1. The Process of Human Behavior Change
Carlo C. DiClemente
Professor of Psychology
University of Maryland, Baltimore County

2. Behavior Change is Critical to the Growth and Development Organizations, Societies, and Individuals
Organizations and societies must adapt their practices in order to survive and thrive
Even very successful organizations must continue to change to survive (GM, IBM, Rolls Royce)
Key questions are what, whether, and how to change
Individuals must constantly change behaviors in response to shifting demands of the life context
Failure to change is often a sign of stagnation, pathology and decline
Key questions are what, whether and how to change

3. HEALTH PROMOTION & REQUIRE BEHAVIOR DISEASE PREVENTION CHANGE
CANCER PREVENTION CHRONIC ILLNESS MANAGEMENT MENTAL HEALTH MEDICATION ADHERENCE HEALTH PROTECTION SUBSTANCE ABUSE
INITIATION MODIFICATION CESSATION

4. COMMUNITY HEALTH. ORGANIZATIONAL SERVICE DELIVERY. REQUIRE
COMMUNITY HEALTH ORGANIZATIONAL SERVICE DELIVERY REQUIRE & INDIVIDUAL SYSTEMS BEHAVIOR CHANGE
NEW DISCOVERIES CHRONIC ILLNESS MANAGEMENT NEW POLICY OR PROCEDURES CHANGES IN PROVIDERS CHANGES IN FUNDING SHIFTS IN MANAGEMENT
INITIATION MODIFICATION CESSATION

5. Different Patterns of Behavior Change
Initiation, Modification, Cessation
EXCESS
Moderated and Self-Regulated Behavior Pattern
ABSENCE

7. HEALTH BEHAVIORS* MULTIPLE MULTIDIMENSIONAL VARY IN FREQUENCY
VARY IN INTENSITY
REQUIRE DIFFERING LEVELS OF MOTIVATION
CAN BE INTEGRATED INTO DIFFERENT LIFESTYLES TO VARYING DEGREES
*Includes Mental Health Behaviors

8. WHY DON’T PEOPLE OR ORGANIZATIONS CHANGE?
NOT CONVINCED OF THE PROBLEM OR THE NEED FOR CHANGE – UNMOTIVATED
NOT COMMITTED TO MAKING A CHANGE – UNWILLING
DO NOT BELIEVE THAT THEY CAN MAKE A CHANGE – UNABLE

9. HOW PEOPLE CHANGE

10. Most Models of Change are Multidimensional
There are many models of change that identify separate and distinct aspects of behavior change:
Health Belief Model – Vulnerability, Beliefs, Efficacy
Theory of Reasoned Action or Planned Behavior – Action Intention, Decision, Implementation Intention, Efficacy
Social Learning – Norms, Beliefs, Outcome and Efficacy Expectancies, Cues to Action
Behavior Modification – Reinforcement History, Value and Schedules

11. Clear Difference Between Pre Action and Action Stages
The Key Link
Pre Action
Stages
Action
Stages
What do individuals have to do in Pre Action Stages
to be successful in Action Stages? What do they have to do in the Action stages to sustain success?

12. Behavior Change Requires a Multidimensional Set of Explanatory Variables
When making the transition from status quo to status quo how can I organize these influences
Different tasks and hurdles that need to be accomplished or overcome
Cognitions complicate Behavior Change Transition Probabilities and are less observable
Single dimensions seem inadequate to explain the complexity and diversity of the behavior change process
Self-Regulation is an integral part of the behavior change process

13. What Drives the Behavior Change Transition?
Intentions
Expectancies
Change Language
Decision Making
Skills
Goals
Development
Relationships
Reinforcements
External Pressure
Life Events
Family
Consequences
Teachable Moments
All have been involved on some of the changes I have seen in therapy and research

14. 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

15. Important Steps in Making Behavior Changes that Last
THINK
DECIDE
PREPARE
COMMIT
IMPLEMENT
SUSTAIN
These seem to be different parts of a process of intentional behavior change

16. Stage of Change Tasks Precontemplation Not interested Contemplation
Considering
Preparation
Preparing
Action
Initial change
Maintenance
Sustained change
Interested and Concerned
Risk-Reward Analysis & Decision making
Commitment & Creating an Effective/ Acceptable Plan
Implementation of Plan and Revising as Needed
Consolidating Change into Lifestyle

17. Understanding Barriers to Change and the Tasks of the Stages of Change
UNMOTIVATED UNWILLING UNABLE
Precontemplation Contemplation Preparation Action Maintenance

18. 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

19. 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.

20. WHAT INDIVIDUALS AND ORGANIZATIONS MUST REALIZE
MY BEHAVIOR IS PROBLEMATIC/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
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

21. 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.

22. 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.

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

24. 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 with 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

25. 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

27. Tasks and goals for each of the Stages of Change
PREPARATION – The stage in which the individual or society 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.

29. 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
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.

30. WILLING TO MAKE CHANGE COMMITMENT TO TAKE ACTION
SPECIFIC ACCEPTABLE ACTION PLAN
TIMELINE FOR IMPLEMENTING PLAN
ANTICIPATION OF BARRIERS

31. Tasks and goals for each of the Stages of Change
ACTION – The stage in which the individual or society 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).

32. 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
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.

33. 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.

34. 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
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.

35. ABLE TO CHANGE Continued Commitment Skills to Implement the Plan
Long-term Follow Through
Integrating New Behaviors into Lifestyle or Organization
Creating a New Behavioral Norm

36. 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.

