Managing Multiple Problems and Motivation · Decisional Considerations are Personal * Increase the...

transcript

Presented by:

Carlo C. DiClemente Ph.D. ABPP

www.umbc.edu/psych/habits

www.mdquit.org

*Carlo C. DiClemente, Ph.D. is currently the UMBC

Research Professor of Psychology and has conducted

research on addictions and health behaviors for the

past 30 years. He has published several books and

numerous articles on Motivation and the Process of

Change. He reports the following potential conflicts

of interest:

*Prevention Research Institute – Consultant/Royalties

*Gaudenzia Board of Directors

*NAADAC – Honoraria/Consulting

*Upon completion of this course, participants will be able to:

1. To identify several important reasons for Client Centered and

Integrated Care

2. To identify how commonly occurring complicating mental health

and substance abuse problems affect the change process.

3. To identify critical tasks of different stages of change

4. To identify target behaviors related to the client problems and

evaluate readiness of client for addressing each problem

5. To describe how self-regulation plays a role in the process of

change

6. To describe the differences between Coordinated and Integrated

*Key mechanisms for change reside in the

individual who needs to change for intentional

change to be sustained

*Clients are really consumers of services and to

be engaged and valued, and for whom these

products and services need to be tailored to be

consumer focused and friendly

*Each client has a unique history and set of

problems that make change challenging

*IDEO and its approach to addressing

consumers and consumer demand

*Understand the needs and preferences of

consumers

*Design products and services that meet

these needs in innovative and attractive

*We need to treat people not diagnoses

*The whole person not a single problems

*Every change of a targeted problem really

involves multiple changes and often is

complicated by problems and changes needed in

multiple life domains

*Healthcare providers are facing this reality

particularly with Non Communicable Diseases

(CVD, COPD, Diabetes, Addictions) responsible

for 63% of mortality worldwide (WHO report 2012)

*Focuses on new models for viewing how

behavioral health and physical health should

be viewed and treated

*Sees behavioral health as encompassing both

mental health and substance abuse

*Some models include in behavioral health

other chronic conditions that require behavior

change

*Shift to wellness and health

*Interesting new term being used in a variety of ways

*Mental Health

*Substance Abuse

*Sexual Risk Behaviors

*Domestic Violence

*Criminal Justice

*In primary care often means mental health and substance

abuse but can include obesity, exercise and other

behaviors that are intimately involved in health as well as

adherence and interact with both mental health and

substance abuse problems

*Focus on chronic conditions which always involve some

behavior change and management of

psychological/emotional dimensions of the person

*Multidisciplinary – Medical, Pharmacological,

Psychological Behavioral, Environmental, Community,

Systems Sciences must be blended together to achieve

goals of Healthcare Reform

*Collaborations in terms of where services will be given

and integration of information

*Use of new technologies to reach out and extend services

to where patients are

2 High BH

Low PH Primary and

Specialty

4 High BH

High PH Primary and

Specialty

3 Low BH

High PH Primary Care

1 Low BH

Low PH Primary Care

High B

Physical Health Risk/Complexity

• The model is an essential tool

for integrated care planning

• Individuals in Quadrants 1

and 3 generally served in

primary care, Quadrants 2

and 4 in behavioral health

settings

• Collaborative care involves

behavioral health working with

primary care; Integrated care

involves behavioral health

working within and as a part

of primary care.

Mauer, B.

2002/2006

Richard Doherty, Ph.D.

*The perfect place to see the need for client

centered collaboration and for integrated care

*Mutually Complicating Conditions that are

significantly challenging for the individual to

manage and together create an interactive set of

problems that involve biological, psychological,

social, spiritual, and systems dimensions.

