embracing change: promoting recovery

Embracing Change: Promoting Recovery

Carlo C. DiClemente, Ph.D. ABPPUniversity of Maryland, Baltimore Countywww.umbc.edu/psych/habitswww.mdquit.org

Overview

Addiction and Change Motivation and the Change Process Stages and Tasks of Change Mechanisms (Client) & Strategies

(Provider) of change Treatment Planning Recycling and Challenges of Change

in Individuals with Multiple Problems and Mental Illness

What are Addictions?

Habitual patterns of intentional, appetitive behaviors

Become excessive and produce serious consequences

Stability of these problematic behavior patterns over time

Interrelated physiological and psychological components

Addicted individuals have difficulty modifying and stopping them

Traditional Models for Understanding Addictions

Social/Environmental Models Genetic/Physiological Models Personality/Intra-psychic Models Coping/Social Learning Models Conditioning/Reinforcement

Models Compulsive/Excessive Behavior

Models Integrative Bio-Psycho-Social

Models

Etiology of Addictions

Genetics

Physiology

Environment

Personality

Social Influences

Coping/Expectancies

Initial Use Self-RegulatedUse

Abuse

Dependence

All of these factors can have arrows to initial experience and then to any or all of the three patterns of use. Most could have arrows that demonstrate linear or reciprocal causality as well

Conditioning

Reinforcement

Change the Integrating Principle

No single developmental model or singular historical path can explain acquisition of and recovery from addictions

A focus on the Process of Change and how individuals change offers a developmental, task oriented, learning based view that can be useful to clinicians and researchers using a variety of traditional etiological and cessation models

BECOMING ADDICTED

Happens over a Period of Time

Has a Variable Course Involves a Variety of

Predictors that can be both Risk and Protective Factors

Involves a Process of Change

SUCCESSFUL RECOVERY FROM ADDICTIONS

Occurs over long periods of time Often involves multiple attempts

and treatments Consists of self change and/or

treatment Involves changes in other areas

of psychosocial functioning

Addiction and Change

Both acquisition of and recovery from an addiction require a personal journey through an intentional change process

Journey influenced at various points by many of the factors identified in the previously reviewed etiological models

Addiction and Change

Both are influenced by personal decisional considerations and choices

Personal choices are influenced by and, in turn, influence genetic, developmental, characterological, and social forces

Both involve an interaction between individual and surrounding risk & protective factors that indicate a Process of Change

A LIFE COURSE PERSPECTIVE ON ADDICTION

Cross sectional views and brief follow up studies offer confusing data about predictors and outcomes of prevention and cessation of addiction

Multiple biological, social, individual, environmental factors influence transitions into and out of protective and problematic health behaviors

Understanding initiation and cessation of these behaviors requires a life course and a process of change perspective

Motivation

Motivation can be considered the tipping point for making change happen

Not a simple or single construct or best thought of as an “on-off” switch

Most of the time it is defined post hoc: if you are successful, you were motivated

Motivation

There are various models to explain motivation “Push” Models of internal dynamic forces or

drives “Pull” Models of reinforcement, goals, values “Persuasion” Models of influence, social

forces “Process” Models of readiness and tasks

The Process Model changes the conversation from the “what” of motivation to the “how” of motivation

Motivation and the Change Process

Clients are not unmotivated! They either are just motivated to engage in behaviors that

others consider harmful and problematic or are not ready to begin behaviors that we think

would be helpful. People who seem to have everything to gain

from changing a behavior or doing some activity to relieve negative feelings or consequences do not do these things

Excellent and effective self-management techniques are not used even after they are taught to people who come voluntarily for help

DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; 2003. CSAT Treatment Improvement Protocol Number 35. Enhancing Motivation for Change in Substance Abuse Treatment. 1999;DHHS no. (SMA) 99-3354.

Motivation is Personal

Motivation belongs to clients and their process of change.

However, motivation can be enhanced or hindered by interactions with others (including providers) and events in the life context of the clients.

Motivation is best viewed as the client’s readiness to engage in and complete the various tasks outlined in the Stages of Change for a specific behavior change.

Motivation Is Critical for Successful Change

Both brief interventions and alcoholism and substance abuse treatment research indicate a key role for patient motivation

In many drinking reduction studies motivation predicts decreases (Delta study of Shock Trauma patients)

Project MATCH client initial motivation measured by multidimensional stage measures predicted drinking out to 3 years post-treatment for outpatients

CSAT Treatment Improvement Protocol Number 35. Enhancing Motivation for Change in Substance Abuse Treatment. 1999;DHHS no. (SMA) 99-3354. Project MATCH Research Group. Alcohol Clin Exp Res. 1998;22:1300.

