ADDICTION AND CHANGE:ADDICTION AND CHANGE:Understanding and Intervening Understanding and Intervening

in the Processin the Process

Carlo C.DiClemente, Ph.D. ABPP

UMBC Psychology

www.umbc.edu/psych/habits

What are Addictions?What are Addictions?Habitual patterns of intentional, appetitive

behaviorsBecome excessive and produce serious

consequencesStability of these problematic behavior patterns

over timeInterrelated physiological and psychological

componentsAddicted individuals have difficulty modifying

and stopping them

Traditional Models for Traditional Models for Understanding AddictionsUnderstanding Addictions

Social/Environmental ModelsGenetic/Physiological ModelsPersonality/Intra-psychic ModelsCoping/Social Learning ModelsConditioning/Reinforcement ModelsCompulsive/Excessive Behavior ModelsIntegrative Bio-Psycho-Social Models

Change the Integrating Change the Integrating PrinciplePrinciple

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 can bring together different perspectives

Personal Pathways to ChangePersonal Pathways to Change

Are influenced by personal decisional considerations and choices

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

There is an interaction between the individual and the surrounding risk and protective factors

BECOMING ADDICTEDBECOMING ADDICTED

Happens over a Period of TimeHas a Variable CourseInvolves a Variety of Predictors

that can be both Risk and Protective Factors

Involves a Process of Change

SUCCESSFUL RECOVERY SUCCESSFUL RECOVERY FROM ADDICTIONSFROM ADDICTIONS

Occurs over long periods of timeOften involves multiple attempts and

multiple treatmentsConsists of self change and/or

treatmentInvolves changes in other areas of

psychosocial functioning

Addiction and ChangeAddiction and Change

Both acquisition of and addiction and recovery from an addiction require a personal journey through an intentional change process that is influenced at various points by the host of factors identified in the previous reviewed etiological models.

Involves a Process of Change

How Do People Change? How Do People Change?

People change voluntarily only when they– Become concerned about the need for change– Become convinced that the change is in their best

interests or will benefit them more than cost them

– Organize a plan of action that they are committed to implementing

– Take the actions that are necessary to make the change and sustain the 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 CHANGEDecisional Balance Self-Efficacy/Temptation

Model Components (Stages)Model Components (Stages)

1. Precontemplation - Not Ready to Change2. Contemplation - Thinking About Change3. Preparation - Getting Ready to Make Change4. Action - Making the Change5. Maintenance - Sustaining Behavior Change Until

Integrated into Lifestyle Relapse and Recycling - Slipping Back to Previous

Behavior and Re-entering the Cycle of ChangeTermination - Leaving the cycle of change

Tasks and goals for each of Tasks and goals for each of the Stages of Changethe 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

The “Five R’s” of How and Why The “Five R’s” of How and Why People Stay in PrecontemplationPeople Stay in Precontemplation

RevelingReluctantRebelliousResignedRationalizing

Tasks and goals for each of Tasks and goals for each of the Stages of Changethe Stages of Change

CONTEMPLATION – The stage where the individual 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 (Behavior)_____________________________________________

CONS (Change)_____________________________________________

CHANGE

CONS (Behavior)_____________________________________________

PROS (Change)_____________________________________________

Tasks and goals for each of Tasks and goals for each of the Stages of Changethe Stages of Change

PREPARATION – The stage in which the individual 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 viable, realistic, change plan.

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

Tasks and goals for each of Tasks and goals for each of the Stages of Changethe Stages of Change

ACTION – The stage in which the individual 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).

Tasks and goals for each of Tasks and goals for each of the Stages of Changethe 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.

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

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

Stage of Change TasksStage of Change Tasks Precontemplation

Contemplation

Preparation

Action

Maintenance

Awareness, Concern,Confidence

Risk-Reward Analysis & Decision making

Commitment & Creating an Effective/Acceptable Plan

Adequate Implementation of Plan and Revising as Needed

Integration into Lifestyle

Regression, Relapse and Regression, Relapse and Recycling through the StagesRecycling through the Stages

Regression represents movement backward through the stages

Slips are brief returns to the prior behavior that represent failures of action or the action plan

Relapse is a return to re-engagement in the previous behavior to a significant degree after initial success

After returning to the prior status quo behavior, individuals re-enters pre-action stages at precontemplation, contemplation, or preparation and may feel like a failure and discouraged about her ability to change

Reasons for RelapseReasons for Relapse

Lack of WillpowerEnvironmental PressuresSituational CuesInadequate skillsLack of Support for SobrietyProblematic Self-EfficacyPart of the Process of Change

