Presentation on theme: "Embracing Change: Promoting Recovery"— Presentation transcript:
1 Embracing Change: Promoting Recovery Carlo C. DiClemente, Ph.D. ABPPUniversity of Maryland, Baltimore County
2 Overview Addiction and Change Motivation and the Change Process Stages and Tasks of ChangeMechanisms (Client) & Strategies (Provider) of changeTreatment PlanningRecycling and Challenges of Change in Individuals with Multiple Problems and Mental Illness
3 What are Addictions?Habitual patterns of intentional, appetitive behaviorsBecome excessive and produce serious consequencesStability of these problematic behavior patterns over timeInterrelated physiological and psychological componentsAddicted individuals have difficulty modifying and stopping them
4 Traditional Models for Understanding Addictions Social/Environmental ModelsGenetic/Physiological ModelsPersonality/Intra-psychic ModelsCoping/Social Learning ModelsConditioning/Reinforcement ModelsCompulsive/Excessive Behavior ModelsIntegrative Bio-Psycho-Social Models
5 Etiology of Addictions ConditioningSocial InfluencesGeneticsAbusePhysiologyPersonalityInitial UseSelf-RegulatedUseCoping/ExpectanciesEnvironmentDependenceReinforcementAll of these factors can have arrows to initial experience and then to any or all of the three patterns of use. Most could have arrows that demonstrate linear or reciprocal causality as well
6 Change the Integrating Principle No single developmental model or singular historical path can explain acquisition of and recovery from addictionsA 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 modelsChassin and Colleagues; Jessor and Colleagues; Schulenberg et al.,Dennis Wholley Courage to ChangeAnne Fletcher, Sober for Good
7 Happens over a Period of Time Has a Variable Course BECOMING ADDICTEDHappens over a Period of TimeHas a Variable CourseInvolves a Variety of Predictors that can be both Risk and Protective FactorsInvolves a Process of Change
8 SUCCESSFUL RECOVERY FROM ADDICTIONS Occurs over long periods of timeOften involves multiple attempts and treatmentsConsists of self change and/or treatmentInvolves changes in other areas of psychosocial functioning
9 Addiction and ChangeBoth acquisition of and recovery from an addiction require a personal journey through an intentional change processJourney influenced at various points by many of the factors identified in the previously reviewed etiological models
10 Addiction and ChangeBoth are influenced by personal decisional considerations and choicesPersonal choices are influenced by and, in turn, influence genetic, developmental, characterological, and social forcesBoth 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 addictionMultiple biological, social, individual, environmental factors influence transitions into and out of protective and problematic health behaviorsUnderstanding initiation and cessation of these behaviors requires a life course and a process of change perspective
12 MotivationMotivation can be considered the tipping point for making change happenNot a simple or single construct or best thought of as an “on-off” switchMost 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 tasksThe 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 eitherare just motivated to engage in behaviors that others consider harmful and problematic orare 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 thingsExcellent and effective self-management techniques are not used even after they are taught to people who come voluntarily for helpDiClemente. 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)
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 motivationIn 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 outpatientsBullets 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.
17 WHY ARE PEOPLE NOT MOTIVATED TO CHANGE? NOT CONVINCED OF THE PROBLEM OR THE NEED FOR CHANGE – UNMOTIVATEDNOT COMMITTED TO MAKING A CHANGE – UNWILLINGACTUAL OR PERCEIVED ABILITY TO MAKE A CHANGE – UNABLEDIFFERENT PARTS OF A PROCESSThese are different phenomena and indicate that there are different parts or aspects of making a successful behavior change
19 PRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE The Transtheoretical Model of Intentional Behavior ChangeSTAGES OF CHANGEPRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCEPROCESSES OF CHANGECOGNITIVE/EXPERIENTIAL BEHAVIORALConsciousness Raising Self-LiberationSelf-Revaluation Counter-conditioningEnvironmental Reevaluation Stimulus ControlEmotional Arousal/Dramatic Relief Reinforcement ManagementSocial Liberation Helping RelationshipsCONTEXT OF CHANGE1. Current Life Situation2. Beliefs and Attitudes3. Interpersonal Relationships4. Social Systems5. Enduring Personal CharacteristicsMARKERS OF CHANGEDecisional Balance Self-Efficacy/TemptationThe 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.
