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Embracing Change: Promoting Recovery
Carlo C. DiClemente, Ph.D. ABPPUniversity of Maryland, Baltimore Countywww.umbc.edu/psych/habitswww.mdquit.org
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
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
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
Etiology of Addictions
Genetics
Physiology
Environment
Personality
Social Influences
Coping/Expectancies
Initial Use Self-RegulatedUse
Abuse
Dependence
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
Conditioning
Reinforcement
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
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
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
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
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
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
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
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
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. 1999;DHHS no. (SMA) 99-3354.
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 client’s readiness to engage in and complete the various tasks outlined in the Stages of Change for a specific behavior change.
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. 1999;DHHS no. (SMA) 99-3354. Project MATCH Research Group. Alcohol Clin Exp Res. 1998;22:1300.
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
The Transtheoretical Model of Intentional Behavior Change
STAGES OF CHANGE
PRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE
PROCESSES OF CHANGECOGNITIVE/EXPERIENTIAL BEHAVIORAL Consciousness Raising Self-LiberationSelf-Revaluation Counter-conditioningEnvironmental Reevaluation Stimulus ControlEmotional Arousal/Dramatic Relief Reinforcement ManagementSocial Liberation Helping Relationships
CONTEXT OF CHANGE1. Current Life Situation2. Beliefs and Attitudes3. Interpersonal Relationships4. Social Systems5. Enduring Personal Characteristics
MARKERS OF CHANGE Decisional Balance Self-Efficacy/Temptation
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
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. 2005;16:5.
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
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; 2002:201.
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 forIndividuals with mental health and addiction problems.
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
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
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
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.
Decisional Balance Worksheet
NO CHANGE
PROS (Status Quo)_____________________________________________
CONS (Change)_____________________________________________
CHANGE
CONS (Status Quo)_____________________________________________
PROS (Change)_____________________________________________
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
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
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.
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
WILLING TO MAKE CHANGE
COMMITMENT TO TAKE ACTION SPECIFIC ACCEPTABLE ACTION
PLAN TIMELINE FOR IMPLEMENTING PLAN ANTICIPATION OF BARRIERS BUT YOU STILL HAVEN’T DONE IT
YET
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).
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
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.
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
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
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
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).
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
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 OrganizationalConcerns Pressure Balance Experiential Processes
(Pros & Cons) Processes
Recycling Relapse
PrecontemplationIncrease awareness of need to change
ContemplationMotivate and increase confidence
in ability to change
ActionReaffirm commitment
and follow-up
Termination
Stages of Change Model
RelapseAssist in Coping
MaintenanceEncourage activeproblem-solving
PreparationNegotiate a plan
Self-Evaluation Ruler - AlcoholSelf-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
Actively changing
my drinking
Planning andmaking a
commitment to change my
drinking
MECHANISMS OF CHANGE: A CLIENT PERSPECTIVE
What is the client’s work in making change happen?
What is the provider’s tasks? What is the difference? Client Processes Provider Strategies and Services
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
Processes of Change
Experiential Processes Concern the person’s thought processes Generally seen in the early Stages of
Change
Behavioral Processes Action oriented Usually seen in the later Stages of Change
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
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)
PROCESSES OF CHANGE by STAGE
STAGES
PC C PA A M
Consciousness raising Self-reevaluation Dramatic relief
Helping relationship Self- liberation Contingency management Counter-
conditioning Stimulus control
PROCESSES
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?
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.
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
Making Changes in Substance AbuseAction/Maintenance Sequence
1. The Stages of Change2. Identifying “Triggers”- Stimulus Control
3. Managing Stress-Counterconditioning
4. Rewarding My Sucesses-Reinforcement Management
5. Effective Communication-Counterconditioning, Reinforcement Management
6. Effective Refusals-Counterconditioning, Reinforcement Management
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.
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?
THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY
ADDICTIONADDICTION
RECOVERYRECOVERYSustainedCessation
Dependence
PROCESSES, CONTEXT AND MARKERS OF CHANGE
Dependence
PC C PA A M
PC C PA A M
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
PREVENTION OF INITIATION OF ADDICTIONPREVENTION OF INITIATION OF ADDICTION
PC - CPC - C C - PAC - PA PA - APA - A A - MA - M
POPULATIONPREVENTION
AT- RISKPREVENTION
ALREADY AFFLICTED
A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLENA STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLEN
TYPE OFBEHAVIOR
STAGE OF INITIATION
PC C PA A M
ALCOHOL
NICOTINE
MARIJUANA
HEROIN
COCAINE
AMPHETAMINES
LSD
GAMBLING
EATING DISORDER
XXXXXX
XXXX
XXXX
XXXX
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
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
2000 Maryland Youth Tobacco Survey (MYTS)
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
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?
