
as used here, is the work of supporting someone in the process of making positive
decisions. The client-centered model has been called a "feelings first" approach that
allows the partners, the client, and the provider, to work together to achieve positive
results. In client-centered counseling, the focus is on the client's concerns and interests.
Client-centered counseling has many benefits in terms of client risk reduction, behavior
change, client satisfaction and counselor effectiveness. Unlike the medical model of
patient education, in this model the provider, or care coordinator, listens rather than
speaks, offers options rather than directs, and provides support rather than advises. The
counselor brings to the client-centered interaction a set of skills that can enable the client
to reach a better understanding of the problem, deal with the attendant feelings and
concerns, and assume responsibility for evaluating alternatives and making choices.
Effective client-centered counseling in Prenatal Plus can:
• Help clients prioritize their needs
• Negotiate a workable plan
• Support behavior changes
• Empower clients to continue to make decisions that are good for them and their
infants
Try these tips to keep your work with clients interactive and productive:
• Solicit information from clients
• Reinforce knowledge, confirm accuracy
• Provide a brief, easily understood response to client's information needs
• Check to confirm understanding and solicit questions


CLIENT-CENTERED GOAL SETTING
A key element in client-centered counseling is goal setting. The process of goal setting
helps clients define specifically what behavior they want to change, and to develop a plan
for change. Each client contact should be unique and tailored to the specifics of what is
happening at that time to the client. To be effective in working on behavior changes with
a client:
• Ask the client to identify a behavior she wants to change
• Ask the client for possible solutions
• Praise her willingness to make change
• Deal with just one change at a time, if there is more than one change, ask which is
most important
• Help the client weigh the pros and cons of each possible solution
• Break the behavior change down to small, achievable, measurable steps
• Avoid scare tactics because they are usually not effective for a behavior that is
done repeatedly (such as smoking)
• Allow the client to select solutions and implement a plan
• Make a contract with the client to encourage her to agree to the changes she will
make (this is the Service Plan)
THE STAGES OF CHANGE MODEL
Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Am Psychol 1992; 47:1102-4.
Assessment and Appropriate Intervention In Behavior Change Counseling
Before setting a goal with the client, the care coordinator should assess the client’s
readiness to change. The purpose of assessing the client’s readiness to change is to ensure
the greatest possibility for success. This is a period of exploration for the client, which
can serve an educational purpose. Even if the client determines not to change certain
risky behaviors, the contemplation process begins to promote a new way of thinking
about old behaviors. Thus, information introduced during the assessment stage can help
foster insight, which may lead to change later. The stages of change and the level of
intervention the care coordinator may choose to impact the change are described below.

Precontemplation
Client's Role
The client is not yet or not currently considering the possibility of change, i.e., she is
motivated not to change. Client may not be interested in talking about a change or may be
defensive. The four reasons a client may be in precontemplation are the four “Rs":
• Reluctance- through lack of knowledge or through inertia does not want to consider
change; not resistant, but reluctant
• Rebellion- has a heavy investment in the problem behavior and in making her own
decisions, resistant to being told what to do, appears hostile and resistant
• Resignation- lack of energy and investment, has given up on possibility of change and
seems overwhelmed by the problem
• Rationalization- has all the answers, it feels like a debate when talking
Care Coordinator’s Role
In general, give information to raise her awareness of the problem and the possibility of
change. Have her explore the drawbacks of staying the same and the benefits of
changing. Validate her reasons for not wanting to change. Specifically address the
appropriate “R”:
• Provide information in a sensitive, empathetic manner.
• Provide choices.
• Instill hope, explore barriers.
• Listen empathetically and reflectively, acknowledge what she says and add to it the
other sides of the issues.
• Be respectful and considerate, it will probably take time for her to work her way out
of precontemplation.
• Plant a seed and leave the door open.