WHY ARE PEOPLE NOT MOTIVATED TO CHANGE?

NOT CONVINCED OF THE PROBLEM OR THE NEED FOR CHANGE – UNMOTIVATED

NOT COMMITTED TO MAKING A CHANGE – UNWILLING

ACTUAL OR PERCEIVED ABILITY TO MAKE A CHANGE – UNABLE

DIFFERENT PARTS OF A PROCESS

HOW PEOPLE CHANGE

The Transtheoretical Model of Intentional Behavior Change

STAGES OF CHANGE

PRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE

PROCESSES OF CHANGECOGNITIVE/EXPERIENTIAL BEHAVIORAL Consciousness Raising Self-LiberationSelf-Revaluation Counter-conditioningEnvironmental Reevaluation Stimulus ControlEmotional Arousal/Dramatic Relief Reinforcement ManagementSocial Liberation Helping Relationships

CONTEXT OF CHANGE1. Current Life Situation2. Beliefs and Attitudes3. Interpersonal Relationships4. Social Systems5. Enduring Personal Characteristics

MARKERS OF CHANGE Decisional Balance Self-Efficacy/Temptation

How Do People Change?

People change voluntarily only when They become interested and

concerned about the need for change

They become convinced the change is in their best interest or will benefit them more than cost them

They organize a plan of action that they are committed to implementing

They take the actions necessary to make the change and sustain the change

Stage of Change Labels and Tasks

Precontemplation Not interested

Contemplation Considering

Preparation Preparing

Action Initial change

Maintenance Sustained

change

Interested, concerned and willing to consider

Risk-reward analysis and decision making

Commitment and creating a plan that is effective/acceptable

Implementing plan and revising as needed

Consolidating change into lifestyle

DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; 2003. DiClemente. J Addictions Nursing. 2005;16:5.

Motivation is Multidimensional

Motivation is best understood as the readiness and ability to accomplish the tasks needed to move individuals successfully through the stages of change

These tasks require self-regulation skills that enable the person to engage in the processes of change needed to accomplish the tasks and move the markers of change

There are facilitating and hindering personal and environmental factors that affect movement through each of the stages

A Consumer perspective

A Consumer Perspective to Care necessitates a shift in emphasis from a concentration on our treatments to a concentration on our consumers and their processes to regain some balance

Most treatment services provide good, effective action-oriented treatments

Many of our consumers are unmotivated, overwhelmed with multiple problems, feeling hopeless, or simply not interested or engaged by our services

DiClemente & Velasquez. Motivational interviewing and the stages of change. In: Miller & Rollnick, eds. Motivational Interviewing, 2nd ed. NY: Guilford Publications; 2002:201.

Understanding Motivation and Movement through the Stages of Change

UNMOTIVATED UNWILLING UNABLE

Precontemplation Contemplation Preparation Action Maintenance

This Process is as relevant for organizations and service providers as it is forIndividuals with mental health and addiction problems.

Tasks and Goals for each of the Stages of Change

PRECONTEMPLATION - The state in which there is little or no consideration of change of the current pattern of behavior in the foreseeable future.

TASKS: Increase awareness of need for change and concern about the current pattern of behavior; envision possibility of change

GOAL: Serious consideration of change for this behavior

WHAT INDIVIDUALS or ORGANIZATIONS MUST REALIZE

MY BEHAVIOR IS PROBLEMATIC OR EXCESSIVE

MY DRUG USE IS CAUSING PROBLEMS IN MY LIFE

I HAVE OR AM AT RISK FOR SERIOUS PROBLEMS

MY BEHAVIOR IS INCONSISTENT WITH SOME IMPORTANT VALUES

MY LIFE IS OUT OF CONTROL

WHAT WE ARE DOING IS NOT EFFECTIVE IN MEETING THE NEEDS OF OUR CLIENTS

OUR APPROACH IS COSTING TOO MUCH FOR THE OUTCOMES WE ARE GETTING

THERE ARE SERIOUS PROBLEMS IN OUR PROCEDURES, PROGAMMMING,OR PRODUCT

Key Issues and Intervention Considerations

Coercion or Courts cannot do it alone Confrontation breeds Resistance Motivation not simply Education is

needed Intrinsic and Extrinsic Motivations Proactive versus Reactive

Approaches Smaller versus Larger goals and

Motivation

Tasks and goals for each of the Stages of Change

CONTEMPLATION – The stage where the individual or society examines the current pattern of behavior and the potential for change in a risk – reward analysis.

TASKS: Analysis of the pros and cons of the current behavior pattern and of the costs and benefits of change. Decision-making.