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?”
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
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
Mean Number of Friends who Smoke
0.23
0.63
0.19
0.50
0.78
1.11
0.740.92
2.041.94
1.76 1.67
2.66
2.93
2.67 2.70
2.262.38
2.502.73
0
1
2
3
4
MS HS MS HS
2000 2002
PC C P A M
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
* p<.001
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
* p<.001
Smoking makes young people look cool or fit in by Stage, School & Wave
6.2 7.3 6.8 7.5
21.516.8
24.220.2
44.5
31.0
49.2
32.541.2
25.5
44.5
29.0
38.2
23.4
51.2
27.0
0
20
40
60
80
100
MS HS MS HS
2000 2002
PC C P A M
Adolescent Smoking in Maryland: Stage Status / Transitions
PC C P A M
STATEWIDE
Middle School 74.5% 20.4% 2.6% 1.5% 1.1% High School 55.2% 24.4% 5.9% 5.0% 9.5%
PC C P A M
STATEWIDE
Middle School 77.6% 18.6% 1.9% 1.1% 0.8% High School 59.5% 24.4% 5.0% 4.3% 6.8%
PC C P A M
STATEWIDE
Middle School 3.1% -1.8% -0.7% -0.4% -0.3% High School 4.3% 0.0% -0.9% -0.7% -2.7%
Change: 2002-2000
2000
2002
Some Data related to Some Data related to MechanismsMechanisms
Where should we look for the critical Where should we look for the critical mechanisms of change?mechanisms of change?
Look in the Drinkers process of Look in the Drinkers process of change and how interventions change and how interventions interact with that processinteract with that process
Some thoughts and data from Project Some thoughts and data from Project MATCH may illustrate some ways and MATCH may illustrate some ways and places to look.places to look.
Project MATCHProject MATCH Tested 3 distinct alcohol treatmentsTested 3 distinct alcohol treatments
Cognitive Behavioral Treatment (CBT) (12/12 Cognitive Behavioral Treatment (CBT) (12/12 wks)wks)
Twelve Step Facilitation (TSF) (12/12 wks)Twelve Step Facilitation (TSF) (12/12 wks) Motivational Enhancement Therapy (MET) (4/12 Motivational Enhancement Therapy (MET) (4/12
wks)wks)
Examined 21 hypothesized matching effects Examined 21 hypothesized matching effects and over 30 baseline predictors of drinkingand over 30 baseline predictors of drinking
Comprised 9 centers with over 20 sites and Comprised 9 centers with over 20 sites and 75 therapists 75 therapists
Included 952 outpatients and 774 aftercare Included 952 outpatients and 774 aftercare patientspatients
Project MATCH Research Group. J Stud Alcohol. 1997;58:7.
Alcohol Impairment at Alcohol Impairment at BaselineBaseline
Outpatient Aftercare
Percent of Days Abstinent 34.3 26.8
Drinks per Drinking Day 13.5 20.5
No. of SCID Symptoms 5.77 6.79
Prior IP Alcohol Treatment 45.0% 58.3%
Number of Participants 952 774
Predictors of Drinking at Predictors of Drinking at Months 4-15Months 4-15Outpatient p values Aftercare p values
Attribute PDA DDD PDA DDD
Alcohol involvement (+).002
Gender (Male) (-).004 (+).035
MotivationalReadinesss
(+)<.001 (-)<.001
Support for Drinking (-).005 (+).026 (+).024
AASE (+).0003 (-).0002
Temptation – AASE(Highly Tempted)
(-).0004 (+).0003 (-).0429 (+).0019
Alcohol Dependence (+) .002
Alcohol-specificreadiness
(+).0001 (-).014
Religious beliefs andbackground
(-) .044 (+).011
Predictors of Drinking at 3-year Predictors of Drinking at 3-year Follow-UpFollow-Up
Outpatient p values
Attribute PDA DDD
Alcohol involvement (+).0001 (-).0001
Alcohol Dependence (+).0001
Meaning Seeking (+).0106
Religiousity (-).0012
Prior engagement in AA (+).0144
Motivational Readiness (+).0001 (-).0001
Readiness to Change (+).0001 (-).0092
AASE (-).0006
Temptation – AASE (Highly Tempted) (+).0024
Social Functioning (-).0051
Type of Alcoholic (+).0016
Mean Percent Days Mean Percent Days Abstinent as a Function Abstinent as a Function
of Time (Outpatient)of Time (Outpatient)
0102030405060708090
100
-2 -1 0 4 5 6 7 8 9 10 11 12 13 14 15
CBT MET TSF
End of Treatment Process End of Treatment Process Profiles Predict Outcomes Profiles Predict Outcomes
Client status during follow-up period:Client status during follow-up period: AbstinentAbstinent Moderate drinkingModerate drinking Heavier drinkingHeavier drinking
Client Profile on Stage of change Client Profile on Stage of change Subscales, Temptation to Drink, Subscales, Temptation to Drink, Abstinence Self-Efficacy, Experiential Abstinence Self-Efficacy, Experiential and Behavioral Processes of Changeand Behavioral Processes of Change
TTM = Transtheoretical model
Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.