20 How Do People Change? People change voluntarily only when They become interested and concerned about the need for changeThey become convinced the change is in their best interest or will benefit them more than cost themThey organize a plan of action that they are committed to implementingThey take the actions necessary to make the change and sustain the change
21 Stage of Change Labels and Tasks PrecontemplationNot interestedContemplationConsideringPreparationPreparingActionInitial changeMaintenanceSustained changeInterested, concerned and willing to considerRisk-reward analysis and decision makingCommitment and creating a plan that is effective/acceptableImplementing plan and revising as neededConsolidating change into lifestyleDiClemente. 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 changeThese 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 changeThere 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 balanceMost treatment services provide good, effective action-oriented treatmentsMany of our consumers are unmotivated, overwhelmed with multiple problems, feeling hopeless, or simply not interested or engaged by our servicesDiClemente & 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 UNABLEPrecontemplation Contemplation Preparation Action MaintenanceThis Process is as relevant for organizations and service providers as it is forIndividuals 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 changeGOAL: Serious consideration of change for this behavior
26 WHAT INDIVIDUALS or ORGANIZATIONS MUST REALIZE MY BEHAVIOR IS PROBLEMATIC OR EXCESSIVEMY DRUG USE IS CAUSING PROBLEMS IN MY LIFEI HAVE OR AM AT RISK FOR SERIOUS PROBLEMSMY BEHAVIOR IS INCONSISTENT WITH SOME IMPORTANT VALUESMY LIFE IS OUT OF CONTROLWHAT WE ARE DOING IS NOT EFFECTIVE IN MEETING THE NEEDS OF OUR CLIENTSOUR APPROACH IS COSTING TOO MUCH FOR THE OUTCOMES WE ARE GETTINGTHERE ARE SERIOUS PROBLEMS IN OUR PROCEDURES, PROGAMMMING,OR PRODUCT
27 Key Issues and Intervention Considerations Coercion or Courts cannot do it aloneConfrontation breeds ResistanceMotivation not simply Education is neededIntrinsic and Extrinsic MotivationsProactive versus Reactive ApproachesSmaller versus Larger goals and MotivationMandated 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 promiseConsequences teach but foxhole motivation is ephemeralNew motivational approaches show great promise to promote changeHarm reduction needs to be done in a manner that promotes motivation to changeSmaller versus larger goals represents issue of harm reduction or in organizations the get what you can while trying to get what you want.
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.
30 Key Issues and Intervention Considerations Decisional Considerations are PersonalIncrease the Costs of the Status Quo and the Benefits of ChangeChallenge and Work with AmbivalenceEnvision the ChangeEngender Culturally Relevant Considerations that are MotivationalSee how families and larger organizations can influence change by providing incentives or putting up barriersMultiple problems or issues interfere and complicatePersonal 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 goalsAmbivalence is normalProviding a vision of the possible that seems realisticCultural 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
31 MOTIVATED TO CHANGEAdmit that the status quo is problematic and needs changingThe pros for change outweigh the consChange is in our own best interestThe future will be better if we make changes in these behaviorsBut this is only the first two steps toward making a change happen
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.
35 Key Issues and Intervention Considerations Effective, Acceptable and Accessible PlansSetting Timelines for ImplementationBuilding Commitment and ConfidenceCreating IncentivesDeveloping and Refining Skills Needed to Implement the PlansTreatment Plan and Change PlanAction takes 3 to 6 monthsRevising the plan needs responsive treatment optionsMaking 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.
36 WILLING TO MAKE CHANGE COMMITMENT TO TAKE ACTION SPECIFIC ACCEPTABLE ACTION PLANTIMELINE FOR IMPLEMENTING PLANANTICIPATION OF BARRIERSBUT 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 difficultiesGOAL: 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 SolvingSupport for ChangeReward ProgressCreate Consequences for Failure to ImplementContinue Development and Refining Skills Needed to Implement the PlanAction takes 3 to 6 monthsRevising the plan needs responsive treatment optionsMaking 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.
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 OverSupport and ReinforcementAvailability of Services or Resources to Address Other Issues In Contextual Areas of FunctioningOffering Valued Alternative Sources of ReinforcementInstitutionalization of changeMaintaining change requires a long-term perspectiveUnrealistic 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.
