136
* Presented by: Carlo C. DiClemente Ph.D. ABPP www.umbc.edu/psych/habits www.mdquit.org
*
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
Care
*
*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
ways
*
*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
Low
High
High B
eh
avio
ral H
ea
lth
Ris
k/C
om
ple
xity
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
Use
*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
Or
*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
Precontemplation Contemplation Preparation Action Maintenance
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
X X
X X
X
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
us.
*
*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
Precontemplation Contemplation Preparation Action Maintenance
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
AVOID
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
PP TS
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
INTER
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
Multi-Service Center
Sheltered Employment
Day Rehabiliation
Community Living
HHISN
Residential Treatment
Crisis Residential
Emergency Shelter
County Mental H
ealth
General Assistance
Veterans’ Services
Substance Abuse Treatment
Vocational R
ehabilitatio
n
Social Security
Homeless Services
*
PreC Cont Prep Action Maint
I Sit
II Cog
III Rel
IV Sys
V Per
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
Use
Legal
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
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
LSD
GAMBLING
EATING DISORDER
X X
X X X
X
X X X
* 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
*
PC
C
PA A M
M PC
C PA
A
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
2000
2002
Mean Number of Friends who Smoke
0.23
0.63
0.19
0.50
0.78
1.11
0.740.92
2.041.94
1.761.67
2.66
2.93
2.67 2.70
2.262.38
2.50
2.73
0
1
2
3
4
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
-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
*
*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
areas
*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
1
2
3 A
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.
