Embracing Change: Promoting Recovery

1
Embracing Change Promoting Recovery

• Carlo C. DiClemente, Ph.D. ABPP
• University of Maryland, Baltimore County
• www.umbc.edu/psych/habits
• www.mdquit.org

2
Overview

• Addiction and Change
• Motivation and the Change Process
• Stages and Tasks of Change
• Mechanisms (Client) Strategies (Provider) of
  change
• Treatment Planning
• Recycling and Challenges of Change in Individuals
  with Multiple Problems and Mental Illness

3
What are Addictions?

• Habitual patterns of intentional, appetitive
  behaviors
• Become excessive and produce serious consequences
• Stability of these problematic behavior patterns
  over time
• Interrelated physiological and psychological
  components
• Addicted individuals have difficulty modifying
  and stopping them

4
Traditional Models for Understanding Addictions

• Social/Environmental Models
• Genetic/Physiological Models
• Personality/Intra-psychic Models
• Coping/Social Learning Models
• Conditioning/Reinforcement Models
• Compulsive/Excessive Behavior Models
• Integrative Bio-Psycho-Social Models

5
Etiology of Addictions
Conditioning
Social Influences
Genetics
Abuse
Personality
Initial Use
Self-RegulatedUse
Physiology
Coping/Expectancies
Environment
Dependence
Reinforcement
All of these factors can have arrows to initial
experience and then to any or all of the three
patterns of use. Most could have arrows that
demonstrate linear or reciprocal causality as
well
6
Change the Integrating Principle

• No single developmental model or singular
  historical path can explain acquisition of and
  recovery from addictions
• A focus on the Process of Change and how
  individuals change offers a developmental, task
  oriented, learning based view that can be useful
  to clinicians and researchers using a variety of
  traditional etiological and cessation models

7
BECOMING ADDICTED

• Happens over a Period of Time
• Has a Variable Course
• Involves a Variety of Predictors that can be both
  Risk and Protective Factors
• Involves a Process of Change

8
SUCCESSFUL RECOVERY FROM ADDICTIONS

• Occurs over long periods of time
• Often involves multiple attempts and treatments
• Consists of self change and/or treatment
• Involves changes in other areas of psychosocial
  functioning

9
Addiction and Change

• Both acquisition of and recovery from an
  addiction require a personal journey through an
  intentional change process
• Journey influenced at various points by many of
  the factors identified in the previously reviewed
  etiological models

10
Addiction and Change

• Both are influenced by personal decisional
  considerations and choices
• Personal choices are influenced by and, in turn,
  influence genetic, developmental,
  characterological, and social forces
• Both involve an interaction between individual
  and surrounding risk protective factors that
  indicate a Process of Change

11
A LIFE COURSE PERSPECTIVE ON ADDICTION

• Cross sectional views and brief follow up studies
  offer confusing data about predictors and
  outcomes of prevention and cessation of addiction
• Multiple biological, social, individual,
  environmental factors influence transitions into
  and out of protective and problematic health
  behaviors
• Understanding initiation and cessation of these
  behaviors requires a life course and a process
  of change perspective

12
Motivation

• Motivation can be considered the tipping point
  for making change happen
• Not a simple or single construct or best thought
  of as an on-off switch
• Most of the time it is defined post hoc if you
  are successful, you were motivated

13
Motivation

• There are various models to explain motivation
• Push Models of internal dynamic forces or
  drives
• Pull Models of reinforcement, goals, values
• Persuasion Models of influence, social forces
• Process Models of readiness and tasks
• The Process Model changes the conversation from
  the what of motivation to the how of
  motivation

14
Motivation and the Change Process

• Clients are not unmotivated! They either
• are just motivated to engage in behaviors that
  others consider harmful and problematic or
• are not ready to begin behaviors that we think
  would be helpful.
• People who seem to have everything to gain from
  changing a behavior or doing some activity to
  relieve negative feelings or consequences do not
  do these things
• Excellent and effective self-management
  techniques are not used even after they are
  taught to people who come voluntarily for help

DiClemente. Addiction and Change How Addictions
Develop and Addicted People Recover. NY Guilford
Press 2003. CSAT Treatment Improvement Protocol
Number 35. Enhancing Motivation for Change in
Substance Abuse Treatment. 1999DHHS no. (SMA)
99-3354.
15
Motivation is Personal

• Motivation belongs to clients and their process
  of change.
• However, motivation can be enhanced or hindered
  by interactions with others (including providers)
  and events in the life context of the clients.
• Motivation is best viewed as the clients
  readiness to engage in and complete the various
  tasks outlined in the Stages of Change for a
  specific behavior change.