Contemplation
Client's Role
This period is characterized by ambivalence; the client both considers change and rejects
it. She has reasons for concern and justifications for unconcern. The client is willing to
consider the problem and the possibility of change. This offers hope. However,
ambivalence can make contemplation a chronic condition. Contemplation is not
commitment. Ambivalence is the archenemy of commitment and a prime reason for
chronic contemplation.
Care Coordinator’s Role
• Help her work toward resolving her ambivalence, have her explore issues and
examine consequences.
• Have her compare the pros and cons of staying the same to the pros and cons of
making a change.
• Further help her resolve her ambivalence by using information about past change
attempts to increase self-efficacy, get her to see “some success” instead of “failure,”
help her develop an attitude of “want to” instead of “have to.”
Determination/Preparation
Client's Role
The client’s statements reflect a good deal of what might be judged to be “motivation.”
This stage represents preparation as much as it does further developing determination.
She may be making some changes already. Commitment to change does not necessarily
mean that change is automatic, that change methods used will be efficient, or that the
attempt will be successful in the long term. All ambivalence is not necessarily resolved.
The decision-making process continues. This stage offers a window of opportunity. If the
client enters into action, the change process continues; if not, the client slips back into
contemplation.
Care Coordinator’s Role
• Assess her strength and level of commitment; continue to help her resolve her
ambivalence.
• Help her to determine the best course of action to take in seeking change.
• The task is not one of motivating so much as matching and helping her find a change
strategy that is acceptable, accessible, appropriate, and effective.
• Help her to explore the plan and focus on details, anticipating problems and pitfalls.
• Help her prepare mentally, emotionally and practically to do what will be required.

Action
Client's Role
Client engages in particular actions intended to bring about change. The client often uses
the meeting with the care coordinator to:
• Make a public commitment to change.
• Get some external confirmation of the plan.
• Seek support.
• Gain greater self-efficacy.
• Create artificial external monitors of her activity.
Change requires building a new pattern of behavior. It takes time to establish this new
pattern. This stage typically takes 3-6 months. Relapse is always possible.
Care Coordinator’s Role
These efforts may or may not be assisted by formal counseling. If the care coordinator is
involved in counseling the task is to:
• Help her take steps toward change.
• Help her increase her self-efficacy.
• Reaffirm her decisions.
• Focus on successful activity.
Help her identify and use strategies to prevent relapse. Specifically counsel her to
anticipate and to prepare to survive any relapse crisis situations (situations that will
challenge her new position and tempt her to go back to old behavior).
Maintenance
Client's Role
Client attempts to sustain the change accomplished by previous action, and to prevent
relapse. May be maintaining strict changes or may occasionally be slipping. Slips are
common, but can lead to full-scale relapse if not addressed. Relapse is always possible.
As time goes on, if relapse does not occur, the change requires less effort and vigilance
and becomes routine. If maintenance continues, the changes ultimately become habits
and the client’s identity evolves to incorporate the changes.

Care Coordinator’s Role
• Teach the difference between just “maintaining” the status quo versus working
through a “trial and error learning period.”
• Help her know what to expect, feedback concerning the length of time it takes to
accomplish sustained change and the fact that some situations or cues can bring back
a flood of memories associated with the problem behavior.
• Help her identify and use strategies to prevent relapse, have her periodically review
her reasons for making the change and identify the benefits that have resulted from
the change.
Relapse/Recycle
Client's Role
• Full-scale return to previous behavior with no pretense of continuing the changes,
client surrenders, relapse begins and progresses for many reasons.
• The client may experience a particularly strong, unexpected urge or temptation and
fail to cope with it successfully.
• Sometimes relaxing her guard or testing herself begins the slide back.
• Often the costs of the change are not realized until later, and the commitment or self efficacy
erodes.
• Most often relapse does not occur automatically, but takes place gradually after an
initial slip occurs.
Care Coordinator’s Role
The client’s task is to go back and start again through the stages, beginning with
contemplation, rather than getting stuck in relapse or returning to pre - contemplation. The
care coordinator’s task is to help the client:
• Avoid discouragement and demoralization.
• Continue contemplating change.
• Renew determination and preparation.
• Resume action and maintenance efforts.