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Embracing Change: Promoting Recovery Carlo C. DiClemente, Ph.D. ABPP University of Maryland, Baltimore County www.umbc.edu/psych/habits www.mdquit.org.

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Presentation on theme: "Embracing Change: Promoting Recovery Carlo C. DiClemente, Ph.D. ABPP University of Maryland, Baltimore County www.umbc.edu/psych/habits www.mdquit.org."— Presentation transcript:

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

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

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

4 Traditional Models for Understanding Addictions  Social/Environmental Models  Genetic/Physiological Models  Personality/Intra-psychic Models  Coping/Social Learning Models  Conditioning/Reinforcement Models  Compulsive/Excessive Behavior Models  Integrative Bio-Psycho-Social Models

5 Etiology of Addictions Genetics Physiology Environment Personality Social Influences Coping/Expectancies Initial UseSelf- Regulated Use 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

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

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

8 SUCCESSFUL RECOVERY FROM ADDICTIONS  Occurs over long periods of time  Often involves multiple attempts and treatments  Consists of self change and/or treatment  Involves changes in other areas of psychosocial functioning

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

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

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

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

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

14 Motivation and the Change Process  Clients are not unmotivated! They either are just motivated to engage in behaviors that others consider harmful and problematic or are not ready to begin behaviors that we think would be helpful.  People who seem to have everything to gain from changing a behavior or doing some activity to relieve negative feelings or consequences do not do these things  Excellent and effective self-management techniques are not used even after they are taught to people who come voluntarily for help DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; CSAT Treatment Improvement Protocol Number 35. Enhancing Motivation for Change in Substance Abuse Treatment. 1999;DHHS no. (SMA)

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

16 Motivation Is Critical for Successful Change  Both brief interventions and alcoholism and substance abuse treatment research indicate a key role for patient motivation  In many drinking reduction studies motivation predicts decreases (Delta study of Shock Trauma patients)  Project MATCH client initial motivation measured by multidimensional stage measures predicted drinking out to 3 years post-treatment for outpatients CSAT Treatment Improvement Protocol Number 35. Enhancing Motivation for Change in Substance Abuse Treatment. 1999;DHHS no. (SMA) Project MATCH Research Group. Alcohol Clin Exp Res. 1998;22:1300.

17 WHY ARE PEOPLE NOT MOTIVATED TO CHANGE?  NOT CONVINCED OF THE PROBLEM OR THE NEED FOR CHANGE – UNMOTIVATED  NOT COMMITTED TO MAKING A CHANGE – UNWILLING  ACTUAL OR PERCEIVED ABILITY TO MAKE A CHANGE – UNABLE  DIFFERENT PARTS OF A PROCESS

18 HOW PEOPLE CHANGE

19 The Transtheoretical Model of Intentional Behavior Change STAGES OF CHANGE PRECONTEMPLATION  CONTEMPLATION  PREPARATION  ACTION  MAINTENANCE PROCESSES OF CHANGE COGNITIVE/EXPERIENTIALBEHAVIORAL Consciousness RaisingSelf-Liberation Self-RevaluationCounter-conditioning Environmental ReevaluationStimulus Control Emotional Arousal/Dramatic ReliefReinforcement Management Social LiberationHelping Relationships CONTEXT OF CHANGE 1. Current Life Situation 2. Beliefs and Attitudes 3. Interpersonal Relationships 4. Social Systems 5. Enduring Personal Characteristics MARKERS OF CHANGE Decisional Balance Self-Efficacy/Temptation

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

21 Stage of Change Labels and Tasks  Precontemplation Not interested  Contemplation Considering  Preparation Preparing  Action Initial change  Maintenance Sustained change  Interested, concerned and willing to consider  Risk-reward analysis and decision making  Commitment and creating a plan that is effective/acceptable  Implementing plan and revising as needed  Consolidating change into lifestyle DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; DiClemente. J Addictions Nursing. 2005;16:5.

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

23 A Consumer perspective  A Consumer Perspective to Care necessitates a shift in emphasis from a concentration on our treatments to a concentration on our consumers and their processes to regain some balance  Most treatment services provide good, effective action-oriented treatments  Many of our consumers are unmotivated, overwhelmed with multiple problems, feeling hopeless, or simply not interested or engaged by our services DiClemente & Velasquez. Motivational interviewing and the stages of change. In: Miller & Rollnick, eds. Motivational Interviewing, 2nd ed. NY: Guilford Publications; 2002:201.

