ADDICTION AND CHANGE: Understanding and Intervening in the Process

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ADDICTION AND CHANGEUnderstanding and
Intervening in the Process

• Carlo C.DiClemente, Ph.D. ABPP
• UMBC Psychology
• www.umbc.edu/psych/habits

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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

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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

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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 can bring together different
  perspectives

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Personal Pathways to Change

• Are influenced by personal decisional
  considerations and choices
• Personal choices are influenced by and influence
  genetic, characterological, and social forces
• There is an interaction between the individual
  and the surrounding risk and protective factors

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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

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SUCCESSFUL RECOVERY FROM ADDICTIONS

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

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Addiction and Change

• Both acquisition of and addiction and recovery
  from an addiction require a personal journey
  through an intentional change process that is
  influenced at various points by the host of
  factors identified in the previous reviewed
  etiological models.
• Involves a Process of Change

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How Do People Change?

• People change voluntarily only when they
• Become concerned about the need for change
• Become convinced that the change is in their best
  interests or will benefit them more than cost
  them
• Organize a plan of action that they are committed
  to implementing
• Take the actions that are necessary to make the
  change and sustain the change

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The Transtheoretical Model of Intentional
Behavior Change
STAGES OF CHANGE PRECONTEMPLATION ?
CONTEMPLATION ? PREPARATION ? ACTION ?
MAINTENANCE
PROCESSES OF CHANGE COGNITIVE/EXPERIENTIAL
BEHAVIORAL   Consciousness Raising
Self-Liberation Self-Revaluation
Counter-conditioning Environmental
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/Tempta
tion
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Model Components (Stages)

• 1. Precontemplation - Not Ready to Change
• 2. Contemplation - Thinking About Change
• 3. Preparation - Getting Ready to Make Change
• 4. Action - Making the Change
• 5. Maintenance - Sustaining Behavior Change Until
  Integrated into Lifestyle
• Relapse and Recycling - Slipping Back to Previous
  Behavior and Re-entering the Cycle of Change
• Termination - Leaving the cycle of change

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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

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The Five Rs of How and Why People Stay in
Precontemplation

• Reveling
• Reluctant
• Rebellious
• Resigned
• Rationalizing

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Tasks and goals for each of the Stages of Change

• CONTEMPLATION The stage where the individual
  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.

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Decisional Balance Worksheet
NO CHANGE PROS (Behavior) _______________ _______
________ _______________ CONS
(Change) _______________ _______________ _________
______
CHANGE CONS (Behavior) _______________ __________
_____ _______________ PROS (Change) ____________
__________________ _______________
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Tasks and goals for each of the Stages of Change

• PREPARATION The stage in which the individual
  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
  viable, realistic, change plan.
• GOAL An action plan to be implemented in the
  near term.

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Tasks and goals for each of the Stages of Change

• ACTION The stage in which the individual
  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).

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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.
• TASKS Sustaining change over time and across a
  wide range of different situations. Avoiding
  slips and relapse back to the old pattern of
  behavior.
• GOAL Long-term sustained change of the old
  pattern and establishment of a new pattern of
  behavior.

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Stage of Change Tasks

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance

• Awareness, Concern,Confidence
• Risk-Reward Analysis Decision making
• Commitment Creating an Effective/Acceptable
  Plan
• Adequate Implementation of Plan and Revising as
  Needed
• Integration into Lifestyle

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Regression, Relapse and Recycling through the
Stages

• Regression represents movement backward through
  the stages
• Slips are brief returns to the prior behavior
  that represent failures of action or the action
  plan
• Relapse is a return to re-engagement in the
  previous behavior to a significant degree after
  initial success
• After returning to the prior status quo behavior,
  individuals re-enters pre-action stages at
  precontemplation, contemplation, or preparation
  and may feel like a failure and discouraged about
  her ability to change

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Reasons for Relapse

• Lack of Willpower
• Environmental Pressures
• Situational Cues
• Inadequate skills
• Lack of Support for Sobriety
• Problematic Self-Efficacy
• Part of the Process of Change

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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
Concerns Pressure Balance
Experiential
Processes (Pros
Cons) Processes Recycling
Relapse
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Stages of Change Model
Precontemplation Awareness of need to change
Contemplation Increasing the Pros for Change and
decreasing the Cons
Preparation Commitment Planning
Relapse and Recycling
Maintenance Integrating Change into Lifestyle
Action Implementing and Revising the Plan
Termination
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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
Sustained Cessation
Dependence
RECOVERY
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THE COURSE OF ADDICTION
DEPENDENCE
ABUSE
REGULAR USE
REGULAR USE
CASUAL USE
CASUAL USE
EXPERIMENTATION
EXPERIMENTATION
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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
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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

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PREVENTION OF INITIATION OF ADDICTION
PC - C
C - PA
PA - A
A - M
ALREADY AFFLICTED
AT- RISK PREVENTION
POPULATION PREVENTION
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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
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Key Issues In Prevention