16
Motivation Is Critical for Successful Change

• Both brief interventions and alcoholism and
  substance abuse treatment research indicate a key
  role for patient motivation
• In many drinking reduction studies motivation
  predicts decreases (Delta study of Shock Trauma
  patients)
• Project MATCH client initial motivation measured
  by multidimensional stage measures predicted
  drinking out to 3 years post-treatment for
  outpatients

CSAT Treatment Improvement Protocol Number 35.
Enhancing Motivation for Change in Substance
Abuse Treatment. 1999DHHS no. (SMA) 99-3354.


Project MATCH Research Group.
Alcohol Clin Exp Res. 1998221300.
17
WHY ARE PEOPLE NOT MOTIVATED TO CHANGE?

• NOT CONVINCED OF THE PROBLEM OR THE NEED FOR
  CHANGE UNMOTIVATED
• NOT COMMITTED TO MAKING A CHANGE UNWILLING
• ACTUAL OR PERCEIVED ABILITY TO MAKE A CHANGE
  UNABLE
• DIFFERENT PARTS OF A PROCESS

18
HOW PEOPLE CHANGE
19
The Transtheoretical Model of Intentional
Behavior Change
STAGES OF CHANGE PRECONTEMPLATION ?
CONTEMPLATION ? PREPARATION ? ACTION ?
MAINTENANCE
PROCESSES OF CHANGE COGNITIVE/EXPERIENTIAL BEH
AVIORAL   Consciousness Raising Self-Liberation
Self-Revaluation Counter-conditioning Environm
ental Reevaluation Stimulus Control Emotional
Arousal/Dramatic Relief Reinforcement
Management Social Liberation Helping
Relationships CONTEXT OF CHANGE 1. Current
Life Situation 2. Beliefs and Attitudes 3.
Interpersonal Relationships 4. Social Systems 5.
Enduring Personal Characteristics MARKERS OF
CHANGE Decisional Balance
Self-Efficacy/Temptation
20
How Do People Change?

• People change voluntarily only when
• They become interested and concerned about the
  need for change
• They become convinced the change is in their best
  interest or will benefit them more than cost them
• They organize a plan of action that they are
  committed to implementing
• They take the actions necessary to make the
  change and sustain the change

21
Stage of Change Labels and Tasks

• Precontemplation
• Not interested
• Contemplation
• Considering
• Preparation
• Preparing
• Action
• Initial change
• Maintenance
• Sustained change

• Interested, concerned and willing to consider
• Risk-reward analysis and decision making
• Commitment and creating a plan that is
  effective/acceptable
• Implementing plan and revising as needed
• Consolidating change into lifestyle

DiClemente. Addiction and Change How Addictions
Develop and Addicted People Recover. NY Guilford
Press 2003.



DiClemente. J Addictions Nursing. 2005165.
22
Motivation is Multidimensional

• Motivation is best understood as the readiness
  and ability to accomplish the tasks needed to
  move individuals successfully through the stages
  of change
• These tasks require self-regulation skills that
  enable the person to engage in the processes of
  change needed to accomplish the tasks and move
  the markers of change
• There are facilitating and hindering personal and
  environmental factors that affect movement
  through each of the stages

23
A Consumer perspective

• A Consumer Perspective to Care necessitates a
  shift in emphasis from a concentration on our
  treatments to a concentration on our consumers
  and their processes to regain some balance
• Most treatment services provide good, effective
  action-oriented treatments
• Many of our consumers are unmotivated,
  overwhelmed with multiple problems, feeling
  hopeless, or simply not interested or engaged by
  our services

DiClemente Velasquez. Motivational interviewing
and the stages of change. In Miller Rollnick,
eds. Motivational Interviewing, 2nd ed. NY
Guilford Publications 2002201.
24
Understanding Motivation and Movement through the
Stages of Change
UNMOTIVATED UNWILLING UNABLE
Precontemplation Contemplation
Preparation Action Maintenance
This Process is as relevant for organizations and
service providers as it is for Individuals with
mental health and addiction problems.
25
Tasks and Goals for each of the Stages of Change

