Precontemplation – When the Patient Doesn’t See the Problem
Helping Prescribers Spark Insight Without Resistance
Clinical Vignette
Ms. D is a 29-year-old woman with obesity, prediabetes, and early signs of fatty liver disease. Her A1C has crept up to 6.4%, and she sleeps poorly. You bring up possible dietary changes. She replies:
“I’ve always been big. Everyone in my family is like this. I don’t really think it’s that bad.”
She’s in precontemplation, and she is not at the optimal level of preparedness, not thinking about change, and possibly she is even defensive. However, the visit isn’t a waste, and this is your window to plant a seed.
What is Precontemplation?
Precontemplation is the first stage in the Stages of Change Model (Prochaska & DiClemente, 1983). The person is not yet considering change. They may:
Be unaware of the risks
Minimize the issue
Feel ambivalent or defensive
Have failed in the past and lost hope
Trying to push action here is like trying to climb a ladder with missing rungs; and you’ll both fall.
Goal for the Prescriber: Raise Awareness, Not Argue
Your task is not to convince, persuade, or educate in a traditional sense; rather, it’s to evoke curiosity, elicit discrepancy, and plant a seed.
Tool: Ask–Reflect–Evoke
Use this simple 3-step flow:
1. Ask permission
“Tell me if it would be okay if I shared something I’ve noticed.”
2. Reflect what you hear
“So it sounds like change isn’t something you’re considering right now.”
3. Evoke future-focused thinking
“Tell me what would have to happen for this to become more of a concern for you.”
These steps are MI-based (Motivational Interviewing) and help reduce resistance by respecting autonomy.
What Not to Do
🚫 Don’t shame, scare, or argue
🚫 Don’t say “You need to…”
🚫 Don’t jump into action planning
Instead, show respect for autonomy, genuine curiosity, and a willingness to walk with them, not ahead of them.
Scientific Citations
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395.
Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Press.
DiClemente, C. C., et al. (2004). The Process of Change. In Changing for Good. Avon Books.
Resnicow, K., & McMaster, F. (2012). Motivational Interviewing: Moving from Why to How with Autonomy Support. International Journal of Behavioral Nutrition and Physical Activity, 9(19).
Reflection Prompt
“What would it look like if I let go of trying to fix and focused on sparking curiosity?”
“How can I honor my patient’s autonomy without giving up on the goal of change?”
“Am I trying to jump ahead of where the patient actually is?”