41 ABLE TO CHANGE Continued Commitment Skills to Implement the Plan Self Control Strength that is not exhausted by other problemsLong-term Follow ThroughIntegrating New Behaviors into Lifestyle or OrganizationCreating a New Behavioral NormNow you are getting there
42 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 changeA learning perspective of successive approximation rather than one trial learning is needed.
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 behaviorAfter failing to implement or reverting to previous behavior, there is re-entry to precontemplation, contemplation, preparation stagesSense of failure and discouragement about motivation or ability to change
44 Regression, Relapse and Recycling through the Stages Regression represents movement backward through the stagesSlips are brief returns to the prior behavior that represent a some problems in the action planRelapse is a return or re-engaging to a significant degree in the previous behavior after some initial changeAfter 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 ChangeDetermination despite delays and defeatsSupport Re-engagement in the Processes of ChangeRecycling or just Spinning WheelsHope and a Learning Perspective is NeededDisappointment leads to blame and guiltAbstinence 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
46 Theoretical and practical considerations related to movement through the Stages of Change Motivation Decision-Making Self-efficacyPrecontemplation Contemplation Preparation Action MaintenancePersonal Environmental Decisional Cognitive BehavioralOrganizationalConcerns Pressure Balance Experiential Processes(Pros & Cons) ProcessesRecycling Relapse
47 Stages of Change Model Precontemplation Increase awareness of need to changeContemplationMotivate and increase confidencein ability to changeRelapseAssist in CopingPreparationNegotiate a planMaintenanceEncourage activeproblem-solvingActionReaffirm commitmentand follow-upTermination
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 mydrinkingThinkingabout changing my drinkingPlanning andmaking acommitment to change my drinkingActivelychangingmy 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 ProcessesProvider Strategies and Services
51 Processes of ChangeChange engines that enable movement through the stages of changeDoing the right thing at the right timeCognitive/Experiential processes during early stagesBehavioral processes in preparation, action and maintenance
52 Processes of Change Experiential Processes Behavioral Processes Concern the person’s thought processesGenerally seen in the early Stages of ChangeBehavioral ProcessesAction orientedUsually 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 behaviorEmotional 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 valuesEnvironmental 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 changeStimulus 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” behaviorsReinforcement Management: Rewarding sought after new behaviors while extinguishing (eliminating reinforcements) from the status quo behaviorHelping Relationships: Seeking and Receiving support from others (family, friends, peers)
56 STAGES P R O C E S PROCESSES OF CHANGE by STAGE PC C PA A M Consciousness raisingSelf-reevaluationDramatic reliefHelping relationshipSelf- liberationContingencymanagementCounter-conditioningStimulus control
57 Provider Strategies What do you do to engage each of these processes? What do you do with less motivated patients that would activate some of these experiential processes?What do you do with you action oriented patients that activate the behavioral processes?
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 A Day in the Life- Consciousness Raising Thinking About Changing Substance Use Precontemplation-Contemplation-Preparation SequenceThe Stages of ChangeA Day in the Life- Consciousness RaisingPhysiological Effects of Alcohol-Consciousness RaisingPhysiological Effects of Drugs-Consciousness RaisingExpectations-Consciousness RaisingExpressions of Concern-Self-Reevaluation, Dramatic Relief
61 Making Changes in Substance Abuse Action/Maintenance Sequence The Stages of ChangeIdentifying “Triggers”- Stimulus ControlManaging Stress-CounterconditioningRewarding My Sucesses-Reinforcement ManagementEffective Communication-Counterconditioning, Reinforcement ManagementEffective 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?