*These problems test the breadth and depth of any

treatment program and present significant barriers

for integrated treatment

*Most of our healthcare focuses on defining care by

problem type (diabetes, cancer alcohol illegal drugs,

serious mental illness)

*Specialty care often defines problems by Provider

types (need to see a psychiatrist, a podiatrist, a

gastroenterologist, a cardiologist)

*Focusing on problems makes people “patients” and

simply problem carriers

*Most client/patients have multiple problems

*Need an integrative perspective to be able to create

integrated care

*A focus on the process of change can shift the focus

from problems to how to develop resilience and

coping activities that can address what needs to be

changed

*Shift from etiology and how problems develop to

wellness and how to manage needed changes in

behavior, lifestyle, and environment

CANCER PREVENTION INITIATION

CHRONIC ILLNESS MANAGEMENT

MENTAL HEALTH

MODIFICATION

MEDICATION ADHERENCE

HEALTH PROTECTION

SUBSTANCE ABUSE CESSATION

HEALTHCARE INTERVENTIONS & REQUIRE BEHAVIOR

DISEASE PREVENTION CHANGE

Initiation, Modification, Cessation

Moderated and Self-Regulated Behavior Pattern

EXCESS

ABSENCE

*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

*Cardiovascular Risk

Reduction

*Physical Activity

*Cholesterol screening

and treatment

*Weight Reduction

*Dietary changes

*Aspirin regimen

*Alcohol and Substance

*Diabetes Prevention and

Treatment

*Obesity Prevention and

Reduction

*Glucose monitoring

*Dietary changes

*Physical Activity

*Regular screening for

associated problems

*Alcohol Consumption

*Quitting Substance Abuse

*Stopping substance use

*Possible medication

adherence

*Changing social

network

*Stress Management

*Co-morbid conditions

*Healthy Lifestyle

*Drinking behaviors

*Reducing Excessive

Drinking

*Drinking behaviors

*Social situations and

networks

*Assertiveness

*Associated legal

problems

*Managing anxiety and

stress/PTSD

*Domestic Violence

*Serious Mental Illness

*Managing symptoms

*Medication adherence

*Creating appropriate

social network

*Stress Management

*Co-morbid conditions

*Healthy Lifestyle

*Drug and Alcohol Use

*Depression

*Stopping Depressive

thought patterns

*Behavioral Activation

*Challenging Irrational

beliefs

*Engagement in social

networks

*Drugs and Alcohol Use

*Managing Relationship

issues

*What are the Biggest Challenges you face in

helping people change?

*What are the client’s biggest challenges for

change?

*What interferes with Client Centered Care?

*What do you think you would need (besides

money) to get people to change?

*Basic self-regulatory capacity and self control

strength (Change Regulating Mechanisms)

*Motivation and completing critical tasks of stages

through engagement in appropriate coping

processes of change to create sustained change

*Understanding target behavioral goal and

connected goals

*Managing complicating problems and securing

important resources to accomplish and sustain

change of target behavior

*In a large study researchers at

National Cancer Institute in the US

have discovered that watching

television more than 1 to 2 hours a

week causes brain cancer.

*How many of you would stop

watching TV immediately?

*Clients are not unmotivated! They are either

*Just motivated to engage in behaviors that others consider harmful and problematic

*Not ready to begin behaviors that we think would be helpful

*Motivation belongs to clients and their process of change

*However, motivation can be enhanced or hindered by interactions with others and events in the life-context of the clients

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

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

SAMHSA/CSAT Treatment Improvement Protocol Number 35

*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

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?

**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

*Precontemplation

*Not interested

*Contemplation

*Considering

*Preparation

*Preparing

Action

* Initial change

*Maintenance

*Sustained change

*Interested and concerned

*Risk-reward analysis and decision making

*Commitment and creating an effective/acceptable plan

*Implementation of plan and revision 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-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

Theoretical and Practical Considerations

Related to Movement Through the Stages of

Change

Motivation

Personal

Concerns

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

Environmental

Pressure

Decisional

Balance

Cognitive

Experiential

Processes

Behavioral

Processes

Recycling

*Readiness is usually behavior specific.

*Involves one key behavioral goal and important

component behaviors related to the goal. (Cutting

Down vs. Abstaining; Dietary change vs. Exercise)

*Quantum Change is also possible:

*A constellation of behaviors Under an

overarching goal (healthy lifestyle)

*A conversion or awakening to new life

* A STAGE BY HEALTH BEHAVIOR INITIATION

TYPE OF

BEHAVIOR

STAGE OF INITIATION

PC C PA A M

Physical Activity

Medication - A

Glucose Monitoring

Fruits & Vegetables

Medication - B

*Recovery/Change is a journey through a change process.