• PRECONTEMPLATION - The state in which there is
  little or no consideration of change of the
  current pattern of behavior in the foreseeable
  future.
• TASKS Increase awareness of need for change and
  concern about the current pattern of behavior
  envision possibility of change
• GOAL Serious consideration of change for this
  behavior

26
WHAT INDIVIDUALS or ORGANIZATIONS MUST REALIZE

• MY BEHAVIOR IS PROBLEMATIC OR EXCESSIVE
• MY DRUG USE IS CAUSING PROBLEMS IN MY LIFE
• I HAVE OR AM AT RISK FOR SERIOUS PROBLEMS
• MY BEHAVIOR IS INCONSISTENT WITH SOME IMPORTANT
  VALUES
• MY LIFE IS OUT OF CONTROL

• WHAT WE ARE DOING IS NOT EFFECTIVE IN MEETING THE
  NEEDS OF OUR CLIENTS
• OUR APPROACH IS COSTING TOO MUCH FOR THE OUTCOMES
  WE ARE GETTING
• THERE ARE SERIOUS PROBLEMS IN OUR PROCEDURES,
  PROGAMMMING,OR PRODUCT

27
Key Issues and Intervention Considerations

• Coercion or Courts cannot do it alone
• Confrontation breeds Resistance
• Motivation not simply Education is needed
• Intrinsic and Extrinsic Motivations
• Proactive versus Reactive Approaches
• Smaller versus Larger goals and Motivation

28
Tasks and goals for each of the Stages of
Change

• CONTEMPLATION The stage where the individual or
  society examines the current pattern of behavior
  and the potential for change in a risk reward
  analysis.
• TASKS Analysis of the pros and cons of the
  current behavior pattern and of the costs and
  benefits of change. Decision-making.
• GOAL A considered evaluation that leads to a
  decision to change.

29
Decisional Balance Worksheet
NO CHANGE PROS (Status Quo) _______________ _____
__________ _______________ CONS
(Change) _______________ _______________ _________
______
CHANGE CONS (Status Quo) _______________ ________
_______ _______________ PROS (Change) ___________
___________________ _______________
30
Key Issues and Intervention Considerations

• Decisional Considerations are Personal
• Increase the Costs of the Status Quo and the
  Benefits of Change
• Challenge and Work with Ambivalence
• Envision the Change
• Engender Culturally Relevant Considerations that
  are Motivational
• See how families and larger organizations can
  influence change by providing incentives or
  putting up barriers
• Multiple problems or issues interfere and
  complicate

31
MOTIVATED TO CHANGE

• Admit that the status quo is problematic and
  needs changing
• The pros for change outweigh the cons
• Change is in our own best interest
• The future will be better if we make changes in
  these behaviors
• But this is only the first two steps toward
  making a change happen

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Tasks and goals for each of the Stages of Change

• PREPARATION The stage in which the individual
  or organization makes a commitment to take action
  to change the behavior pattern and develops a
  plan and strategy for change.
• TASKS Increasing commitment and creating a
  change plan.
• GOAL An action plan to be implemented in the
  near term.

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Key Issues and Intervention Considerations

• Effective, Acceptable and Accessible Plans
• Setting Timelines for Implementation
• Building Commitment and Confidence
• Creating Incentives
• Developing and Refining Skills Needed to
  Implement the Plans
• Treatment Plan and Change Plan

36
WILLING TO MAKE CHANGE

• COMMITMENT TO TAKE ACTION
• SPECIFIC ACCEPTABLE ACTION PLAN
• TIMELINE FOR IMPLEMENTING PLAN
• ANTICIPATION OF BARRIERS
• BUT YOU STILL HAVENT DONE IT YET

37
Tasks and goals for each of the Stages of Change

• ACTION The stage in which the individual or
  organization implements the plan and takes steps
  to change the current behavior pattern and to
  begin creating a new behavior pattern.
• TASKS Implementing strategies for change
  revising plan as needed sustaining commitment in
  face of difficulties
• GOAL Successful action to change current
  pattern. New pattern established for a
  significant period of time (3 to 6 months).