65 THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY DependencePCCPAAMPROCESSES, CONTEXT AND MARKERS OF CHANGEPCCPAAMDependenceSustainedCessationRECOVERY
66 Expectancies/Beliefs Decision-Making Self-efficacy Theoretical and practical considerations related to Prevention and Stages of INITIATIONExpectancies/Beliefs Decision-Making Self-efficacyPrecontemplation Contemplation Preparation Action MaintenancePersonal Environmental Decisional Cognitive/ BehavioralConcerns Pressure Balance Experiential Processes(Pros & Cons) ProcessesExperimentation Casual use Regular Use Dependence
67 PREVENTION OF INITIATION OF ADDICTION PC - CC - PAPA - AA - MALREADYAFFLICTEDPOPULATIONPREVENTIONAT- RISKPREVENTION
68 A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLEN TYPE OFBEHAVIORSTAGE OF INITIATIONPCCPAAMALCOHOLXNICOTINEXMARIJUANAXXHEROINXCOCAINEAMPHETAMINESXXLSDGAMBLINGXEATING DISORDERX
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 behaviorWe can distinguish between prevention and treatment betterWe can target interventions to the process of change
70 2000 Maryland Youth Tobacco Survey (MYTS) Secondary data analyses of the Maryland Youth Tobacco Survey (MYTS, 2000)Classroom-based survey, administered throughout MarylandParticipants were public school students (N = 47,839), between the ages of 12 and 18 yearsThe majority of the sample was Caucasian (69%) and over half were Female (52%), with a median age of 14 years
71 2002 Maryland Youth Tobacco Survey (MYTS) Secondary data analyses of the Maryland Youth Tobacco Survey (MYTS, 2002)Classroom-based survey, administered throughout MarylandParticipants were public school students (N = 56,820), between the ages of 12 and 17 yearsThe 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 withNever Smoked = ‘Inexperienced’;Smoked Less than 6 days = ‘Exposed’;Smoked 6+ days = ‘Experienced’Youth were classified according to their Stage of Smoking Initiation usingLifetime SmokingEver smokedFuture IntentionsSmoke in next year?Current Smoking# of days smoked past 30 daysDuration of Current SmokingHow long smoked current rate?We assessed both level of experience with smoking and the Stages of Smoking InitiationLevel of Experience is analogous to prevalence measures while the Stages incorporate experience with cigarette smoking as well as intentions about smokingWe 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 smokingThe 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
73 Logistic RegressionsUsing 2000 MYTS data, Logistic Regressions were estimated for both the Stages of Smoking Initiation & Level of Experience3 Key Risk Factors from 3 Domains of Influence were selectedBehavioral“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 InitiationAdd 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
74 Table 1. Distributions of Stage of Smoking Initiation & Level of Experience %Levels of ExperienceInexperienced29,62861.9Exposed8,27417.3Experienced9,93720.8Stages of Smoking InitiationPrecontemplation29,06460.8Contemplation10,85822.7Preparation2,3114.8Action1,6563.5Maintenance3,9508.3This 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 PrecontemplatorsAll youth in Contemplation were collapsed to form 1 group of Contemplators and so onResulting in the 5 Stages of Smoking Initiation
75 Distribution of Stages of Smoking Initiation by Wave & School Status MS 2000HS 2000MS 2002HS 2002PC14,57614,21818,37118,263C4,0396,6874,5957,826P5391,7525601,695A3741,6873951,587M2553,3732802,646
76 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 growsinteractional
77 * 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 FriendORCILevel of ExperienceInexperienced1.0--Exposed5.6*5.2 – 6.1Experienced66.4*61.7 – 71.5Stages of InitiationPrecontemplationContemplation27.1*24.2 – 30.5Preparation258.1*223.6 – 298.0Action686.6*568.8 – 828.8Maintenance1,780.7*1,480.7 – 2,141.5We examined the Odds Ratios for key risk factors associated with adolescent cigarette smokingLevel of Experience is presented first and then the Stages of Smoking InitiationFor 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 friendFor 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
78 * 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’ORCILevel of ExperienceInexperienced1.0--Exposed1.8*1.7 – 1.9Experienced2.6*2.5 – 2.8Stages of InitiationPrecontemplationContemplation2.1*2.0 – 2.2Preparation4.1*3.8 – 4.5Action3.7*Maintenance3.6*3.3 – 3.9Table 3 also presents Odds Ratios with the interpretation being the same as the last slideWhat 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
79 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 attitudesIf we collapse youth in Preparation with the youth in Action and Maintenance to form ‘current smokers’ group we would miss these vulnerable youth
80 Adolescent Smoking in Maryland: Stage Status / Transitions
81 Some Data related to Mechanisms Where should we look for the critical mechanisms of change?Look in the Drinkers process of change and how interventions interact with that processSome thoughts and data from Project MATCH may illustrate some ways and places to look.