You need to bring the right clothes and equipment

successfully negotiate the journey.

*Recently two mountain climbers scaled the sheer face of El

Capitan in Yosemite. I was amazed with the different things

they had with them to make the climb: different spikes for

different configurations of stone, equipment to be able to

sleep at night, and ropes and safety harnesses needed to

make the climb safely.

*The journey of recovery is like that climb. Counselors need

to know how to help clients manage the different

challenges of their journey.

*We need to match our strategies to accommodate where

they are in the journey. The tasks of the stages can guide

*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

*The “Five R’s” of How

and Why People Stay in

Precontemplation

*Reveling

*Reluctant

*Rebellious

*Resigned

*Rationalizing

*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

*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

*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)

_______________

*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

*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

*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.

*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

*COMMITMENT TO TAKE ACTION

*SPECIFIC ACCEPTABLE ACTION PLAN

*TIMELINE FOR IMPLEMENTING PLAN

*ANTICIPATION OF BARRIERS

*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).

*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

*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.

*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

*Continued Commitment

*Skills to Implement the Plan

*Long-term Follow Through

*Integrating New Behaviors into

Lifestyle or Organization

*Creating a New Behavioral Norm

*Read the paragraph and then identify the stage

*Pick a partner and talk about a change you are

considering or think you should make and talk

about it for 4-5 minutes then switch

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

*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

Precontemplation

Increase awareness of need to change

Contemplation

Motivate and increase confidence

in ability to change

Action

Reaffirm commitment

and follow-up

Termination

Stages of Change Model

Relapse

Assist in Coping

Maintenance

Encourage active

problem-solving

Preparation

Negotiate a plan

Theoretical and Practical Considerations

Related to Movement Through the Stages of

Change

Motivation

Personal

Concerns

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

Environmental

Pressure

Decisional

Balance

Cognitive

Experiential

Processes

Behavioral

Processes

Recycling

PC CON PREP ACT MAIN

INTEREST

CONCERN RISK/REWARD

DECISION

COMMMITMENT

PLANNING

PRIORITIZING

IMPLEMENT

THE PLAN

REVISE

LIFESTYLE

INTEGRATION

RELAPSE

*To Promote accomplishment of each of these tasks:

*Interest and Concern

*Decision Making

*Planning and Commitment

*Sustaining Action and Plan Revision

*Integrating Pattern of Behavior into Lifestyle

*Managing Slips and Relapses

STAGES OF CHANGE AND INTERVENTION TASKS

RELAPSE

CONTEMPLATION

PRECONTEMPLATION Raise 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

PREPARATION Help the client to determine the best course of

action to take in seeking change; Develop a plan

ACTION Help the client implement the plan; Use skills;

Problem solve; Support self-efficacy

MAINTENANCE Help 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

*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

*Usually when you change a system

everyone needs to make changes (Families)

*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

*Most models of self regulation include self-observation, self-evaluation, decision making, willingness to consider change, and planning (Miller &

Brown, 1991, Bandura, 1986)

*Self Management, Self Control, Self Monitoring have been critical concepts in treatment so this is not new to treatment providers

*The ability to manage both internal and external demands in a way that is

*responsive to feedback and available information,

*flexible in seeking solutions, and

*does not overtax the system

*Important Self Regulation Skills & Abilities) for behavior change:

*Executive Cognitive Functioning

*Affect Regulation

Self-regulation seems critical for understanding addictions, recovery from addictions, and management of other types of health problems

*Deficits in self-regulation are at the core of definitions of addiction and mental illness

*Interesting new information that looks at more generic mechanisms involved in self-regulation

**Occurs when a person attempts to change the

way he or she would otherwise think, feel or

behave

*Is needed to follow rules or inhibit immediate

desires and to delay gratification

*Involves overriding or inhibiting competing urges,

behaviors, or desires as well as production of

behaviors that are not immediately reinforcing

*Differs from purely automatic processes since

involves effort

Muraven & Baumeister, Psych Bull 126, 247-259, 2000

*“Is necessary for the executive component of the self (i.e., the aspect of the self that makes decisions, initiates and interrupts behavior, and otherwise exerts control) to function (Baumeister, 1998)”