38
Key Issues and Intervention Considerations

• Flexible and Responsive Problem Solving
• Support for Change
• Reward Progress
• Create Consequences for Failure to Implement
• Continue Development and Refining Skills Needed
  to Implement the Plan

39
Tasks and goals for each of the Stages of Change

• MAINTENANCE The stage where the new behavior
  pattern is sustained for an extended period of
  time and is consolidated into the lifestyle of
  the individual and society.
• TASKS Sustaining change over time and across a
  wide range of situations. Avoiding going back to
  the old pattern of behavior.
• GOAL Long-term sustained change of the old
  pattern and establishment of a new pattern of
  behavior.

40
Key Issues and Intervention Considerations

• It is Not Over Till Its Over
• Support and Reinforcement
• Availability of Services or Resources to Address
  Other Issues In Contextual Areas of Functioning
• Offering Valued Alternative Sources of
  Reinforcement
• Institutionalization of change

41
ABLE TO CHANGE

• Continued Commitment
• Skills to Implement the Plan
• Self Control Strength that is not exhausted by
  other problems
• Long-term Follow Through
• Integrating New Behaviors into Lifestyle or
  Organization
• Creating a New Behavioral Norm
• Now you are getting there

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Relapse and Recycling - Slipping Back to Previous
Behavior and Trying to Resume Change

• Characteristics
• The person or organizations has failed to
  implement the plan or is re-engaged in the
  previous behavior
• After failing to implement or reverting to
  previous behavior, there is re-entry to
  precontemplation, contemplation, preparation
  stages
• Sense of failure and discouragement about
  motivation or ability to change

44
Regression, Relapse and Recycling through the
Stages

• Regression represents movement backward through
  the stages
• Slips are brief returns to the prior behavior
  that represent a some problems in the action plan
• Relapse is a return or re-engaging to a
  significant degree in the previous behavior after
  some initial change
• After returning to the prior behavior,
  individuals Recycle back into pre-action stages
  (precontemplation, contemplation, or preparation).

45
Key Issues and Intervention Considerations

• Blame and Guilt Undermine Motivation for Change
• Determination despite delays and defeats
• Support Re-engagement in the Processes of Change
• Recycling or just Spinning Wheels
• Hope and a Learning Perspective is Needed

46
Theoretical and practical considerations related
to movement through the Stages of Change
Motivation Decision-Making
Self-efficacy
Precontemplation Contemplation
Preparation Action Maintenance
Personal Environmental Decisional
Cognitive Behavioral
Organizational Concerns Pressure
Balance Experiential Processes
(Pros Cons) Processes Recycling
Relapse
47
Stages of Change Model
Precontemplation Increase awareness of need to
change
Contemplation Motivate and increase confidence
in ability to change
Relapse Assist in Coping
Preparation Negotiate a plan
Maintenance Encourage active problem-solving
Action Reaffirm commitment and follow-up
Termination
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Self-Evaluation Ruler - Alcohol
On the following scale, which point best reflects
how ready you are at the present time to changing
your drinking?
Not at all ready to change my drinking
Thinking about changing my drinking
Planning and making a commitment to change my
drinking
Actively changing my drinking
50
MECHANISMS OF CHANGE A CLIENT PERSPECTIVE

• What is the clients work in making change
  happen?
• What is the providers tasks?
• What is the difference?
• Client Processes
• Provider Strategies and Services

51
Processes of Change

• Change engines that enable movement through the
  stages of change
• Doing the right thing at the right time
• Cognitive/Experiential processes during early
  stages
• Behavioral processes in preparation, action and
  maintenance

52
Processes of Change

• Experiential Processes
• Concern the persons thought processes
• Generally seen in the early Stages of Change
• Behavioral Processes
• Action oriented
• Usually seen in the later Stages of Change

53
Transtheoretical Model Experiential Processes of
Change

• Consciousness Raising Gaining information
  increasing awareness about the current habitual
  behavior pattern or the potential new behavior
• Emotional Arousal Experiencing emotional
  reactions about the status quo and/or the new
  behavior
•   Self Revaluation Seeing when and how the
  status quo or the new behavior fit in with or
  conflict with personal values
• Environmental Reevaluation Recognizing the
  effects the status quo or new behavior have upon
  others and the environment
•   Social Liberation Noticing and increasing
  social alternatives and norms that help support
  change in the status quo and/or initiation of the
  new behavior

54
Transtheoretical Model Behavioral Processes of
Change

• Self Liberation Accepting responsibility for
  and committing to make a behavior change
• Stimulus Control Creating, altering or
  avoiding cues/stimuli that trigger or encourage a
  particular behavior
•   Counter-Conditioning Substituting new,
  competing behaviors and activities for the old
  behaviors
• Reinforcement Management Rewarding sought after
  new behaviors while extinguishing (eliminating
  reinforcements) from the status quo behavior
• Helping Relationships Seeking and Receiving
  support from others (family, friends, peers)