24 Understanding Motivation and Movement through the Stages of Change UNMOTIVATED UNWILLING UNABLE Precontemplation Contemplation Preparation Action Maintenance This Process is as relevant for organizations and service providers as it is for Individuals with mental health and addiction problems.

25 Tasks and Goals for each of the Stages of Change  PRECONTEMPLATION - The state in which there is little or no consideration of change of the current pattern of behavior in the foreseeable future.  TASKS: Increase awareness of need for change and concern about the current pattern of behavior; envision possibility of change  GOAL: Serious consideration of change for this behavior

26 WHAT INDIVIDUALS or ORGANIZATIONS MUST REALIZE  MY BEHAVIOR IS PROBLEMATIC OR EXCESSIVE  MY DRUG USE IS CAUSING PROBLEMS IN MY LIFE  I HAVE OR AM AT RISK FOR SERIOUS PROBLEMS  MY BEHAVIOR IS INCONSISTENT WITH SOME IMPORTANT VALUES  MY LIFE IS OUT OF CONTROL  WHAT WE ARE DOING IS NOT EFFECTIVE IN MEETING THE NEEDS OF OUR CLIENTS  OUR APPROACH IS COSTING TOO MUCH FOR THE OUTCOMES WE ARE GETTING  THERE ARE SERIOUS PROBLEMS IN OUR PROCEDURES, PROGAMMMING,OR PRODUCT

27 Key Issues and Intervention Considerations  Coercion or Courts cannot do it alone  Confrontation breeds Resistance  Motivation not simply Education is needed  Intrinsic and Extrinsic Motivations  Proactive versus Reactive Approaches  Smaller versus Larger goals and Motivation

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

29 Decisional Balance Worksheet NO CHANGE PROS (Status Quo) _______________ CONS (Change) _______________ CHANGE CONS (Status Quo) _______________ PROS (Change)_______________ _______________

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

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

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33 Tasks and goals for each of the Stages of Change  PREPARATION – The stage in which the individual or organization makes a commitment to take action to change the behavior pattern and develops a plan and strategy for change.  TASKS: Increasing commitment and creating a change plan.  GOAL: An action plan to be implemented in the near term.

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35 Key Issues and Intervention Considerations  Effective, Acceptable and Accessible Plans  Setting Timelines for Implementation  Building Commitment and Confidence  Creating Incentives  Developing and Refining Skills Needed to Implement the Plans  Treatment Plan and Change Plan

36 WILLING TO MAKE CHANGE  COMMITMENT TO TAKE ACTION  SPECIFIC ACCEPTABLE ACTION PLAN  TIMELINE FOR IMPLEMENTING PLAN  ANTICIPATION OF BARRIERS  BUT YOU STILL HAVEN’T DONE IT YET

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

38 Key Issues and Intervention Considerations  Flexible and Responsive Problem Solving  Support for Change  Reward Progress  Create Consequences for Failure to Implement  Continue Development and Refining Skills Needed to Implement the Plan

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

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

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

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43 Relapse and Recycling - Slipping Back to Previous Behavior and Trying to Resume Change Characteristics:  The person or organizations has failed to implement the plan or is re-engaged in the previous behavior  After failing to implement or reverting to previous behavior, there is re-entry to precontemplation, contemplation, preparation stages  Sense of failure and discouragement about motivation or ability to change

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

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

46 Theoretical and practical considerations related to movement through the Stages of Change MotivationDecision-Making Self-efficacy Precontemplation Contemplation Preparation Action Maintenance Personal Environmental Decisional Cognitive Behavioral Organizational Concerns Pressure BalanceExperiential Processes (Pros & Cons)Processes Recycling Relapse

47 Precontemplation Increase awareness of need to change Contemplation Motivate and increase confidence in ability to change Action Reaffirm commitment and follow-up Termination Stages of Change Model Relapse Assist in Coping Maintenance Encourage active problem-solving Preparation Negotiate a plan

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49 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 Actively changing my drinking Planning and making a commitment to change my drinking

50 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

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

52 Processes of Change  Experiential Processes Concern the person’s thought processes Generally seen in the early Stages of Change  Behavioral Processes Action oriented Usually seen in the later Stages of Change

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

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

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56 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 PROCESSESPROCESSES

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

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59 A Transtheoretical Model Group Therapy Each group session is based on a specific TTM process of change. Motivational Interviewing counseling strategies are used throughout the sessions.

