the process of human behavior change carlo c. diclemente professor of psychology university of...

The Process of Human Behavior Change

Carlo C. DiClementeProfessor of Psychology

University of Maryland, Baltimore Countywww.umbc.edu/psych/habits

www.mdquit.org

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

HEALTH PROMOTION & REQUIRE BEHAVIORDISEASE PREVENTION CHANGE

CANCER PREVENTION

CHRONIC ILLNESS MANAGEMENT

MENTAL HEALTH

MEDICATION ADHERENCE

HEALTH PROTECTION

SUBSTANCE ABUSE

INITIATION

MODIFICATION

CESSATION

COMMUNITY HEALTH ORGANIZATIONALSERVICE DELIVERY REQUIRE & INDIVIDUALSYSTEMS BEHAVIOR CHANGE

NEW DISCOVERIES

CHRONIC ILLNESS MANAGEMENT

NEW POLICY OR PROCEDURES

CHANGES IN PROVIDERS

CHANGES IN FUNDING

SHIFTS IN MANAGEMENT

INITIATION

MODIFICATION

CESSATION

Different Patterns of Behavior Change

Initiation, Modification, Cessation

Moderated and Self-Regulated Behavior Pattern

EXCESS

ABSENCE

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

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

HOW PEOPLE CHANGE

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

Clear Difference Between Pre Action and Action Stages

The Key Link

Pre ActionStages

ActionStages

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?

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

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

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

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

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

Understanding Barriers to Change and the Tasks of the Stages of Change

UNMOTIVATED UNWILLING UNABLE

Precontemplation Contemplation Preparation Action Maintenance

The Transtheoretical Model of Intentional Behavior Change

STAGES OF CHANGE

PRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE

PROCESSES OF CHANGE

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

CONTEXT OF CHANGE

1. Current Life Situation2. Beliefs and Attitudes3. Interpersonal Relationships4. Social Systems5. Enduring Personal Characteristics

MARKERS OF CHANGE

Decisional Balance Self-Efficacy/Temptation

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 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

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 with 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

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.

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

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).

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

• Long-term Follow Through

• Integrating New Behaviors into Lifestyle or Organization

• Creating a New Behavioral Norm

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

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

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

Theoretical and Practical Considerations Related to Movement Through the Stages of Change

Motivation

Precontemplation Contemplation Preparation Action Maintenance

PersonalConcerns

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?

Decision Making Self-efficacy

Relapse

EnvironmentalPressure

Decisional Balance

CognitiveExperiential Processes

Behavioral Processes

Recycling

TASK COMPLETION AND MOVEMENT BETWEEN STAGES

PC CON PREP ACT MAIN

INTERESTCONCERN

RISK/REWARDDECISION

COMMMITMENTPLANNINGPRIORITIZING

IMPLEMENTTHE PLANREVISE

LIFESTYLEINTEGRATIONAVOIDRELAPSE

The Smoker’s Journey

Satisfied Dependentor CasualSmoker

Dissatisfied but ambivalent

Decided toMake a QuitAttempt

ChoosingA MethodNRT, TX, Cold Turkey,Quitline

QuitAttempt

ShortTermSuccess

LongTermSuccess

RelapseAndRecycling

Policy

Price

Social pressure

SmokingIn

Network Tobacco Advertising

Beliefs & Myths

Quitting History

PersonalConcerns

SpecialEvents

PsychiatricConditionsAnd Other

Life Problems

Promotion

SocialSupport

Products&

Services

STAGES OF CHANGE AND INTERVENTION TASKS STAGES OF CHANGE AND INTERVENTION TASKS

RELAPSE

CONTEMPLATION

PRECONTEMPLATIONRaise doubt - Increase the client’s perception of risks and problems with current behavior

Tip the decisional balance - Evoke reasons for change, risks of not changing; Strengthen client’s self-efficacy for change of current behavior

PREPARATIONHelp the client to determine the best course of action to take in seeking change; Develop a plan

ACTIONHelp the client implement the plan; Use skills; Problem solve; Support self-efficacy

MAINTENANCEHelp the client identify and use strategies to prevent relapse; Resolve associated problems

Help the client recycle through the stages of contemplation, preparation, and action, without becoming stuck or demoralized because of relapse

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

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

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

Some Examples

• Initiation and Recovery from Addiction

• Medication & HIV/AIDS Compliance enhancement

• Trauma Unit Screening and Interventions for Risky Drinking

• Group Therapy Manual

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

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

ADDICTIONADDICTION

RECOVERYRECOVERY

SustainedCessation

Dependence

PROCESSES, CONTEXT AND MARKERS OF CHANGE

Dependence

PC C PA A M

PC C PA A M

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

Adolescents, Emerging Adults and Recovery

• Precontemplation• Contemplation• Preparation• Action• Maintenance• Relapse

• Fewer Consequences• Developing Self-

Regulation• Impulsivity• Poor Planning• Abstinence Forever• Social Pressures

Multiple Problems Complicate the Process of

Change

The Context of Change:A Figure Ground Perspective

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

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

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

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.

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.

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

How Do Interventions Work?

INDIVIDUAL INTERVENTION

Static Interaction Model

How Do Interventions Work?

Dynamic Model: Stepping into a Flowing Stream

PROCESS OF INTENTIONAL

BEHAVIOR CHANGE

CLIENT

PROVIDER

TREATMENT

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