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PROCESSES OF CHANGE by STAGE
STAGES
PC C PA
A M
P R O C E S S E S
Consciousness raising Self-reevaluation
Dramatic relief Helping relationship
Self- liberation
Contingency management
Counter-
conditioning Stimulus
control
57
Provider Strategies

• What do you do to engage each of these processes?
• What do you do with less motivated patients that
  would activate some of these experiential
  processes?
• What do you do with you action oriented patients
  that activate the behavioral processes?

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A Transtheoretical Model Group Therapy Each
group session is based on a specific TTM process
of change. Motivational Interviewing counseling
strategies are used throughout the sessions.
60
Thinking About Changing Substance
UsePrecontemplation-Contemplation-Preparation
Sequence

1. The Stages of Change
2. A Day in the Life- Consciousness Raising
3. Physiological Effects of Alcohol-Consciousness
   Raising
4. Physiological Effects of Drugs-Consciousness
   Raising
5. Expectations-Consciousness Raising
6. Expressions of Concern-Self-Reevaluation,
   Dramatic Relief

61
Making Changes in Substance AbuseAction/Maintenan
ce Sequence

• The Stages of Change
• Identifying Triggers- Stimulus Control
• Managing Stress-Counterconditioning
• Rewarding My Sucesses-Reinforcement Management
• Effective Communication-Counterconditioning,
  Reinforcement Management
• Effective Refusals-Counterconditioning,
  Reinforcement Management

62
Motivating Movement through the Early Stages of
Change

• Critical tasks of the early stages are eliciting
  concern, dealing with ambivalence regarding
  change, decision-making, creating commitment,
  careful and comprehensive planning.
• Motivational Interviewing/Enhancement approaches
  are important strategies to engage and work with
  clients helping them successfully complete these
  tasks.

63
Treatment Planning

• Connecting what you do with what they need.
• Key questions
• Where in the stages are they?
• What are the tasks that need to be accomplished
  or accomplished better?
• What processes are needed?
• What can I do to activate these processes in the
  session or in the environment?

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THE STAGES OF CHANGE FOR ADDICTION AND
RECOVERY
ADDICTION
Dependence
PC
C
PA
A
M
PROCESSES, CONTEXT AND MARKERS OF CHANGE
PC
C
PA
A
M
Dependence
Sustained Cessation
RECOVERY
66
Theoretical and practical considerations related
to Prevention and Stages of INITIATION
Expectancies/Beliefs Decision-Making
Self-efficacy
Precontemplation Contemplation
Preparation Action Maintenance
Personal Environmental Decisional
Cognitive/ Behavioral Concerns Pressure
Balance Experiential
Processes (Pros Cons)
Processes


Experimentation Casual use Regular Use
Dependence
67
PREVENTION OF INITIATION OF ADDICTION
PC - C
C - PA
PA - A
A - M
ALREADY AFFLICTED
AT- RISK PREVENTION
POPULATION PREVENTION
68
A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE
ON ALLEN
TYPE OF BEHAVIOR
STAGE OF INITIATION
PC
C
PA
A
M
X
ALCOHOL
X
NICOTINE
X
MARIJUANA
X
HEROIN
X
COCAINE
X
AMPHETAMINES
X
LSD
X
GAMBLING
X
EATING DISORDER
69
Implications for Acquisition and Prevention

• If there is a common but unique pathway, we can
  better understand where individuals are in this
  process of change for each addictive behavior
• We can distinguish between prevention and
  treatment better
• We can target interventions to the process of
  change

70
2000 Maryland Youth Tobacco Survey (MYTS)

• Secondary data analyses of the Maryland Youth
  Tobacco Survey (MYTS, 2000)
• Classroom-based survey, administered throughout
  Maryland
• Participants were public school students (N
  47,839), between the ages of 12 and 18 years
• The majority of the sample was Caucasian (69)
  and over half were Female (52), with a median
  age of 14 years

71
2002 Maryland Youth Tobacco Survey (MYTS)