GOAL: A considered evaluation that leads to a decision to change.

Decisional Balance Worksheet

NO CHANGE

PROS (Status Quo)_____________________________________________

CONS (Change)_____________________________________________

CHANGE

CONS (Status Quo)_____________________________________________

PROS (Change)_____________________________________________

Key Issues and Intervention Considerations

Decisional Considerations are Personal Increase the Costs of the Status Quo and

the Benefits of Change Challenge and Work with Ambivalence Envision the Change Engender Culturally Relevant

Considerations that are Motivational See how families and larger organizations

can influence change by providing incentives or putting up barriers

Multiple problems or issues interfere and complicate

MOTIVATED TO CHANGE

Admit that the status quo is problematic and needs changing

The pros for change outweigh the cons

Change is in our own best interest The future will be better if we make

changes in these behaviors But this is only the first two steps

toward making a change happen

Tasks and goals for each of the Stages of Change

PREPARATION – The stage in which the individual or organization makes a commitment to take action to change the behavior pattern and develops a plan and strategy for change.

TASKS: Increasing commitment and creating a change plan.

GOAL: An action plan to be implemented in the near term.

Key Issues and Intervention Considerations

Effective, Acceptable and Accessible Plans

Setting Timelines for Implementation

Building Commitment and Confidence

Creating Incentives Developing and Refining Skills

Needed to Implement the Plans Treatment Plan and Change Plan

WILLING TO MAKE CHANGE

COMMITMENT TO TAKE ACTION SPECIFIC ACCEPTABLE ACTION

PLAN TIMELINE FOR IMPLEMENTING PLAN ANTICIPATION OF BARRIERS BUT YOU STILL HAVEN’T DONE IT

YET

Tasks and goals for each of the Stages of Change

ACTION – The stage in which the individual or organization implements the plan and takes steps to change the current behavior pattern and to begin creating a new behavior pattern.

TASKS: Implementing strategies for change; revising plan as needed; sustaining commitment in face of difficulties

GOAL: Successful action to change current pattern. New pattern established for a significant period of time (3 to 6 months).

Key Issues and Intervention Considerations

Flexible and Responsive Problem Solving

Support for Change Reward Progress Create Consequences for

Failure to Implement Continue Development and

Refining Skills Needed to Implement the Plan

Tasks and goals for each of the Stages of Change

MAINTENANCE – The stage where the new behavior pattern is sustained for an extended period of time and is consolidated into the lifestyle of the individual and society.

TASKS: Sustaining change over time and across a wide range of situations. Avoiding going back to the old pattern of behavior.

GOAL: Long-term sustained change of the old pattern and establishment of a new pattern of behavior.

Key Issues and Intervention Considerations

It is Not Over Till Its Over Support and Reinforcement Availability of Services or

Resources to Address Other Issues In Contextual Areas of Functioning

Offering Valued Alternative Sources of Reinforcement

Institutionalization of change

ABLE TO CHANGE

Continued Commitment Skills to Implement the Plan Self Control Strength that is not

exhausted by other problems Long-term Follow Through Integrating New Behaviors into

Lifestyle or Organization Creating a New Behavioral Norm Now you are getting there

Relapse and Recycling - Slipping Back to Previous Behavior and Trying to Resume Change

Characteristics: The person or organizations has failed to

implement the plan or is re-engaged in the previous behavior

After failing to implement or reverting to previous behavior, there is re-entry to precontemplation, contemplation, preparation stages

Sense of failure and discouragement about motivation or ability to change

Regression, Relapse and Recycling through the Stages

Regression represents movement backward through the stages

Slips are brief returns to the prior behavior that represent a some problems in the action plan

Relapse is a return or re-engaging to a significant degree in the previous behavior after some initial change

After returning to the prior behavior, individuals Recycle back into pre-action stages (precontemplation, contemplation, or preparation).

Key Issues and Intervention Considerations

Blame and Guilt Undermine Motivation for Change

Determination despite delays and defeats

Support Re-engagement in the Processes of Change

Recycling or just Spinning Wheels Hope and a Learning Perspective is

Needed

Theoretical and practical considerations related to movement through the Stages of Change

Motivation Decision-Making Self-efficacy

Precontemplation Contemplation Preparation Action Maintenance

Personal Environmental Decisional Cognitive Behavioral OrganizationalConcerns Pressure Balance Experiential Processes

(Pros & Cons) Processes

Recycling Relapse

PrecontemplationIncrease awareness of need to change

ContemplationMotivate and increase confidence

in ability to change

ActionReaffirm commitment

and follow-up

Termination

Stages of Change Model

RelapseAssist in Coping

MaintenanceEncourage activeproblem-solving

PreparationNegotiate a plan

Self-Evaluation Ruler - AlcoholSelf-Evaluation Ruler - Alcohol

On the following scale, which point best reflects how ready you are at the present time to changing your drinking?