*“Acts of volition and control require strength”

*This strength is a limited resource that is like a muscle that can become fatigued and depleted but can be replenished with regular exercise followed by periods of rest – Not just a Skill or a Capacity

Muraven & Baumeister, Psych Bull 126, 248, 2000

Coping with stress (focus attention, monitor, stop

thoughts, urges, etc)

Affect Regulation and managing negative and

emotions of depression, anxiety, anger

Changing habits (until new becomes habitual)

Managing or stopping addictive and excessive

behaviors

Inhibiting thoughts and behaviors may require

more self-control than performing behaviors

Muraven & Baumeister, 2000

*Not a limitless resource

*Must be conserved

*Can be increased but not infinitely

*Can be strengthened by exercise of self-

control but need time to consolidate gains in

strength

*Is involved in all efforts to inhibit or

perform behaviors but less or not involved

when they become automatic or habitual

*How does motivation and the process

of change interact with this self

regulation process and the self-

control “muscle”?

*Recognize that this can disrupt the client’s

work and the process of change

*Provide “scaffolding” external support systems

that can support the change process

*Provide a way the client can build self-control

muscle

*Make sure the building is well build before you

take down the “scaffolding”

*What drives change and makes change

happen for each individual?

*Where should we look for these Mechanisms?

*Are there some common Mechanisms that are

responsible for change across addictions and

across behaviors

*There are several areas where candidates for mechanisms of change can be found:

*Person (biology and neuroscience, personality, motivation, demographics)

*Provider (therapist characteristics, skill, empathy)

*Intervention/Treatment (therapy theory or strategies, alliance, dose, type)

*Attribute x Treatment interactions (matching)

*Environmental mechanisms (social, peer, policy, physical (built), enforcement, reinforcement)

*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

* 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

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

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 Emotional Arousal Helping relationship Self- liberation Contingency management Counter- conditioning Stimulus control

P R O C E S S E S

*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.

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

1. The Stages of Change

2. Identifying “Triggers”- Stimulus Control

3. Managing Stress-Counter-conditioning

4. Rewarding My Successes-Reinforcement Management

5. Effective Communication-Counter-conditioning, Reinforcement Management

6. Effective Refusals-Counter-conditioning, Reinforcement Management

*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?

Personal Processes

Treatment Strategies

The Context of Change:

A Figure Ground Perspective

How do these further complicate the change process?

* CONTEXT OF CHANGE

Where to look for complicating problems

I. SITUATIONAL RESOURCES AND

PROBLEMS

II. COGNITIONS AND BELIEFS

III. INTERPERSONAL

RESOURCES/PROBLEMS

IV. FAMILY & SYSTEMS

V. ENDURING PERSONAL

CHARACTERISTICS

*Symptom/Situation

*Psychiatric

*Financial/housing

*Beliefs and Attitudes (explicit and implicit)

*Religious views

*Cultural beliefs and family myths

* Interpersonal (dyadic)

*Marital/Significant Other Issues

*Systemic and Ecological/Environmental

*Employment

*Family/Children dynamics

* Intrapersonal

*Self-Esteem

*Sexual Identity

STAGES OF CHANGE CONTEXT OF

CHANGE PC C C PA PA A A M

SPECIFIC BEHAVIORAL/

SITUATIONAL

BELIEFS &

EXPECTANCIES

PERSONAL

SOCIAL SYSTEMS (Family, Employment, Social)

ENDURING PERSONAL

CHARACTERISTICS

*Housing and Financial Problems need specific

social services

*Belief systems may require consultation with

specialists and cognitive therapy skills

*Interpersonal and Systems Problems need special

expertise

*Legal problems need criminal justice involvement

*Personality disorders and deep seated problems

need long term treatment

Multi-Service Center

Homeless Encampment

Multi-Service Center

Sheltered Employment

Day Rehabiliation

Community Living

Residential Treatment

Crisis Residential

Emergency Shelter

County Mental H

General Assistance

Veterans’ Services

Substance Abuse Treatment

Vocational R

ehabilitatio

Social Security

Homeless Services

PreC Cont Prep Action Maint

II Cog

III Rel

IV Sys

Experiential Processes

Behavioral Processes

*Safety and security needs of client or others

*Critical first Problem to be addressed (Patient)

*Problem that Provider evaluates as critical key

to change target behavior

*Problem where I have the most leverage

(motivation, importance, identified problem

*Collaboration in prioritizing with client(s)

Family

Problems

Cocaine

Problems

No Stable

Housing

HIV Positive No Job or

Job Skills

Excessive

Drinking

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

*KEY AREA OR CONTEXT – Find problem or area where you may have the most leverage 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

*How serious is the problem?