• Secondary data analyses of the Maryland Youth
  Tobacco Survey (MYTS, 2002)
• Classroom-based survey, administered throughout
  Maryland
• Participants were public school students (N
  56,820), between the ages of 12 and 17 years
• The majority of the sample was Caucasian (66)
  and over half were Male (53), with a median age
  of 14 years

72
Youth were classified into Stages of Smoking
Initiation Levels of Experience

• Level of Experience is analogous to prevalence
  measures with
• Never Smoked Inexperienced
• Smoked Less than 6 days Exposed
• Smoked 6 days Experienced
• Youth were classified according to their Stage of
  Smoking Initiation using
• Lifetime Smoking
• Ever smoked
• Future Intentions
• Smoke in next year?
• Current Smoking
• of days smoked past 30 days
• Duration of Current Smoking
• How long smoked current rate?

73
Logistic Regressions

• Using 2000 MYTS data, Logistic Regressions were
  estimated for both the Stages of Smoking
  Initiation Level of Experience
• 3 Key Risk Factors from 3 Domains of Influence
  were selected
• Behavioral
• Would you ever use or wear something that has a
  tobacco company name or picture on it such as a
  lighter, t-shirt, hat, or sunglasses?
• Attitudinal
• Do you think young people who smoke cigarettes
  have more friends?
• Intention
• If One of Your Best Friends Offered You a
  Cigarette, Would You Smoke It?

74
Table 1. Distributions of Stage of Smoking
Initiation Level of Experience
n
Levels of Experience
Inexperienced 29,628 61.9
Exposed 8,274 17.3
Experienced 9,937 20.8
Stages of Smoking Initiation
Precontemplation 29,064 60.8
Contemplation 10,858 22.7
Preparation 2,311 4.8
Action 1,656 3.5
Maintenance 3,950 8.3
75
Distribution of Stages of Smoking Initiation by
Wave School Status
MS 2000 HS 2000 MS 2002 HS 2002
PC 14,576 14,218 18,371 18,263
C 4,039 6,687 4,595 7,826
P 539 1,752 560 1,695
A 374 1,687 395 1,587
M 255 3,373 280 2,646
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Table 4. Odds-Ratios of Stages of Smoking
Initiation and Level of Experience for Intention
Risk Factor Accept Cigarette Offer from Best
Friend
OR CI
Level of Experience
Inexperienced 1.0 --
Exposed 5.6 5.2 6.1
Experienced 66.4 61.7 71.5
Stages of Initiation
Precontemplation 1.0 --
Contemplation 27.1 24.2 30.5
Preparation 258.1 223.6 298.0
Action 686.6 568.8 828.8
Maintenance 1,780.7 1,480.7 2,141.5
plt.001
78
Table 3. Odds-Ratios of Stages of Smoking
Initiation Level of Experience for Attitudinal
Risk Factor Smokers Have More Friends
OR CI
Level of Experience
Inexperienced 1.0 --
Exposed 1.8 1.7 1.9
Experienced 2.6 2.5 2.8
Stages of Initiation
Precontemplation 1.0 --
Contemplation 2.1 2.0 2.2
Preparation 4.1 3.8 4.5
Action 3.7 3.3 - 4.1
Maintenance 3.6 3.3 3.9
plt.001
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Adolescent Smoking in Maryland Stage Status /
Transitions
81
Some Data related to Mechanisms

• Where should we look for the critical mechanisms
  of change?
• Look in the Drinkers process of change and how
  interventions interact with that process
• Some thoughts and data from Project MATCH may
  illustrate some ways and places to look.

82
Project MATCH

• Tested 3 distinct alcohol treatments
• Cognitive Behavioral Treatment (CBT) (12/12 wks)
• Twelve Step Facilitation (TSF) (12/12 wks)
• Motivational Enhancement Therapy (MET) (4/12 wks)
• Examined 21 hypothesized matching effects and
  over 30 baseline predictors of drinking
• Comprised 9 centers with over 20 sites and 75
  therapists
• Included 952 outpatients and 774 aftercare
  patients

Project MATCH Research Group. J Stud Alcohol.
1997587.
83
Alcohol Impairment at Baseline
84
Predictors of Drinking at Months 4-15
85
Predictors of Drinking at 3-year Follow-Up
86
Mean Percent Days Abstinent as a Function of Time
(Outpatient)
87
End of Treatment Process Profiles Predict
Outcomes