Not at all ready to change my

drinking

Thinking about

changing my drinking

Actively changing

my drinking

Planning andmaking a

commitment to change my

drinking

MECHANISMS OF CHANGE: A CLIENT PERSPECTIVE

What is the client’s work in making change happen?

What is the provider’s tasks? What is the difference? Client Processes Provider Strategies and Services

Processes of Change

Change engines that enable movement through the stages of change

Doing the right thing at the right time Cognitive/Experiential processes

during early stages Behavioral processes in preparation,

action and maintenance

Processes of Change

Experiential Processes Concern the person’s thought processes Generally seen in the early Stages of

Change

Behavioral Processes Action oriented Usually seen in the later Stages of Change

Transtheoretical Model: Experiential Processes of Change

Consciousness Raising: Gaining information increasing awareness about the current habitual behavior pattern or the potential new behavior

Emotional Arousal: Experiencing emotional reactions about the status quo and/or the new behavior

  Self –Revaluation: Seeing when and how the status quo or the new behavior fit in with or conflict with personal values

Environmental Reevaluation: Recognizing the effects the status quo or new behavior have upon others and the environment

  Social Liberation: Noticing and increasing social alternatives and norms that help support change in the status quo and/or initiation of the new behavior

Transtheoretical Model: Behavioral Processes of Change

Self Liberation: Accepting responsibility for and committing to make a behavior change

Stimulus Control: Creating, altering or avoiding cues/stimuli that trigger or encourage a particular behavior

  Counter-Conditioning: Substituting new, competing behaviors and activities for the “old” behaviors

Reinforcement Management: Rewarding sought after new behaviors while extinguishing (eliminating reinforcements) from the status quo behavior

Helping Relationships: Seeking and Receiving support from others (family, friends, peers)

PROCESSES OF CHANGE by STAGE

STAGES

PC C PA A M

Consciousness raising Self-reevaluation Dramatic relief

Helping relationship Self- liberation Contingency management Counter-

conditioning Stimulus control

PROCESSES

Provider Strategies

What do you do to engage each of these processes?

What do you do with less motivated patients that would activate some of these experiential processes?

What do you do with you action oriented patients that activate the behavioral processes?

A Transtheoretical Model Group Therapy

Each group session is based on a specific TTM process of change. Motivational Interviewing counseling strategies are used throughout the sessions.

Thinking About Changing Substance UsePrecontemplation-Contemplation-Preparation Sequence

1. The Stages of Change

2. A Day in the Life- Consciousness Raising

3. Physiological Effects of Alcohol-Consciousness Raising

4. Physiological Effects of Drugs-Consciousness Raising

5. Expectations-Consciousness Raising

6. Expressions of Concern-Self-Reevaluation, Dramatic Relief

Making Changes in Substance AbuseAction/Maintenance Sequence

1. The Stages of Change2. Identifying “Triggers”- Stimulus Control

3. Managing Stress-Counterconditioning

4. Rewarding My Sucesses-Reinforcement Management

5. Effective Communication-Counterconditioning, Reinforcement Management

6. Effective Refusals-Counterconditioning, Reinforcement Management

Motivating Movement through the Early Stages of Change

Critical tasks of the early stages are eliciting concern, dealing with ambivalence regarding change, decision-making, creating commitment, careful and comprehensive planning.

Motivational Interviewing/Enhancement approaches are important strategies to engage and work with clients helping them successfully complete these tasks.

Treatment Planning

Connecting what you do with what they need.

Key questions: Where in the stages are they? What are the tasks that need to be

accomplished or accomplished better? What processes are needed? What can I do to activate these

processes in the session or in the environment?

THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY

ADDICTIONADDICTION

RECOVERYRECOVERYSustainedCessation

Dependence

PROCESSES, CONTEXT AND MARKERS OF CHANGE

Dependence

PC C PA A M

PC C PA A M

Theoretical and practical considerations related to Prevention and Stages of INITIATION

Expectancies/Beliefs Decision-Making Self-efficacy

Precontemplation Contemplation Preparation Action Maintenance

Personal Environmental Decisional Cognitive/ Behavioral Concerns Pressure Balance Experiential Processes

(Pros & Cons) Processes

Experimentation Casual use Regular Use Dependence

PREVENTION OF INITIATION OF ADDICTIONPREVENTION OF INITIATION OF ADDICTION

PC - CPC - C C - PAC - PA PA - APA - A A - MA - M

POPULATIONPREVENTION

AT- RISKPREVENTION

ALREADY AFFLICTED

A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLENA STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLEN