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

Motivation Decision-Making Self-efficacy

Precontemplation Contemplation Preparation Action Maintenance

Personal Environmental Decisional Cognitive Behavioral Concerns Pressure Balance Experiential Processes

(Pros & Cons) Processes

Recycling Relapse

PrecontemplationAwareness of need to change

ContemplationIncreasing the Pros for Change

and decreasing the Cons

ActionImplementing and Revising the Plan

Termination

Stages of Change Model

Relapse andRecycling

MaintenanceIntegrating Change into

Lifestyle

PreparationCommitment & Planning

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

THE COURSE OF ADDICTIONTHE COURSE OF ADDICTIONTHE COURSE OF ADDICTIONTHE COURSE OF ADDICTION

EXPERIMENTATIONEXPERIMENTATION

CASUAL USECASUAL USE

REGULAR USEREGULAR USE

EXPERIMENTATION

CASUAL USE

REGULAR USE

ABUSE

DEPENDENCEDEPENDENCE

Theoretical and practical considerations related Theoretical and practical considerations related to Prevention and Stages of Initiationto 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

Implications for Acquisition Implications for Acquisition and Preventionand 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

PREVENTION OF INITIATION OF ADDICTIONPREVENTION OF INITIATION OF ADDICTIONPREVENTION 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 A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLENALLEN

A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLENALLEN

TYPE OFBEHAVIOR

STAGE OF INITIATION

PC C PA A M

ALCOHOL

NICOTINE

MARIJUANA

HEROIN

COCAINE

AMPHETAMINES

LSD

GAMBLING

EATING DISORDER

XXXXXX

XXXX

XXXX

XXXX

2000 Cross-sectional Data: Q85 How many of your four closest friends

smoke?

0.45

1.06

1.95

2.54

2.87

0.00

1.00

2.00

3.00

4.00

Mean

PC C P A M

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

Q55: % who would smoke a cigarette if offered by best friend

1.1 0.9 1.2 1.1

22.7 23.6 24.9 25.5

80.7 82.9

73.4 76.1

87.8 88.6 87.3 87.9

94.8 94.9 95.9 94.8

0

20

40

60

80

100

2000 2002 2000 2002

Middle School High School

PC C P A M

Key Issues In PreventionKey Issues In Prevention

Know where individuals are in the process of initiation

Create credible messages that do not do more harm than good

Target high risk individuals in the preparation and action stages who are at highest risk

Focus on the context of change not simply the behavior

Realize that individuals are in different stages with regard to different problematic and positive behaviors

The Well-Maintained AddictionThe Well-Maintained Addiction

Defining action and maintenance is critical for initiation of health risks, like addiction, as well as health protection behaviors

Regular, dependent use of a substance that creates creates a pattern that eludes self-regulatory control, continues despite negative feedback, and becomes an integral part of the individual’s life and coping

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 Concerns Pressure Balance Experiential Processes

(Pros & Cons) Processes

Recycling Relapse

STAGES OF CHANGE AND THERAPIST TASKS STAGES OF CHANGE AND THERAPIST 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

Key Issues In InterventionsKey Issues In Interventions

Coercion, Courts and Mandated TreatmentFamily Frustration and InterventionsConfrontation breeds ResistanceMotivation not simply Education neededIntrinsic and Extrinsic MotivationsProactive versus Reactive ApproachesHarm Reduction and Motivation

Pregnancy Smoking Pregnancy Smoking CessationCessation

Many addicted pregnant smokers stop smoking for the pregnancy

Stopping is not quittingMotivation for postpartum cessation differsChange motivation is baby focused and

NOT for selfImposed change

Special Issues for Drug Courts Special Issues for Drug Courts and Mandated Assessment & TXand Mandated Assessment & TXAccurate assessment: Initiation or RecoveryCritical Distinctions:

– Extrinsic and Intrinsic Motivations– Consequences and Punishment versus

Motivation and Change– Mandated Treatment versus Mandated Change

Clear Communication between Legal System and Intervention System

Approaches that Pay Attention Approaches that Pay Attention to the Process of Changeto the Process of Change

Clearly identify the target behavior Evaluate stage of readiness to change Evaluate beliefs 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 process of change

Processes of Change Processes of Change

Change engines that enable movement through the stages of change

Doing the right thing at the right timeCognitive/behavioral processes during early

stagesBehavioral processes in preparation, action

and maintenance

Processes of ChangeProcesses 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: Transtheoretical Model: Experiential Processes of ChangeExperiential 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: Transtheoretical Model: Behavioral Processes of Behavioral Processes of