• Client status during follow-up period
• Abstinent
• Moderate drinking
• Heavier drinking
• Client Profile on Stage of change Subscales,
  Temptation to Drink, Abstinence Self-Efficacy,
  Experiential and Behavioral Processes of Change

88
TTM Profile Outpatient PDA Baseline
TTM Transtheoretical model Carbonari
DiClemente. J Consult Clin Psychol. 200068810.
89
TTM Profile Outpatient PDA Post-treatment
Abstinent
Moderate
Heavier
0.8
0.6
0.4
0.2
Standard Scores
0
-0.2
-0.4
-0.6
Pre
Con
Act
Main
Conf
Temp
Exp
Beh
-0.8
TTM Variables
PDA percent days abstinent Carbonari, JP
DiClemente, CC. J Consult and Clin Psych. 2000
68810.
90
TTM Profile Aftercare PDA Baseline
Carbonari DiClemente. J Consult Clin Psychol.
200068810.
91
TTM Profile Aftercare PDA Post-treatment
Carbonari DiClemente. J Consult Clin Psychol.
200068810.
92
WHERE TO LOOK FOR MECHANISMS OF CHANGE

• CLIENT PROCESS OF CHANGE
• ACCOMPLISHMENT OF CRITICAL STAGE TASKS AND
  LEARNING OVER TIME
• ENGAGEMENT OF CLIENT PROCESSES OF CHANGE
• SELF-REGULATION AND SELF-CONTROL MECHANISMS
• HOW INTERVENTION ACTIVITIES ENGAGE OR ACTIVATE
  THESE PROCESSES AND ASSIST IN ACCOMPLISHMENT OF
  CHANGE TASKS
• INVOLVEMENT AND MANAGEMENT OF CONTEXTUAL PROBLEMS

93
Where Do We Go From Here?

• Stepped care approaches
• Matching techniques of treatment to client
  problem and process of change dimensions
• Integrating formal and self-help approaches as
  well as different treatment approaches
• Client-titrated treatment
• Treatment shifts from being reactive and
  regimented to becoming proactive and personalized

DiClemente. Addiction and Change How Addictions
Develop and Addicted People Recover. NY Guilford
Press 2003.
94
Multiple Problems Complicate the Process of Change

• The Context of Change
• A Figure Ground Perspective

95
CONTEXT OF CHANGE
I. SITUATIONAL RESOURCES AND PROBLEMS
II. COGNITIONS AND BELIEFS
III. INTERPERSONAL RESOURCES/PROBLEMS
IV. FAMILY SYSTEMS
V. ENDURING PERSONAL CHARACTERISTICS
96
Typical Complications forIndividual and
Organizations

• Symptom/Situation
• Psychiatric
• Financial
• Beliefs
• Religious views
• Cultural beliefs
• Interpersonal
• Marital
• Systemic
• Employment
• Family/Children
• Intrapersonal
• Self-Esteem

• Situation
• Inadequate facilities
• Financial
• Beliefs
• Only one right way
• Interpersonal
• Leadership Conflicts
• Systemic
• Funding Sources
• Political forces
• Subgroup conflicts
• Institutional
• Traditions
• Organizational Culture

97
Stages by Context Analysis
Experiential Processes
Behavioral Processes
98
PROBLEM FOCUS

• Since change goals and motivations are often
  behavior specific, it is critical to be specific
  about the focus of interventions
• We need to evaluate in collaboration with the
  client what is the primary target behaviors that
  needs to be changed and the client goals
• Target behavior is figure and additional problems
  become the ground or context for that change

99
Evaluating Client Problems

• How serious is the problem?
• Not Evident
• Not Serious
• Serious
• Very Serious
• Extremely Serious

• When and What Intervention is needed?
• Needs no intervention
• Needs intervention in the future
• Needs Secondary Intervention
• Needs primary intervention but can wait
• Needs immediate intervention

100
Intervention Strategies

• SEQUENTIAL start with initial symptom or
  situation and try to resolve that and work way
  down.
• KEY AREA OR LEVEL Find problem or area where
  you have the most leverage either the most
  serious or salient problem or client is most
  motivated
• MULTI-LEVEL OR MULTI-PROBLEM Work back and forth
  across the context identifying and addressing
  client stage and processes of change for each
  separate problem

