Embracing Change: Promoting Recovery

Embracing Change: Promoting Recovery
Carlo C. DiClemente, Ph.D. ABPP University of Maryland, Baltimore County

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
Conditioning Social Influences Genetics Abuse Physiology Personality Initial Use Self-RegulatedUse 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

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 Chassin and Colleagues; Jessor and Colleagues; Schulenberg et al., Dennis Wholley Courage to Change Anne Fletcher, Sober for Good

Happens over a Period of Time Has a Variable Course
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)

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 Bullets 2 and 4 have no verbs—a little unclear. CSAT Treatment Improvement Protocol Number 35. Enhancing Motivation for Change in Substance Abuse Treatment. 1999;DHHS no. (SMA) 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 These are different phenomena and indicate that there are different parts or aspects of making a successful behavior change

HOW PEOPLE CHANGE

PRECONTEMPLATION  CONTEMPLATION  PREPARATION  ACTION  MAINTENANCE
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/Temptation The perspective I use to help understand the personal process of change that I have been researching for the past 20 plus years is the Transtheoretical Model. This model tries to identify critical dimensions that seem to impact behavior change and describe these dimensions and interactions among these dimensions. This is not presented as if these were the only dimensions but in my work they seem to be relevant and important ones. It matters if while I am trying to change one behavior and engage in the processes that would help me complete the tasks of each of these stages well enough to make progress there are other problems or resources in various areas of my life that would help me or hinder me in engaging in the processes and completing the tasks. The Markers are signposts that seem to be important at different parts of the process. Not clear if they should be called moderators, mediators, mechanisms or simply markers of the change process. Again these are not the only ones possible, they are just ones we have studied.

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; 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 for Individuals 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 Mandated treatment produces modest outcomes similar to “voluntary” clients but treatment system must be trained to motivate the mandated. Promise only what you will do, do what you promise Consequences teach but foxhole motivation is ephemeral New motivational approaches show great promise to promote change Harm reduction needs to be done in a manner that promotes motivation to change Smaller versus larger goals represents issue of harm reduction or in organizations the get what you can while trying to get what you want.

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) _______________ _______________

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 Personal values,family influences, and important events are critical in the individual’s consideration of change. Consequences can teach but first must reach the individual where he or she lives. Values clarification and finding meaningful goals Ambivalence is normal Providing a vision of the possible that seems realistic Cultural competence needed to reach the personal considerations for each substance abuser. Programs for Native Americans using sweat lodges, for African Americans using a culturally sensitive engagement strategy, family values emphasis for Hispanic clients

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

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.

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 Action takes 3 to 6 months Revising the plan needs responsive treatment options Making sure there is support for change in the environment or seeking alternative environments when the natural environment is saturated with drugs and alcohol. When some of the issues that were in the Background become foreground, providing resources and options for assistance to protect the action stage activity. Multisystemic Family Therapy. Bringing the family into the treatment whenever that is feasible and reasonable. It is particularly important to include any significant other that is in the picture. SO substance abuse is the most potent relapse predictor. Contingency management has shown great promise if used well. Payments for clean urines, contingencies for housing, increasing social support, addressing the network. Contingencies include consequences, loss of privileges, etc.

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

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).

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 Action takes 3 to 6 months Revising the plan needs responsive treatment options Making sure there is support for change in the environment or seeking alternative environments when the natural environment is saturated with drugs and alcohol. When some of the issues that were in the Background become foreground, providing resources and options for assistance to protect the action stage activity. Multisystemic Family Therapy. Bringing the family into the treatment whenever that is feasible and reasonable. It is particularly important to include any significant other that is in the picture. SO substance abuse is the most potent relapse predictor. Contingency management has shown great promise if used well. Payments for clean urines, contingencies for housing, increasing social support, addressing the network. Contingencies include consequences, loss of privileges, etc.

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.

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 Maintaining change requires a long-term perspective Unrealistic expectations from residential, inpatient, and intensive programs that last anywhere from 1 to 12 weeks. Resolving associated problems and other life context problems critical to support the change. Life must become different.

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

The reality of relapse must be incorporated into the programs and policies for treatment of substance abuse. Relapse is not a problem of substance abuse; it is a problem of behavior change A learning perspective of successive approximation rather than one trial learning is needed.

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).

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 Disappointment leads to blame and guilt Abstinence must be seen as a goal but not treated as a sacred state. It must become second nature and part of an entire lifestyle rather that a constantly sought after state. Don’t restrict recycling but there is a difference between someone who is truly recycling and those who are simply spinning their wheels because there is some singificant flaw in the process of change. Hope is not foolhardy. Lessons from smoking cessation

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

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

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

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 Behavioral 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)

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

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.