*Not Evident

*Not Serious

*Serious

*Very Serious

*Extremely Serious

*Differs whether the perspective is that of patient or provider

*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

*Clearly identify target behavior and contextual problems

*Evaluate stage of readiness to change

*Evaluate beliefs, values and practices related to target behavior

*Examine routes and mechanisms of influence that are culturally and personally relevant

*Create stage based multi-component interventions

*Re-evaluate regularly the change process

*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

*Involve Symptoms, Emotions, Cognitions and

Behaviors

*Although illness is not chosen, it 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

*Exhausts Self-Control Strength

*How connected?

*Understand the Interactions?

*Where do you have some leverage?

*Can you stabilize one or another problem?

*Where do you have motivation?

*What does the client really want?

*What can your system provide?

*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,

Decision Making, Persuasion approaches are

important strategies to engage and work with

clients helping them to engages

cognitive/experiential processes of change and to

successfully complete these tasks.

*Facilitating Factors

*Accurate, empathic feedback

*Good Self-Evaluation skills

*Important values, goals and self-standards

*Understandable consequences and reasons

*Good Affect Regulation

*Hindering Factors

*Obsessive style

*Environments and experiences that protect against consequences

*Ambivalence

*Impulsiveness and poor ECF skills

*Depression

*Facilitating Factors

*Support Systems

*Choice

*Public Commitment

*Ability to defer

gratification

*Ability to take a

long-term

perspective

*Hindering Factors

*Poor planning ability

*Multiple Problems

*Distracting Activities

and Events

*Stress

*Multiple Tasks

*Depleted Self-Control

Strength

*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.

*Skills

*Self Control Strength

*Environment

*Social Networks

*Support Systems (Helping Relationships)

*Self-Efficacy

* THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY

ADDICTION

RECOVERY Sustained

Cessation

Dependence

PROCESSES, CONTEXT AND MARKERS

OF CHANGE

Dependence

PC C PA A M

* A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLEN

TYPE OF

BEHAVIOR

STAGE OF INITIATION

PC C PA A M

ALCOHOL

NICOTINE

MARIJUANA

HEROIN

COCAINE

AMPHETAMINES

GAMBLING

EATING DISORDER

* PREVENTION OF INITIATION OF ADDICTION

PC - C C - PA PA - A A - M

POPULATION

PREVENTION

AT- RISK

PREVENTION

ALREADY

AFFLICTED

*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

PA A M

Lifetime and 30 day prevalence: Population Prevalence 50% lifetime and 20% current smoking; apply to populations or subpopulations

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

Mean Number of Friends who Smoke

0.740.92

2.041.94

1.761.67

2.67 2.70

2.262.38

MS HS MS HS

2000 2002

PC C P A M

*Client status during follow-up period:

*Abstinent

*Moderate drinking

*Heavier drinking

*Client Profile on Stage of change Subscales,

Temptation to Drink, Abstinence Self-

Efficacy, Experiential and Behavioral

Processes of Change

TTM Profile: Outpatient PDA Baseline

Pre Con Act Main Conf TempTTM Variables

Abstinent

Moderate

Heavier

TTM Profile: Outpatient PDA Post Treatment

Pre Con Act Main Conf Temp Exp BehTTM Variables

Abstinent

Moderate

Heavier

*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

*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

*Single agency with all services

*Multiple Agencies in single building

*Case Management

*Single server with multiple roles

*Referral Internal

*Referral External

*Patient controlled as needed

*A manager of problems or

services

*Tries to link patient and

various providers

*Often affiliated with a single

provider and trying to

connect to others

*Inadequate resources to

meet needs

*A coordinated approach to

addressing the person in

light of multiple

complicating problems

*A team of providers

working together linked by

client needs

*Reciprocal Communication

and Referral flow

*Case Managers act as triage and connectors

to providers

*Patient Navigators

*Key Provider (Family practitioner; MST

Therapist)