82 Project MATCH Tested 3 distinct alcohol treatments Cognitive Behavioral Treatment (CBT) (12/12 wks)Twelve Step Facilitation (TSF) (12/12 wks)Motivational Enhancement Therapy (MET) (4/12 wks)Examined 21 hypothesized matching effects and over 30 baseline predictors of drinkingComprised 9 centers with over 20 sites and 75 therapistsIncluded 952 outpatients and 774 aftercare patientsProject MATCH Research Group. J Stud Alcohol. 1997;58:7.
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:AbstinentModerate drinkingHeavier drinkingClient Profile on Stage of change Subscales, Temptation to Drink, Abstinence Self-Efficacy, Experiential and Behavioral Processes of Change
92 WHERE TO LOOK FOR MECHANISMS OF CHANGE CLIENT PROCESS OF CHANGEACCOMPLISHMENT OF CRITICAL STAGE TASKS AND LEARNING OVER TIMEENGAGEMENT OF CLIENT PROCESSES OF CHANGESELF-REGULATION AND SELF-CONTROL MECHANISMSHOW INTERVENTION ACTIVITIES ENGAGE OR ACTIVATE THESE PROCESSES AND ASSIST IN ACCOMPLISHMENT OF CHANGE TASKSINVOLVEMENT AND MANAGEMENT OF CONTEXTUAL PROBLEMS
93 Where Do We Go From Here? Stepped care approaches Matching techniques of treatment to client problem and process of change dimensionsIntegrating formal and self-help approaches as well as different treatment approachesClient-titrated treatmentTreatment shifts from being reactive and regimented to becoming proactive and personalizedDiClemente. 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 I. SITUATIONAL RESOURCES AND PROBLEMS CONTEXT OF CHANGEI. SITUATIONAL RESOURCES AND PROBLEMSII. COGNITIONS AND BELIEFSIII. INTERPERSONAL RESOURCES/PROBLEMSIV. FAMILY & SYSTEMSV. ENDURING PERSONAL CHARACTERISTICS
96 Typical Complications for Individual and Organizations Symptom/SituationPsychiatricFinancialBeliefsReligious viewsCultural beliefsInterpersonalMaritalSystemicEmploymentFamily/ChildrenIntrapersonalSelf-EsteemSituationInadequate facilitiesFinancialBeliefsOnly one right wayInterpersonalLeadership ConflictsSystemicFunding SourcesPolitical forcesSubgroup conflictsInstitutionalTraditionsOrganizational Culture
97 Stages by Context Analysis Experiential ProcessesBehavioral Processes
98 PROBLEM FOCUSSince change goals and motivations are often behavior specific, it is critical to be specific about the focus of interventionsWe need to evaluate in collaboration with the client what is the primary target behaviors that needs to be changed and the client goalsTarget behavior is figure and additional problems become the ground or context for that change
99 Evaluating Client Problems How serious is the problem?Not EvidentNot SeriousSeriousVery SeriousExtremely SeriousWhen and What Intervention is needed?Needs no interventionNeeds intervention in the futureNeeds Secondary InterventionNeeds primary intervention but can waitNeeds 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 motivatedMULTI-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 problemsEvaluate stage of readiness to changeEvaluate beliefs, values and practices related to target behaviorExamine routes and mechanisms of influence in the culture and for the individualCreate sensitive stage based multi-component interventionsRe-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 patientsAlthough 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 BehaviorsAlthough 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 conditionsShifting MotivationCognitive ImpairmentSelf Regulation ProblemsSituational/Environmental IssuesSystem of Care Problems
107 Multiple Problems Need an Integrated Continuum of Care
108 Support and Cultural Issues Social Networks and Social SupportHow to UseWhere to FindSpiritualityCan be a two-edged swordCultural SensitivityCultural CompetenceStigma
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 livesIndividuals with an array of interests, values, tastes, opinions, attitudes and intentionsA valued commodity to those who offer products and servicesNot 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 servicesThey have to make informed choices about treatments (especially as the options increase)They can bring lawsuitsThey have to comply with any treatmentThey are in charge of their personal process of change
112 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 CareExamples
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 fundedFind out what the consumer needs and wants before planning services and strategiesReward Progress not just Ideal or Ultimate OutcomesAddress 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 clientNegotiating 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