37. 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

38. Key Issues and Intervention Considerations
Blame and Guilt Undermine Motivation for Change
Determination despite delays and defeats
Support Re-engagement in the Process of Change
Recycling or just Spinning Wheels
Hope and a Learning Perspective
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

39. 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

40. 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

41. Theoretical and Practical Considerations Related to Movement Through the Stages of Change
Motivation
Self-efficacy
Decision Making
Precontemplation Contemplation Preparation Action Maintenance
Personal Concerns
Environmental
Pressure
Decisional Balance
Cognitive Experiential Processes
Behavioral
Processes
How can we help case managers understand where the client is with regard to a specific problem and change that is needed. If the action is to become employed, where is the client in this process. Precontemplation because they believe they cannot get a job. Ambivalent and unable to make a decision to seek it. Trying to get jobs without skills needed or a proper plan?.
Recycling
Relapse
What would help or hinder completion of the tasks of each of the stages and deplete the self-control strength needed to engage in the processes of change needed to complete the tasks?

42. TASK COMPLETION AND MOVEMENT BETWEEN STAGES
LIFESTYLE
INTEGRATION
AVOID
RELAPSE
IMPLEMENT
THE PLAN
REVISE
COMMMITMENT
PLANNING
PRIORITIZING
INTEREST
CONCERN
RISK/REWARD
DECISION
PREP
ACT
MAIN PC
CON

43. The Smoker’s Journey Social pressure Policy Products & Services Price
Support
Smoking In
Network
Promotion
Long
Term
Success
Tobacco
Advertising
Satisfied
Dependent
or Casual
Smoker
Choosing
A Method
NRT, TX, Cold Turkey,
Quitline
Dissatisfied but ambivalent
Decided to
Make a Quit
Attempt
Quit
Attempt
Short
Term
Success
Personal
Concerns
Special
Events
Relapse
And
Recycling
Beliefs
& Myths
Quitting
History
Psychiatric
Conditions
And Other
Life Problems

44. STAGES OF CHANGE AND INTERVENTION TASKS
Raise doubt - Increase the client’s perception of
risks and problems with current behavior
PRECONTEMPLATION
Tip the decisional balance - Evoke reasons for
change, risks of not changing; Strengthen client’s
self-efficacy for change of current behavior
CONTEMPLATION
Help the client to determine the best course of
action to take in seeking change; Develop a plan
PREPARATION
Help the client implement the plan; Use skills;
Problem solve; Support self-efficacy
ACTION
Help the client identify and use strategies to
prevent relapse; Resolve associated problems
MAINTENANCE
Help the client recycle through the stages of
contemplation, preparation, and action, without
becoming stuck or demoralized because of relapse
RELAPSE

45. WHO IS THE CLIENT
Most of the time we think of clients as individual patients in a system
However, clients from a process of change perspective are anyone who needs to make a behavior change
The challenge from a systems perspective is who needs to change to make a system change

46. Important Considerations about System Change
Usually when you change a system everyone needs to make changes
Roles may be differentiated: decision makers, implementers, etc.
However, most parts of a system have to make some behavioral changes in procedure, process, protocol, or personnel

47. IN MAKING AN INDIVIDUAL OR ORGANIZATIONAL CHANGE
Pick a target behavior or constellation of behaviors
Make a solid decision
Prioritize and Prepare
Make a plan and revise as needed
Keep going and do not get discouraged
Find and build a network of support
Make the change a new norm

48. Some Examples Initiation and Recovery from Addiction
Medication & HIV/AIDS Compliance enhancement
Trauma Unit Screening and Interventions for Risky Drinking
Group Therapy Manual

49. Addiction and Change
Both acquisition of and recovery from an addiction require a personal journey through an intentional change process that is influenced at various points by a host of factors.
Involve a Process of Change

51. 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
Sustained
Cessation
Dependence
RECOVERY

52. 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

53. Adolescents, Emerging Adults and Recovery
Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Fewer Consequences
Developing Self-Regulation
Impulsivity
Poor Planning
Abstinence Forever
Social Pressures

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

55. 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

56. Challenging Populations and the Process of Change
Multiple Addictions
Multiple motivations
Comprehensive or sequential strategies
Criminal Justice
Restricted Access to target behaviors
Process of Change
Dually Diagnosed
Same Process of Change
Integrated Treatment
Homeless
Not helpless
Housing First

57. Difficult Clients Necessitate Managing Client Difficulties: A TTM Analysis
Target Problem and Contextual Problems
Stage of Change for Each Problem
Identifying Key Processes of Change
Finding Appropriate Strategies to Engage Processes
Recycling and Learning from the Past
Accomplishing Stage Tasks Adequately

58. 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.

59. Motivating Movement through the Later Stages of Change
Critical tasks of the later stages involve commitment, effective planning, sustained implementation, using behavioral skills, sustaining change despite obstacles, coping with slips and relapse.
Cognitive/Behavioral approaches and engaging support systems are important strategies to help clients successfully complete these tasks.

60. Job Corps Challenges Target and Contextual Problems
When to work with which problem
Self-Regulation Challenges
Building effective and acceptable action plans
Sustaining Change
Collaboration and Coordination of Care with Other Providers

61. How Do Interventions Work?
INDIVIDUAL
Static Interaction Model

62. How Do Interventions Work?
Dynamic Model: Stepping into a Flowing Stream

64. 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 belief in the potential for change