ChangeChange 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 STAGEPROCESSES 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

CONTEXT OF CHANGECONTEXT OF CHANGECONTEXT OF CHANGECONTEXT OF CHANGE

I. SITUATIONAL RESOURCES AND PROLBLEMS

II. COGNITIONS AND BELIEFS

III. INTERPERSONAL RESOURCES/PROBLEMS

IV. FAMILY & SYSTEMS

V. ENDURING PERSONAL CHARACTERISTICS

Stages by Context AnalysisStages by Context Analysis

PreC Cont Prep Action Maint

1. Sit

2. Cog

3. Rel

4. Sys

5. Per

Experiential Processes

Behavioral Processes

TRANSITIONS THROUGH THE TRANSITIONS THROUGH THE STAGES OF ADDICTION FOR ALLEN:STAGES OF ADDICTION FOR ALLEN:

Potential Complicating ProblemsPotential Complicating Problems

TRANSITIONS THROUGH THE TRANSITIONS THROUGH THE STAGES OF ADDICTION FOR ALLEN:STAGES OF ADDICTION FOR ALLEN:

Potential Complicating ProblemsPotential Complicating Problems

STAGE OF CHANGE TRANSTIONSCONTEXT OF CHANGE

PC C C PA PA A A M

SPECIFIC BEHAVIORAL &SITUATIONAL ISSUES

BELIEFS &EXPECTANCIES

INTERPERSONAL

SOCIAL SYSTEMS (Family, Employment, Social)

ENDURING PERSONALCHARACTERISTICS

Multiple Addictions

Sex & alcohol

Girlfriend/Intimacy

Peers

Soft vs. Hard Drugs

Brother &Peers

Parentalsmoking

Risk taking

Schoolsuccess

Religiousbeliefs

TRANSITIONS THROUGH THE TRANSITIONS THROUGH THE STAGES OF RECOVERY FOR ALLEN:STAGES OF RECOVERY FOR ALLEN:

Potential Complicating ProblemsPotential Complicating Problems

TRANSITIONS THROUGH THE TRANSITIONS THROUGH THE STAGES OF RECOVERY FOR ALLEN:STAGES OF RECOVERY FOR ALLEN:

Potential Complicating ProblemsPotential Complicating Problems

STAGES OF CHANGECONTEXT OF CHANGE

PC C C PA PA A A M

SPECIFIC BEHAVIORAL &SITUATIONAL ISSUES

BELIEFS &EXPECTANCIES

INTERPERSONAL

SOCIAL SYSTEMS (Family, Employment, Social)

ENDURING PERSONALCHARACTERISTICS

Multiple Addictions

Sex & alcohol

Girlfriend/Intimacy

Peers

Soft vs. hard drugs

Brother &Peers

AA Work

SeekingHelp

Impulsive

Difficult Clients and Client Difficulties: Difficult Clients and Client Difficulties: A TTM AnalysisA TTM Analysis

Target Problem and Contextual ProblemsStage of Change for Each ProblemIdentifying Key Processes of ChangeFinding Appropriate Strategies to Engage

ProcessesRecycling and Learning from the PastAccomplishing Stage Tasks Adequately

Project MATCH: Alcohol Project MATCH: Alcohol Impairment at BaselineImpairment at Baseline

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

Mean Percent Days Abstinent as a Mean Percent Days Abstinent as a Function of Time (Outpatient)Function of Time (Outpatient)

0102030405060708090

100

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

CBT MET TSF

TTM Profile: Outpatient PDA Baseline

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Pre Con Act Main Conf TempTTM Variables

Sta

nd

ard

Sco

res

Abstinent

Moderate

Heavier

TTM Profile: Outpatient PDA Post Treatment

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Pre Con Act Main Conf Temp Exp BehTTM Variables

Sta

nd

ard

Sco

res

Abstinent

Moderate

Heavier

TTM Profile: Aftercare PDA Baseline

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Pre Con Act Main Conf TempTTM Variables

Sta

nd

ard

Sco

res

Abstinent

Moderate

Heavier

TTM Profile: Aftercare PDA Post Treatment

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Pre Con Act Main Conf Temp Exp BehTTM Variables

Sta

nd

ard

Sco

res

Abstinent

Moderate

Heavier

PROCESS OFINTENTIONAL

BEHAVIORCHANGE

CLIENT

THERAPIST

TREATMENT

VENTIONSFORMAL INTER

PROCESS OF

CHANGE