• Know where individuals are in the process of
  initiation
• Create credible messages that do not do more harm
  than good
• Target high risk individuals in the preparation
  and action stages who are at highest risk
• Focus on the context of change not simply the
  behavior
• Realize that individuals are in different stages
  with regard to different problematic and positive
  behaviors

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The Well-Maintained Addiction

• Defining action and maintenance is critical for
  initiation of health risks, like addiction, as
  well as health protection behaviors
• Regular, dependent use of a substance that
  creates creates a pattern that eludes
  self-regulatory control, continues despite
  negative feedback, and becomes an integral part
  of the individuals life and coping

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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 Concerns
Pressure Balance Experiential
Processes (Pros
Cons) Processes Recycling
Relapse
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STAGES OF CHANGE AND THERAPIST TASKS
Raise doubt - Increase the clients perception of
risks and problems with current behavior
PRECONTEMPLATION
Tip the decisional balance - Evoke reasons for
change, risks of not changing Strengthen
clients self-efficacy for change of current
behavior
CONTEMPLATION
Help the client to determine the best course of
action to take in seeking change Develop a plan
PREPARATION
Help the client implement the plan Use skills
Problem solve Support self-efficacy
ACTION
Help the client identify and use strategies to
prevent relapse Resolve associated problems
MAINTENANCE
Help the client recycle through the stages of
contemplation, preparation, and action, without
becoming stuck or demoralized because of relapse
RELAPSE
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Key Issues In Interventions

• Coercion, Courts and Mandated Treatment
• Family Frustration and Interventions
• Confrontation breeds Resistance
• Motivation not simply Education needed
• Intrinsic and Extrinsic Motivations
• Proactive versus Reactive Approaches
• Harm Reduction and Motivation

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Pregnancy Smoking Cessation

• Many addicted pregnant smokers stop smoking for
  the pregnancy
• Stopping is not quitting
• Motivation for postpartum cessation differs
• Change motivation is baby focused and NOT for
  self
• Imposed change

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Special Issues for Drug Courts and Mandated
Assessment TX

• Accurate assessment Initiation or Recovery
• Critical Distinctions
• Extrinsic and Intrinsic Motivations
• Consequences and Punishment versus Motivation and
  Change
• Mandated Treatment versus Mandated Change
• Clear Communication between Legal System and
  Intervention System

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Approaches that Pay Attention to the Process of
Change

• Clearly identify the target behavior
• Evaluate stage of readiness to change
• Evaluate beliefs 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 process of change

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Processes of Change

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

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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

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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

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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
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CONTEXT OF CHANGE
I. SITUATIONAL RESOURCES AND PROLBLEMS
II. COGNITIONS AND BELIEFS
III. INTERPERSONAL RESOURCES/PROBLEMS
IV. FAMILY SYSTEMS
V. ENDURING PERSONAL CHARACTERISTICS
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Stages by Context Analysis
Experiential Processes
Behavioral Processes
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TRANSITIONS THROUGH THE STAGES OF ADDICTION
FOR ALLEN Potential Complicating Problems
STAGE OF CHANGE TRANSTIONS
CONTEXT OF CHANGE
PC C
C PA
PA A
A M
SPECIFIC BEHAVIORAL SITUATIONAL ISSUES
Multiple Addictions
Religious beliefs
Soft vs. Hard Drugs
Sex alcohol
BELIEFS EXPECTANCIES
Girlfriend/ Intimacy
INTER PERSONAL
Parental smoking
School success
SOCIAL SYSTEMS (Family, Employment, Social)
Peers
Brother Peers
ENDURING PERSONAL CHARACTERISTICS
Risk taking
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TRANSITIONS THROUGH THE STAGES OF RECOVERY FOR
ALLEN Potential Complicating Problems
STAGES OF CHANGE
CONTEXT OF CHANGE
PC C
C PA
PA A
A M
Seeking Help
SPECIFIC BEHAVIORAL SITUATIONAL ISSUES
Multiple Addictions
Sex alcohol
BELIEFS EXPECTANCIES
Soft vs. hard drugs
Girlfriend/ Intimacy
INTER PERSONAL
AA
SOCIAL SYSTEMS (Family, Employment, Social)
Peers
Brother Peers
Work
ENDURING PERSONAL CHARACTERISTICS
Impulsive
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Difficult Clients and Client Difficulties A TTM
Analysis

• Target Problem and Contextual Problems
• Stage of Change for Each Problem
• Identifying Key Processes of Change
• Finding Appropriate Strategies to Engage
  Processes
• Recycling and Learning from the Past
• Accomplishing Stage Tasks Adequately

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Project MATCH Alcohol Impairment at Baseline
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Mean Percent Days Abstinent as a Function of Time
(Outpatient)
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PROCESS OF
VENTIONS
FORMAL
INTER
CHANGE