TYPE OFBEHAVIOR

STAGE OF INITIATION

PC C PA A M

ALCOHOL

NICOTINE

MARIJUANA

HEROIN

COCAINE

AMPHETAMINES

LSD

GAMBLING

EATING DISORDER

XXXXXX

XXXX

XXXX

XXXX

Implications for Acquisition and Prevention

If there is a common but unique pathway, we can better understand where individuals are in this process of change for each addictive behavior

We can distinguish between prevention and treatment better

We can target interventions to the process of change

Secondary data analyses of the Maryland Youth Tobacco Survey (MYTS, 2000)

Classroom-based survey, administered throughout Maryland

Participants were public school students (N = 47,839), between the ages of 12 and 18 years

The majority of the sample was Caucasian (69%) and over half were Female (52%), with a median age of 14 years

2000 Maryland Youth Tobacco Survey (MYTS)

2002 Maryland Youth Tobacco Survey (MYTS)

Secondary data analyses of the Maryland Youth Tobacco Survey (MYTS, 2002)

Classroom-based survey, administered throughout Maryland

Participants were public school students (N = 56,820), between the ages of 12 and 17 years

The majority of the sample was Caucasian (66%) and over half were Male (53%), with a median age of 14 years

Youth were classified into Stages of Smoking Initiation & Levels of Experience

Level of Experience is analogous to prevalence measures with Never Smoked = ‘Inexperienced’; Smoked Less than 6 days = ‘Exposed’; Smoked 6+ days = ‘Experienced’

Youth were classified according to their Stage of Smoking Initiation using

Lifetime Smoking Ever smoked

Future Intentions Smoke in next year?

Current Smoking # of days smoked past 30 days

Duration of Current Smoking How long smoked current rate?

Logistic Regressions

Using 2000 MYTS data, Logistic Regressions were estimated for both the Stages of Smoking Initiation & Level of Experience

3 Key Risk Factors from 3 Domains of Influence were selected Behavioral

“Would you ever use or wear something that has a tobacco company name or picture on it such as a lighter, t-shirt, hat, or sunglasses?”

Attitudinal “Do you think young people who smoke cigarettes have more

friends?”

Intention “If One of Your Best Friends Offered You a Cigarette, Would You

Smoke It?”

Table 1. Distributions of Stage of Smoking Initiation & Level of Experience

n %

Levels of Experience

Inexperienced 29,628 61.9

Exposed 8,274 17.3

Experienced 9,937 20.8

Stages of Smoking Initiation

Precontemplation 29,064 60.8

Contemplation 10,858 22.7

Preparation 2,311 4.8

Action 1,656 3.5

Maintenance 3,950 8.3

Distribution of Stages of Smoking Initiation by Wave & School Status

MS 2000

HS 2000 MS 2002 HS 2002

PC 14,576 14,218 18,371 18,263

C 4,039 6,687 4,595 7,826

P 539 1,752 560 1,695

A 374 1,687 395 1,587

M 255 3,373 280 2,646

Mean Number of Friends who Smoke

0.23

0.63

0.19

0.50

0.78

1.11

0.740.92

2.041.94

1.76 1.67

2.66

2.93

2.67 2.70

2.262.38

2.502.73

0

1

2

3

4

MS HS MS HS

2000 2002

PC C P A M

Table 4. Odds-Ratios of Stages of Smoking Initiation and Level of Experience for Intention Risk Factor: Accept Cigarette Offer from Best Friend

OR CI

Level of Experience

Inexperienced 1.0 --

Exposed 5.6* 5.2 – 6.1

Experienced 66.4* 61.7 – 71.5

Stages of Initiation

Precontemplation 1.0 --

Contemplation 27.1* 24.2 – 30.5

Preparation 258.1* 223.6 – 298.0

Action 686.6* 568.8 – 828.8

Maintenance 1,780.7* 1,480.7 – 2,141.5

* p<.001

Table 3. Odds-Ratios of Stages of Smoking Initiation & Level of Experience for Attitudinal Risk Factor ‘Smokers Have More Friends’