TTM Profile: TTM Profile: Outpatient PDA BaselineOutpatient PDA Baseline
Pre Con Act Main Conf Temp
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
TTM variables
Sta
nd
ard
sco
res Abstinent Moderate Heavier
-0.8-0.6-0.4-0.2
00.20.40.60.8
Pre Con Act Main Conf Temp Exp Beh
PDA = percent days abstinent
Carbonari, JP & DiClemente, CC. J Consult and Clin Psych. 2000; 68:810.
TTM Variables
Sta
nd
ard
Sco
res
Abstinent Moderate Heavier
TTM Profile: TTM Profile: Outpatient PDA Post-Outpatient PDA Post-
treatment treatment
Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.
TTM Profile: TTM Profile: Aftercare PDA BaselineAftercare PDA Baseline
Pre Con Act Main Conf Temp-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
TTM variables
Sta
nd
ard
sco
res
Abstinent Moderate Heavier
Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
Pre Con Act Main Conf Temp Exp Beh
TTM variables
Sta
nd
ard
sco
res
Abstinent Moderate Heavier
TTM Profile: TTM Profile: Aftercare PDA Post-Aftercare PDA Post-
treatmenttreatment
WHERE TO LOOK FOR WHERE TO LOOK FOR MECHANISMS OF CHANGEMECHANISMS OF CHANGE
CLIENT PROCESS OF CHANGECLIENT PROCESS OF CHANGE ACCOMPLISHMENT OF CRITICAL STAGE ACCOMPLISHMENT OF CRITICAL STAGE
TASKS AND LEARNING OVER TIMETASKS AND LEARNING OVER TIME ENGAGEMENT OF CLIENT PROCESSES OF ENGAGEMENT OF CLIENT PROCESSES OF
CHANGECHANGE SELF-REGULATION AND SELF-CONTROL SELF-REGULATION AND SELF-CONTROL
MECHANISMSMECHANISMS HOW INTERVENTION ACTIVITIES ENGAGE OR HOW INTERVENTION ACTIVITIES ENGAGE OR
ACTIVATE THESE PROCESSES AND ASSIST IN ACTIVATE THESE PROCESSES AND ASSIST IN ACCOMPLISHMENT OF CHANGE TASKSACCOMPLISHMENT OF CHANGE TASKS
INVOLVEMENT AND MANAGEMENT OF INVOLVEMENT AND MANAGEMENT OF CONTEXTUAL PROBLEMSCONTEXTUAL PROBLEMS
Where Do We Go From Where Do We Go From Here?Here?
Stepped care approachesStepped care approaches Matching techniques of treatment to Matching techniques of treatment to
client problem and process of change client problem and process of change dimensionsdimensions
Integrating formal and self-help Integrating formal and self-help approaches as well as different approaches as well as different treatment approachestreatment approaches
Client-titrated treatmentClient-titrated treatment Treatment shifts from being Treatment shifts from being reactive reactive
and and regimentedregimented to becoming to becoming proactiveproactive and and personalizedpersonalized
DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; 2003.
Multiple Problems Complicate the Process of Change
The Context of Change:A Figure Ground Perspective
CONTEXT OF CHANGECONTEXT OF CHANGE
I. SITUATIONAL RESOURCES AND PROBLEMS
II. COGNITIONS AND BELIEFS
III. INTERPERSONAL RESOURCES/PROBLEMS
IV. FAMILY & SYSTEMS
V. ENDURING PERSONAL CHARACTERISTICS
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
Stages by Context Analysis
PreC Cont Prep Action Maint
I Sit
II Cog
III Rel
IV Sys
V Per
Experiential Processes
Behavioral Processes
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
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
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
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
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
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
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
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
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
Multiple Problems Need an Integrated Continuum of Care
Multi-Service Center
Homeless Encampment
Multi-Service Center
Multi-Service Center
Sheltered Employment
Day Rehabiliation
Community Living
HHISN
Residential Treatment
Crisis Residential
Emergency Shelter
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
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?
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
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
A Consumer-Centered Perspective
Critical Shifts in Perspective fromPathology to ProblemsPulling or Pushing to
PersuasionPatient to PartnerProvider to FacilitatorOutcomes to OptionsManagement to Motivation &
MarketingReactive to Proactive Care
Examples
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?
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
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 Client’s Change Process requires patience and persistence; optimism and realism; and the perspective of a coach of a minor league team