A Day in the Life- Consciousness Raising
Thinking About Changing Substance Use Precontemplation-Contemplation-Preparation Sequence The Stages of Change A Day in the Life- Consciousness Raising Physiological Effects of Alcohol-Consciousness Raising Physiological Effects of Drugs-Consciousness Raising Expectations-Consciousness Raising Expressions of Concern-Self-Reevaluation, Dramatic Relief

Making Changes in Substance Abuse Action/Maintenance 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

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
Dependence PC C PA A M PROCESSES, CONTEXT AND MARKERS OF CHANGE PC C PA A M Dependence Sustained Cessation RECOVERY

Expectancies/Beliefs Decision-Making Self-efficacy
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 ADDICTION
PC - C C - PA PA - A A - M ALREADY AFFLICTED POPULATION PREVENTION AT- RISK PREVENTION

A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLEN
TYPE OF BEHAVIOR STAGE OF INITIATION PC C PA A M ALCOHOL X NICOTINE X MARIJUANA X X HEROIN X COCAINE AMPHETAMINES X X LSD GAMBLING X EATING DISORDER X

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

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

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? We assessed both level of experience with smoking and the Stages of Smoking Initiation Level of Experience is analogous to prevalence measures while the Stages incorporate experience with cigarette smoking as well as intentions about smoking We considered youth who have never smoked in their lifetime as Inexperienced, youth who have smoked less than 6 cigarettes in their lifetime as Exposed and youth who have smoked 6 or more cigarettes in their lifetime as Experienced with smoking The next few slides will demonstrate how we classified the youth according to their level of experience with cigarette smoking and their stage of smoking initiation

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?” Prior to advocating switching from Prevalence measures to the Stages of Smoking Initiation Add dummy-coded such that for the Stages of Smoking Initiation youth in Precontemplation are the referent group & for Level of Experience, Inexperienced youth are the referent group

Table 1. Distributions of Stage of Smoking Initiation & Level of Experience
% 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 This table shows the Ns and percentages of youth in each of the classifications: Level of Experience & the Stages of Smoking Initiation. All youth in Precontemplation from the previous slides (incorporating Level of Experience) were collapsed to form 1 group of Precontemplators All youth in Contemplation were collapsed to form 1 group of Contemplators and so on Resulting in the 5 Stages of Smoking Initiation

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

Significant decrease in # of friends from Wave1 to Wave2 (except Middle School students in Contemplation & Middle School students in Maintenance) Almost 3 out of 4 friends smoke # of friends grows as habit grows interactional

* p<.001 OR CI Level of Experience Inexperienced 1.0 -- Exposed
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 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 We examined the Odds Ratios for key risk factors associated with adolescent cigarette smoking Level of Experience is presented first and then the Stages of Smoking Initiation For Level of Experience the Odds Ratios, the Inexperienced group is the referent group. Thus, youth in the Exposed group were 5.6 times more likely to report that they would smoke a cigarette offered from their best friend For the Stages, Youth in Contemplation were 27.1 times more likely to report they would smoke a cigarette offered from their best friend * p<.001

* p<.001 OR CI Level of Experience Inexperienced 1.0 -- Exposed
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 Contemplation 2.1* 2.0 – 2.2 Preparation 4.1* 3.8 – 4.5 Action 3.7* Maintenance 3.6* 3.3 – 3.9 Table 3 also presents Odds Ratios with the interpretation being the same as the last slide What is interesting about this table is for the Stages of Smoking Initiation, youth in Preparation report the highest OR (4.1) suggesting they may be more vulnerable to social influences relative to the other stages. Similarly, examining the ORs for Level of Experience, this relation is not found * p<.001

Highlight Preparation youth –
Demonstrates that not everything goes up – clearly youth in Preparation look more like regular smokers and even exceed regular smokers in terms of their attitudes If we collapse youth in Preparation with the youth in Action and Maintenance to form ‘current smokers’ group we would miss these vulnerable youth

Adolescent Smoking in Maryland: Stage Status / Transitions

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.

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. 1997;58:7.

Alcohol Impairment at Baseline

Predictors of Drinking at Months 4-15

Predictors of Drinking at 3-year Follow-Up

Mean Percent Days Abstinent as a Function of Time (Outpatient)

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

TTM Profile: Outpatient PDA Baseline
-0.8 -0.6 -0.4 -0.2 0.2 0.4 0.6 0.8 TTM variables Standard scores Abstinent Moderate Heavier Pre Con Act Main Conf Temp TTM = Transtheoretical model Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

TTM Profile: Outpatient PDA Post-treatment
Abstinent Moderate Heavier 0.8 0.6 0.4 0.2 Standard Scores -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; 68:810.

TTM Profile: Aftercare PDA Baseline
-0.8 -0.6 -0.4 -0.2 0.2 0.4 0.6 0.8 TTM variables Standard scores Abstinent Moderate Heavier Pre Con Act Main Conf Temp Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

TTM Profile: Aftercare PDA Post-treatment
-0.8 -0.6 -0.4 -0.2 0.2 0.4 0.6 0.8 Pre Con Act Main Conf Temp Exp Beh TTM variables Standard scores Abstinent Moderate Heavier Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

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

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.

Multiple Problems Complicate the Process of Change
The Context of Change: A Figure Ground Perspective

I. SITUATIONAL RESOURCES AND PROBLEMS
CONTEXT OF CHANGE I. SITUATIONAL RESOURCES AND PROBLEMS II. COGNITIONS AND BELIEFS III. INTERPERSONAL RESOURCES/PROBLEMS IV. FAMILY & SYSTEMS V. ENDURING PERSONAL CHARACTERISTICS

Typical Complications for Individual 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
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

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 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

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

Embracing Change: Promoting Recovery

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Embracing Change: Promoting Recovery

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