60 Thinking About Changing Substance Use Precontemplation-Contemplation-Preparation Sequence 1.The Stages of Change 2.A Day in the Life - Consciousness Raising 3.Physiological Effects of Alcohol - Consciousness Raising 4.Physiological Effects of Drugs - Consciousness Raising 5.Expectations- Consciousness Raising 6.Expressions of Concern -Self- Reevaluation, Dramatic Relief

61 Making Changes in Substance Abuse Action/Maintenance Sequence 1. The Stages of Change 2. 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

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

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

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65 THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY ADDICTION RECOVERY Sustained Cessation Dependence PROCESSES, CONTEXT AND MARKERS OF CHANGE Dependence PCCPAAM PCCPAAM

66 Theoretical and practical considerations related to Prevention and Stages of INITIATION Expectancies/Beliefs Decision-Making Self-efficacy Precontemplation Contemplation Preparation Action Maintenance Personal Environmental Decisional Cognitive/Behavioral Concerns Pressure Balance Experiential Processes (Pros & Cons) Processes ExperimentationCasual use Regular Use Dependence

67 PREVENTION OF INITIATION OF ADDICTION PC - C C - PA PA - A A - M POPULATION PREVENTION AT- RISK PREVENTION ALREADY AFFLICTED

68 A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLEN TYPE OF BEHAVIOR STAGE OF INITIATION PCCPAAM ALCOHOL NICOTINE MARIJUANA HEROIN COCAINE AMPHETAMINES LSD GAMBLING EATING DISORDER X X X X X X X X X

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

70  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)

71 2002 Maryland Youth Tobacco Survey (MYTS)  Secondary data analyses of the Maryland Youth Tobacco Survey (MYTS, 2002)  Classroom-based survey, administered throughout Maryland  Participants were public school students (N = 56,820), between the ages of 12 and 17 years  The majority of the sample was Caucasian (66%) and over half were Male (53%), with a median age of 14 years

72 Youth were classified into Stages of Smoking Initiation & Levels of Experience Level of Experience is analogous to prevalence measures with Never Smoked = ‘Inexperienced’; Smoked Less than 6 days = ‘Exposed’; Smoked 6+ days = ‘Experienced’  Youth were classified according to their Stage of Smoking Initiation using Lifetime Smoking  Ever smoked Future Intentions  Smoke in next year? Current Smoking  # of days smoked past 30 days Duration of Current Smoking  How long smoked current rate?

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

74 Table 1. Distributions of Stage of Smoking Initiation & Level of Experience n% Levels of Experience Inexperienced29, Exposed8, Experienced9, Stages of Smoking Initiation Precontemplation29, Contemplation10, Preparation2, Action1, Maintenance3,9508.3

75 Distribution of Stages of Smoking Initiation by Wave & School Status MS 2000 HS 2000 MS 2002HS 2002 PC14,57614,21818,37118,263 C4,0396,6874,5957,826 P5391, ,695 A3741, ,587 M2553, ,646

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77 Table 4. Odds-Ratios of Stages of Smoking Initiation and Level of Experience for Intention Risk Factor: Accept Cigarette Offer from Best Friend ORCI Level of Experience Inexperienced1.0-- Exposed5.6*5.2 – 6.1 Experienced66.4*61.7 – 71.5 Stages of Initiation Precontemplation1.0-- Contemplation27.1*24.2 – 30.5 Preparation258.1*223.6 – Action686.6*568.8 – Maintenance1,780.7*1,480.7 – 2,141.5 * p<.001

78 Table 3. Odds-Ratios of Stages of Smoking Initiation & Level of Experience for Attitudinal Risk Factor ‘Smokers Have More Friends’ ORCI Level of Experience Inexperienced1.0-- Exposed1.8*1.7 – 1.9 Experienced2.6*2.5 – 2.8 Stages of Initiation Precontemplation1.0-- Contemplation2.1*2.0 – 2.2 Preparation4.1*3.8 – 4.5 Action3.7* Maintenance3.6*3.3 – 3.9 * p<.001

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80 Adolescent Smoking in Maryland: Stage Status / Transitions

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

82 Project MATCH Tested 3 distinct alcohol treatments Tested 3 distinct alcohol treatments Cognitive Behavioral Treatment (CBT) (12/12 wks) Cognitive Behavioral Treatment (CBT) (12/12 wks) Twelve Step Facilitation (TSF) (12/12 wks) Twelve Step Facilitation (TSF) (12/12 wks) Motivational Enhancement Therapy (MET) (4/12 wks) Motivational Enhancement Therapy (MET) (4/12 wks) Examined 21 hypothesized matching effects and over 30 baseline predictors of drinking Examined 21 hypothesized matching effects and over 30 baseline predictors of drinking Comprised 9 centers with over 20 sites and 75 therapists Comprised 9 centers with over 20 sites and 75 therapists Included 952 outpatients and 774 aftercare patients Included 952 outpatients and 774 aftercare patients Project MATCH Research Group. J Stud Alcohol. 1997;58:7.