101
Approaches that Pay Attention to the Process of
Change

• Clearly identify the target behavior and the
  contextual problems
• Evaluate stage of readiness to change
• Evaluate beliefs, values and practices related to
  target behavior
• Examine routes and mechanisms of influence in the
  culture and for the individual
• Create sensitive stage based multi-component
  interventions
• Re-evaluate regularly the change process

102
Mental Illness and Addictions

• Rates of addictions among those with psychiatric
  disorders is higher than in the population (2 to
  4 times greater)
• Substance use if often associated with the onset
  of many different disorders (schizophrenia,
  conduct disorder, personality disorders)
• These are reciprocally complicating disorders

103
Additional Considerations for SMI

• Substance abuse by individuals with severe mental
  illness is ubiquitous.
• It is not clear if individuals with schizophrenia
  can access and utilize a similar process of
  change as other drug abusing individuals.
• It is also not clear whether individuals with
  Schizophrenia differ from other non psychotic
  individuals in terms of their profiles on process
  measures identified in the Transtheoretical Model

104
SUMMARY OF RECENT STUDIES

• Measures of readiness and other process variables
  demonstrated reliability and construct validity
  among SMI patients with tobacco dependence and
  cocaine abuse.
• Schizophrenia patients appear to be using the
  same or similar process of change in managing
  their tobacco and cocaine abuse and recovery as
  other drug abusing patients
• Although neurocognitive deficits among patients
  with schizophrenia can interfere with access to
  some higher order cognitive functions and may
  modulate the process, these patients appear to
  access and use the intentional process of change
  as described in the TTM in managing and
  recovering from substance abuse.

DiClemente, Bellack, Nidecker, Gearon, 2003 AABT
105
Mental Illness and Emotional Problems

• Combinations of Symptoms, Emotions, Cognitions
  and Behaviors
• Although illness is not chosen, it develops over
  time and requires initiation, modification, and
  cessation of some behaviors (including medication
  adherence)
• Can interfere with accurate information
  processing and other tasks of the stages of change

106
Challenges for Change in a Mentally Ill
Population

• Multiple Chronic conditions
• Shifting Motivation
• Cognitive Impairment
• Self Regulation Problems
• Situational/Environmental Issues
• System of Care Problems

107
Multiple Problems Need an Integrated Continuum of
Care
108
Support and Cultural Issues

• Social Networks and Social Support
• How to Use
• Where to Find
• Spirituality
• Can be a two-edged sword
• Cultural Sensitivity
• Cultural Competence
• Stigma

109
Developing Process Oriented Treatments

• How would you develop a treatment system that
  took into account what we have learned about the
  process of change?
• How would you manage interactions among providers
  and systems of care?
• How would you allocate your resources and
  personnel?
• How could you address issues of boundaries,
  transitions, patient tracking, and avoiding
  conflicts among providers?

110
What is a Consumer?

• A person who has the power to buy, to choose from
  among options, to demand service, to decide, and
  to manage their choices and lives
• Individuals with an array of interests, values,
  tastes, opinions, attitudes and intentions
• A valued commodity to those who offer products
  and services
• Not just an alternate term for client or patient

111
Why Do We Need Consumer- Centered Care for
Individuals with Mental and Physical Illnesses?

• They have choices about services
• They have to make informed choices about
  treatments (especially as the options increase)
• They can bring lawsuits
• They have to comply with any treatment
• They are in charge of their personal process of
  change

112
A Consumer-Centered Perspective

• Critical Shifts in Perspective from
• Pathology to Problems
• Pulling or Pushing to Persuasion
• Patient to Partner
• Provider to Facilitator
• Outcomes to Options
• Management to Motivation Marketing
• Reactive to Proactive Care
• Examples

113
Changing Substance Abuse and Mental Health Systems

• Pogo
• We have met the enemy and it is us
• How do systems change?
• What if we adopted a consumer perspective?
• What is needed Modification or Transformation?

114
Implications for Policy

• Proactive Approaches and Engagement Activities
  need to be valued and funded
• Find out what the consumer needs and wants before
  planning services and strategies
• Reward Progress not just Ideal or Ultimate
  Outcomes
• Address ambivalence and reluctance to change on
  part of consumer (and provider)
• Build a System of Services

115
Concluding Thoughts

• Change is a complicated process
• Need a roadmap
• Need both an Overview of the larger process as
  well as a Focused view of a particular client
• Negotiating Change and Entering the Clients
  Change Process requires patience and persistence
  optimism and realism and the perspective of a
  coach of a minor league team