OR CI

Level of Experience

Inexperienced 1.0 --

Exposed 1.8* 1.7 – 1.9

Experienced 2.6* 2.5 – 2.8

Stages of Initiation

Precontemplation 1.0 --

Contemplation 2.1* 2.0 – 2.2

Preparation 4.1* 3.8 – 4.5

Action 3.7* 3.3 - 4.1

Maintenance 3.6* 3.3 – 3.9

* p<.001

Smoking makes young people look cool or fit in by Stage, School & Wave

6.2 7.3 6.8 7.5

21.516.8

24.220.2

44.5

31.0

49.2

32.541.2

25.5

44.5

29.0

38.2

23.4

51.2

27.0

0

20

40

60

80

100

MS HS MS HS

2000 2002

PC C P A M

Adolescent Smoking in Maryland: Stage Status / Transitions

PC C P A M

STATEWIDE

Middle School 74.5% 20.4% 2.6% 1.5% 1.1% High School 55.2% 24.4% 5.9% 5.0% 9.5%

PC C P A M

STATEWIDE

Middle School 77.6% 18.6% 1.9% 1.1% 0.8% High School 59.5% 24.4% 5.0% 4.3% 6.8%

PC C P A M

STATEWIDE

Middle School 3.1% -1.8% -0.7% -0.4% -0.3% High School 4.3% 0.0% -0.9% -0.7% -2.7%

Change: 2002-2000

2000

2002

Some Data related to Some Data related to MechanismsMechanisms

Where should we look for the critical Where should we look for the critical mechanisms of change?mechanisms of change?

Look in the Drinkers process of Look in the Drinkers process of change and how interventions change and how interventions interact with that processinteract with that process

Some thoughts and data from Project Some thoughts and data from Project MATCH may illustrate some ways and MATCH may illustrate some ways and places to look.places to look.

Project MATCHProject MATCH Tested 3 distinct alcohol treatmentsTested 3 distinct alcohol treatments

Cognitive Behavioral Treatment (CBT) (12/12 Cognitive Behavioral Treatment (CBT) (12/12 wks)wks)

Twelve Step Facilitation (TSF) (12/12 wks)Twelve Step Facilitation (TSF) (12/12 wks) Motivational Enhancement Therapy (MET) (4/12 Motivational Enhancement Therapy (MET) (4/12

wks)wks)

Examined 21 hypothesized matching effects Examined 21 hypothesized matching effects and over 30 baseline predictors of drinkingand over 30 baseline predictors of drinking

Comprised 9 centers with over 20 sites and Comprised 9 centers with over 20 sites and 75 therapists 75 therapists

Included 952 outpatients and 774 aftercare Included 952 outpatients and 774 aftercare patientspatients

Project MATCH Research Group. J Stud Alcohol. 1997;58:7.

Alcohol Impairment at Alcohol Impairment at BaselineBaseline

Outpatient Aftercare

Percent of Days Abstinent 34.3 26.8

Drinks per Drinking Day 13.5 20.5

No. of SCID Symptoms 5.77 6.79

Prior IP Alcohol Treatment 45.0% 58.3%

Number of Participants 952 774

Predictors of Drinking at Predictors of Drinking at Months 4-15Months 4-15Outpatient p values Aftercare p values

Attribute PDA DDD PDA DDD

Alcohol involvement (+).002

Gender (Male) (-).004 (+).035

MotivationalReadinesss

(+)<.001 (-)<.001

Support for Drinking (-).005 (+).026 (+).024

AASE (+).0003 (-).0002

Temptation – AASE(Highly Tempted)

(-).0004 (+).0003 (-).0429 (+).0019

Alcohol Dependence (+) .002

Alcohol-specificreadiness

(+).0001 (-).014

Religious beliefs andbackground

(-) .044 (+).011

Predictors of Drinking at 3-year Predictors of Drinking at 3-year Follow-UpFollow-Up

Outpatient p values

Attribute PDA DDD

Alcohol involvement (+).0001 (-).0001

Alcohol Dependence (+).0001

Meaning Seeking (+).0106

Religiousity (-).0012

Prior engagement in AA (+).0144

Motivational Readiness (+).0001 (-).0001

Readiness to Change (+).0001 (-).0092

AASE (-).0006

Temptation – AASE (Highly Tempted) (+).0024

Social Functioning (-).0051

Type of Alcoholic (+).0016

Mean Percent Days Mean Percent Days Abstinent as a Function Abstinent as a Function

of Time (Outpatient)of Time (Outpatient)

0102030405060708090

100

-2 -1 0 4 5 6 7 8 9 10 11 12 13 14 15

CBT MET TSF

End of Treatment Process End of Treatment Process Profiles Predict Outcomes Profiles Predict Outcomes

Client status during follow-up period:Client status during follow-up period: AbstinentAbstinent Moderate drinkingModerate drinking Heavier drinkingHeavier drinking

Client Profile on Stage of change Client Profile on Stage of change Subscales, Temptation to Drink, Subscales, Temptation to Drink, Abstinence Self-Efficacy, Experiential Abstinence Self-Efficacy, Experiential and Behavioral Processes of Changeand Behavioral Processes of Change

TTM = Transtheoretical model

Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

TTM Profile: TTM Profile: Outpatient PDA BaselineOutpatient PDA Baseline

Pre Con Act Main Conf Temp

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

TTM variables

Sta

nd

ard

sco

res Abstinent Moderate Heavier

-0.8-0.6-0.4-0.2

00.20.40.60.8

Pre Con Act Main Conf Temp Exp Beh

PDA = percent days abstinent

Carbonari, JP & DiClemente, CC. J Consult and Clin Psych. 2000; 68:810.