83 Alcohol Impairment at Baseline

84 Predictors of Drinking at Months 4-15

85 Predictors of Drinking at 3-year Follow-Up

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

87 End of Treatment Process Profiles Predict Outcomes Client status during follow-up period: Client status during follow-up period: Abstinent Abstinent Moderate drinking Moderate drinking Heavier drinking Heavier drinking Client Profile on Stage of change Subscales, Temptation to Drink, Abstinence Self-Efficacy, Experiential and Behavioral Processes of Change Client Profile on Stage of change Subscales, Temptation to Drink, Abstinence Self-Efficacy, Experiential and Behavioral Processes of Change

88 TTM = Transtheoretical model Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810. TTM Profile: Outpatient PDA Baseline PreConActMainConfTemp TTM variables Standard scores AbstinentModerateHeavier

89 PreConActMainConfTempExpBeh PDA = percent days abstinent Carbonari, JP & DiClemente, CC. J Consult and Clin Psych. 2000; 68:810. TTM Variables Standard Scores AbstinentModerateHeavier TTM Profile: Outpatient PDA Post-treatment

90 Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810. TTM Profile: Aftercare PDA Baseline PreConActMainConfTemp TTM variables Standard scores AbstinentModerateHeavier

91 Carbonari & DiClemente. J Consult Clin Psychol. 2000;68: PreConActMainConfTempExpBeh TTM variables Standard scores AbstinentModerateHeavier TTM Profile: Aftercare PDA Post-treatment

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

93 Where Do We Go From Here? Stepped care approaches Stepped care approaches Matching techniques of treatment to client problem and process of change dimensions Matching techniques of treatment to client problem and process of change dimensions Integrating formal and self-help approaches as well as different treatment approaches Integrating formal and self-help approaches as well as different treatment approaches Client-titrated treatment Client-titrated treatment Treatment shifts from being reactive and regimented to becoming proactive and personalized Treatment shifts from being reactive and regimented to becoming proactive and personalized DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; 2003.

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

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

96 Typical Complications 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

97 Stages by Context Analysis Experiential Processes Behavioral Processes

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

99 Evaluating Client Problems  How serious is the problem? Not Evident Not Serious Serious Very Serious Extremely Serious  When and What Intervention is needed? Needs no intervention Needs intervention in the future Needs Secondary Intervention Needs primary intervention but can wait Needs immediate intervention

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

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

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

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

104 SUMMARY OF RECENT STUDIES  Measures of readiness and other process variables demonstrated reliability and construct validity among SMI patients with tobacco dependence and cocaine abuse.  Schizophrenia patients appear to be using the same or similar process of change in managing their tobacco and cocaine abuse and recovery as other drug abusing patients  Although neurocognitive deficits among patients with schizophrenia can interfere with access to some higher order cognitive functions and may modulate the process, these patients appear to access and use the intentional process of change as described in the TTM in managing and recovering from substance abuse. DiClemente, Bellack, Nidecker, Gearon, 2003 AABT

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

106 Challenges for Change in a Mentally Ill Population  Multiple Chronic conditions  Shifting Motivation  Cognitive Impairment  Self Regulation Problems  Situational/Environmental Issues  System of Care Problems

107 Multiple Problems Need an Integrated Continuum of Care

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

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

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

111 Why Do We Need Consumer- Centered Care for Individuals with Mental and Physical Illnesses?  They have choices about services  They have to make informed choices about treatments (especially as the options increase)  They can bring lawsuits  They have to comply with any treatment  They are in charge of their personal process of change

112 A Consumer-Centered Perspective  Critical Shifts in Perspective from Pathology to Problems Pulling or Pushing to Persuasion Patient to Partner Provider to Facilitator Outcomes to Options Management to Motivation & Marketing Reactive to Proactive Care  Examples

113 Changing Substance Abuse and Mental Health Systems  Pogo  “We have met the enemy and it is us”  How do systems change?  What if we adopted a consumer perspective?  What is needed: Modification or Transformation?

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

115 Concluding Thoughts  Change is a complicated process  Need a roadmap  Need both an Overview of the larger process as well as a Focused view of a particular client  Negotiating Change and Entering the Client’s Change Process requires patience and persistence; optimism and realism; and the perspective of a coach of a minor league team


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