*Managed Care

*Federally Qualified Healthcare Homes

*Targets Substance Use, Mental Health, and

Infectious Disease Testing and Treatment

*Involves Maryland Department of Health and

Mental Hygiene and their Drug Abuse, Mental

Health, Prevention and Health Promotion

administrations and academic partners

*Funded by SAMHSA

*Create a system of care where whatever door

the client enters, he or she will be screened,

assessed and treated for problems in all three

*A Process Model to guide decision making

*Interdisciplinary and multidisciplinary resources

*Time sensitive communication system

*Client oriented, empowerment approaches

*Flexible allocation of Resources

*Lack of adequate actionable

assessment

*Specialist Model of Care

*Lack of collaboration among

providers and programs

*Lack of integrated medical

record accessible to all

healthcare providers

*Lack of incentives and lack

of trust among providers

INDIVIDUAL INTERVENTION

Static Interaction Model

Target

Problem

Dynamic Model: Stepping into a Flowing Stream

B helpful hindering

Problems Process

*Use a model that focus on patient needs and

desires, motivation, and self-regulation

*Create systems of care not treatment programs

*Build Integrated Care training capacity not just

cross training or just learning about what other

specialists do

*Create a system of communication among

professionals that focuses on client and used to

coordinate interventions and treatment (patient

oriented medical record?)

** Connors, G., Donovan, D., & DiClemente, CC. (2012) Substance Abuse Treatment and the Stages of Change

(Second Edition). New York: Guilford Press.

* DiClemente, C. C., Kofeldt, M., & Gemmell, L. (2011). Motivational enhancement. In M. Galanter, H. D. Kleber

(Eds.), Psychotherapy for the treatment of substance abuse (pp. 125-152). Arlington, VA US: American

Psychiatric Publishing.

* DiClemente, C. C., Holmgren, M. A., & Rounsaville, D. (2011). Relapse prevention and recycling in addiction. In

B. Johnson (Ed.), Addiction Medicine: Science and Practice, New York: Springer.

* DiClemente, C.C. (2005) Conceptual Models and Applied Research: The Ongoing Contribution of the

Transtheoretical Model. Journal of Addictions Nursing, 16, 5-12.

* DiClemente, C.C., Schlundt, D., & Gemell, L. (2004) Readiness and Stages of Change in Addiction Treatment.

The American Journal on Addictions, 13, 103-119.

* DiClemente, C.C. (2003). Addiction & Change: How Addictions Develop and Addicted People Recover. New York,

NY: The Guilford Press.

* DiClemente, C.C. (2006) Natural Change and the Troublesome Use of Substances. IN W.R. Miller & K.M. Carroll

(Eds.) Rethinking Substance Abuse: What the science shows and what we should do about it. New York: Guilford

Press.

* DiClemente, C.C., & Velasquez, M. (2002). Motivational interviewing and the stages of change. In W.R. Miller &

S. Rollnick (Eds.), Motivational interviewing (2nd ed., pp. 201-216). New York, NY: Guilford Publications, Inc.

* Gregory, H. Jr., Van Orden, O., Jordan, L., Portnoy, G. A., Welsh, E., Betkowski, J., Charles, J. W., &

DiClemente, C. C. (2012). New directions in capacity building: Incorporating cultural competence into the

interactive systems framework. American Journal of Community Psychology, in press.

* Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational Enhancement Therapy

manual: A clinical research guide for therapists and individuals with alcohol abuse and dependence. Rockville,

MD: NI AAA.

* Prochaska, J.O., Norcross, J.C. & DiClemente, C.C. (1994) Changing for Good. New York: Avon books.

* Velasquez, M.M., Maurer, G.G., Crouch, C. & DiClemente, C.C. (2001). Group Treatment for Substance Abuse: A

Stages of Change Therapy Manual. New York: Guilford Press.

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