TTM Variables

Sta

nd

ard

Sco

res

Abstinent Moderate Heavier

TTM Profile: TTM Profile: Outpatient PDA Post-Outpatient PDA Post-

treatment treatment

Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

TTM Profile: TTM Profile: Aftercare PDA BaselineAftercare PDA Baseline

Pre Con Act Main Conf Temp-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

TTM variables

Sta

nd

ard

sco

res

Abstinent Moderate Heavier

Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Pre Con Act Main Conf Temp Exp Beh

TTM variables

Sta

nd

ard

sco

res

Abstinent Moderate Heavier

TTM Profile: TTM Profile: Aftercare PDA Post-Aftercare PDA Post-

treatmenttreatment

WHERE TO LOOK FOR WHERE TO LOOK FOR MECHANISMS OF CHANGEMECHANISMS OF CHANGE

CLIENT PROCESS OF CHANGECLIENT PROCESS OF CHANGE ACCOMPLISHMENT OF CRITICAL STAGE ACCOMPLISHMENT OF CRITICAL STAGE

TASKS AND LEARNING OVER TIMETASKS AND LEARNING OVER TIME ENGAGEMENT OF CLIENT PROCESSES OF ENGAGEMENT OF CLIENT PROCESSES OF

CHANGECHANGE SELF-REGULATION AND SELF-CONTROL SELF-REGULATION AND SELF-CONTROL

MECHANISMSMECHANISMS HOW INTERVENTION ACTIVITIES ENGAGE OR HOW INTERVENTION ACTIVITIES ENGAGE OR

ACTIVATE THESE PROCESSES AND ASSIST IN ACTIVATE THESE PROCESSES AND ASSIST IN ACCOMPLISHMENT OF CHANGE TASKSACCOMPLISHMENT OF CHANGE TASKS

INVOLVEMENT AND MANAGEMENT OF INVOLVEMENT AND MANAGEMENT OF CONTEXTUAL PROBLEMSCONTEXTUAL PROBLEMS

Where Do We Go From Where Do We Go From Here?Here?

Stepped care approachesStepped care approaches Matching techniques of treatment to Matching techniques of treatment to

client problem and process of change client problem and process of change dimensionsdimensions

Integrating formal and self-help Integrating formal and self-help approaches as well as different approaches as well as different treatment approachestreatment approaches

Client-titrated treatmentClient-titrated treatment Treatment shifts from being Treatment shifts from being reactive reactive

and and regimentedregimented to becoming to becoming proactiveproactive and and personalizedpersonalized

DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; 2003.

Multiple Problems Complicate the Process of Change

The Context of Change:A Figure Ground Perspective

CONTEXT OF CHANGECONTEXT OF CHANGE

I. SITUATIONAL RESOURCES AND PROBLEMS

II. COGNITIONS AND BELIEFS

III. INTERPERSONAL RESOURCES/PROBLEMS

IV. FAMILY & SYSTEMS

V. ENDURING PERSONAL CHARACTERISTICS

Typical Complications forIndividual and Organizations

Symptom/Situation Psychiatric Financial

Beliefs Religious views Cultural beliefs

Interpersonal Marital

Systemic Employment Family/Children

Intrapersonal Self-Esteem

Situation Inadequate facilities Financial

Beliefs Only one right way

Interpersonal Leadership Conflicts

Systemic Funding Sources Political forces Subgroup conflicts

Institutional Traditions Organizational Culture

Stages by Context Analysis

PreC Cont Prep Action Maint

I Sit

II Cog

III Rel

IV Sys

V Per

Experiential Processes

Behavioral Processes

PROBLEM FOCUS

Since change goals and motivations are often behavior specific, it is critical to be specific about the focus of interventions

We need to evaluate in collaboration with the client what is the primary target behaviors that needs to be changed and the client goals

Target behavior is figure and additional problems become the ground or context for that change

Evaluating Client Problems

How serious is the problem? Not Evident Not Serious Serious Very Serious Extremely

Serious

When and What Intervention is needed? Needs no

intervention Needs intervention

in the future Needs Secondary

Intervention Needs primary

intervention but can wait

Needs immediate intervention

Intervention Strategies

SEQUENTIAL – start with initial symptom or situation and try to resolve that and work way down.

KEY AREA OR LEVEL – Find problem or area where you have the most leverage either the most serious or salient problem or client is most motivated

MULTI-LEVEL OR MULTI-PROBLEM –Work back and forth across the context identifying and addressing client stage and processes of change for each separate problem

Approaches that Pay Attention to the Process of Change

Clearly identify the target behavior and the contextual problems

Evaluate stage of readiness to change Evaluate beliefs, values and practices

related to target behavior Examine routes and mechanisms of

influence in the culture and for the individual Create sensitive stage based multi-

component interventions Re-evaluate regularly the change process

Mental Illness and Addictions

Rates of addictions among those with psychiatric disorders is higher than in the population (2 to 4 times greater)

Substance use if often associated with the onset of many different disorders (schizophrenia, conduct disorder, personality disorders)

These are reciprocally complicating disorders

Additional Considerations for SMI

Substance abuse by individuals with severe mental illness is ubiquitous.

It is not clear if individuals with schizophrenia can access and utilize a similar process of change as other drug abusing individuals.

It is also not clear whether individuals with Schizophrenia differ from other non psychotic individuals in terms of their profiles on process measures identified in the Transtheoretical Model

SUMMARY OF RECENT STUDIES

Measures of readiness and other process variables demonstrated reliability and construct validity among SMI patients with tobacco dependence and cocaine abuse.

Schizophrenia patients appear to be using the same or similar process of change in managing their tobacco and cocaine abuse and recovery as other drug abusing patients

Although neurocognitive deficits among patients with schizophrenia can interfere with access to some higher order cognitive functions and may modulate the process, these patients appear to access and use the intentional process of change as described in the TTM in managing and recovering from substance abuse.

DiClemente, Bellack, Nidecker, Gearon, 2003 AABT

Mental Illness and Emotional Problems

Combinations of Symptoms, Emotions, Cognitions and Behaviors

Although illness is not chosen, it develops over time and requires initiation, modification, and cessation of some behaviors (including medication adherence)

Can interfere with accurate information processing and other tasks of the stages of change

Challenges for Change in a Mentally Ill Population

Multiple Chronic conditions Shifting Motivation Cognitive Impairment Self Regulation Problems Situational/Environmental Issues System of Care Problems

Multiple Problems Need an Integrated Continuum of Care

Multi-Service Center

Homeless Encampment

Multi-Service Center

Multi-Service Center

Sheltered Employment

Day Rehabiliation

Community Living

HHISN

Residential Treatment

Crisis Residential

Emergency Shelter

Support and Cultural Issues

Social Networks and Social Support How to Use Where to Find

Spirituality Can be a two-edged sword

Cultural Sensitivity Cultural Competence Stigma

Developing Process Oriented Treatments

How would you develop a treatment system that took into account what we have learned about the process of change?

How would you manage interactions among providers and systems of care?

How would you allocate your resources and personnel?

How could you address issues of boundaries, transitions, patient tracking, and avoiding conflicts among providers?

What is a Consumer?

A person who has the power to buy, to choose from among options, to demand service, to decide, and to manage their choices and lives

Individuals with an array of interests, values, tastes, opinions, attitudes and intentions

A valued commodity to those who offer products and services

Not just an alternate term for client or patient

Why Do We Need Consumer- Centered Care for Individuals with Mental and Physical Illnesses?

They have choices about services They have to make informed choices

about treatments (especially as the options increase)

They can bring lawsuits They have to comply with any

treatment They are in charge of their personal

process of change

A Consumer-Centered Perspective

Critical Shifts in Perspective fromPathology to ProblemsPulling or Pushing to

PersuasionPatient to PartnerProvider to FacilitatorOutcomes to OptionsManagement to Motivation &

MarketingReactive to Proactive Care

Examples

Changing Substance Abuse and Mental Health Systems

Pogo “We have met the enemy and it is

us” How do systems change? What if we adopted a consumer

perspective? What is needed: Modification or

Transformation?

Implications for Policy

Proactive Approaches and Engagement Activities need to be valued and funded

Find out what the consumer needs and wants before planning services and strategies

Reward Progress not just Ideal or Ultimate Outcomes

Address ambivalence and reluctance to change on part of consumer (and provider)

Build a System of Services

Concluding Thoughts

Change is a complicated process Need a roadmap Need both an Overview of the larger

process as well as a Focused view of a particular client

Negotiating Change and Entering the Client’s Change Process requires patience and persistence; optimism and realism; and the perspective of a coach of a minor league team