ADDICTION AND CHANGE: Understanding and Intervening in the Process

Carlo C.DiClemente, Ph.D. ABPP UMBC Psychology www.umbc.edu/psych/habits

What are Addictions?

 Habitual patterns of intentional, appetitive behaviors  Become excessive and produce serious consequences  Stability of these problematic behavior patterns over time  Interrelated physiological and psychological components  Addicted individuals have difficulty modifying and stopping them

Traditional Models for Understanding Addictions

 Social/Environmental Models  Genetic/Physiological Models  Personality/Intra-psychic Models  Coping/Social Learning Models  Conditioning/Reinforcement Models  Compulsive/Excessive Behavior Models  Integrative Bio-Psycho-Social Models

Change the Integrating Principle

 No single developmental model or singular historical path can explain acquisition of and recovery from addictions  A Focus on the Process of Change and how individuals change can bring together different perspectives

Personal 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 ADDICTED



Happens over a Period of Time



Has a Variable Course



Involves a Variety of Predictors that can be both Risk and Protective Factors



Involves a Process of Change

SUCCESSFUL RECOVERY FROM ADDICTIONS

 Occurs over long periods of time  Often involves multiple attempts and multiple treatments  Consists of self change and/or treatment  Involves changes in other areas of psychosocial functioning

Addiction 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?

 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



ACTION



CONTEMPLATION MAINTENANCE



PREPARATION



COGNITIVE/EXPERIENTIAL PROCESSES OF CHANGE BEHAVIORAL Consciousness Raising Self-Revaluation Environmental Reevaluation Emotional Arousal/Dramatic Relief Social Liberation Self-Liberation Counter-conditioning Stimulus Control Reinforcement Management 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

Model Components (Stages)

1.

Precontemplation

- Not Ready to Change 2.

Contemplation

- Thinking About Change 3.

Preparation

- Getting Ready to Make Change 4.

Action

- Making the Change 5.

Maintenance

- Sustaining Behavior Change Until Integrated into Lifestyle Relapse and Recycling - Slipping Back to Previous Behavior and Re-entering the Cycle of Change Termination - Leaving the cycle of change

Tasks and goals for each of the Stages of Change



PRECONTEMPLATION -

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



TASKS

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

GOAL

: Serious consideration of change for this behavior

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



Reveling



Reluctant



Rebellious



Resigned



Rationalizing

Tasks and goals for each of the 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 the 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



the 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 the Stages of Change



MAINTENANCE –

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



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 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 Recycling 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 Relapse

 Lack of Willpower  Environmental Pressures  Situational Cues  Inadequate skills  Lack of Support for Sobriety  Problematic Self-Efficacy  Part of the Process of Change

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 Concerns Pressure Balance Experiential (Pros & Cons) Processes Behavioral Processes Recycling Relapse

Stages of Change Model Precontemplation

Awareness of need to change

Contemplation

Increasing the Pros for Change and decreasing the Cons

Preparation

Commitment & Planning

Relapse and Recycling Maintenance

Integrating Change into Lifestyle

Action

Implementing and Revising the Plan

Termination

THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY PC C ADDICTION PA A Dependence M PROCESSES, CONTEXT AND MARKERS OF CHANGE PC Dependence C PA RECOVERY A M Sustained Cessation

THE COURSE OF ADDICTION DEPENDENCE ABUSE REGULAR USE REGULAR USE

Theoretical and practical considerations related to Prevention and Stages of Initiation

Expectancies/Beliefs Decision-Making Self-efficacy Precontemplation Contemplation Preparation Action Maintenance Personal Environmental Decisional Cognitive/ Concerns Pressure Balance Experiential (Pros & Cons) Processes Experimentation Behavioral Processes Casual use Regular Use Dependence

Implications for Acquisition and Prevention

 If there is a common but unique pathway, we can better understand where individuals are in this process of change for each addictive behavior  We can distinguish between prevention and treatment better  We can target interventions to the process of change

PREVENTION OF INITIATION OF ADDICTION

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

POPULATION PREVENTION AT- RISK PREVENTION ALREADY AFFLICTED

A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLEN TYPE OF BEHAVIOR ALCOHOL NICOTINE MARIJUANA HEROIN COCAINE AMPHETAMINES LSD GAMBLING EATING DISORDER PC X X X X STAGE OF INITIATION C PA A X M X X X X

4.00

3.00

2.00

1.00

0.00

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

0.45

1.06

1.95

2.54

2.87

PC C Mean P A M

STATEWIDE

Middle School High School

STATEWIDE

Middle School High School

STATEWIDE

Middle School High School

PC 74.5% 55.2% PC 77.6% 59.5% PC 3.1% 4.3% C 20.4% 24.4% C 18.6% 24.4% 2000 P 2.6% 5.9% 2002 P 1.9% 5.0% A 1.5% 5.0% A 1.1% 4.3% C Change: 2002-2000 P A -1.8% 0.0% -0.7% -0.9% -0.4% -0.7% M 1.1% 9.5% M 0.8% 6.8% M -0.3% -2.7%

100 80 60 40 20 0

Q55: % who would smoke a cigarette if offered by best friend 80.7

87.8

94.8

82.9

88.6

94.9

73.4

87.3

95.9

76.1

87.9

94.8

23.6

24.9

25.5

22.7

1.1

0.9

1.2

1.1

2000 2002 Middle School PC C P 2000 2002 High School A M

Key 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 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 Concerns Pressure Balance (Pros & Cons) Cognitive Experiential Processes Behavioral Processes Recycling Relapse

STAGES OF CHANGE AND THERAPIST TASKS PRECONTEMPLATION Raise doubt Increase the client’s perception of risks and problems with current behavior CONTEMPLATION PREPARATION ACTION MAINTENANCE RELAPSE Tip the decisional balance - Evoke reasons for change, risks of not changing; Strengthen client’s self-efficacy for change of current behavior Help the client to determine the best course of action to take in seeking change; Develop a plan Help the client implement the plan; Use skills; Problem solve; Support self-efficacy 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

Key Issues In Interventions

 Coercion, Courts and Mandated Treatment  Family Frustration and Interventions  Confrontation breeds Resistance  Motivation not simply Education needed  Intrinsic and Extrinsic Motivations  Proactive versus Reactive Approaches  Harm Reduction and Motivation

Pregnancy Smoking Cessation

 Many addicted pregnant smokers stop smoking for the pregnancy  Stopping is not quitting  Motivation for postpartum cessation differs  Change motivation is baby focused and NOT for self  Imposed change

Special Issues for Drug Courts and Mandated Assessment & TX

 Accurate assessment: Initiation or Recovery  Critical 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 to 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

 Change engines that enable movement through the stages of change  Doing the right thing at the right time  Cognitive/behavioral processes during early stages  Behavioral processes in preparation, action and maintenance

Processes of Change

 – –

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

 – –

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

Transtheoretical Model: Experiential Processes of Change

Consciousness Raising : Gaining information increasing awareness about the current habitual behavior pattern or the potential new behavior Emotional Arousal : Experiencing emotional reactions about the status quo and/or the new behavior Self –Revaluation : Seeing when and how the status quo or the new behavior fit in with or conflict with personal values Environmental Reevaluation : Recognizing the effects the status quo or new behavior have upon others and the environment Social Liberation : Noticing and increasing social alternatives and norms that help support change in the status quo and/or initiation of the new behavior

Transtheoretical Model: Behavioral Processes of Change

Self Liberation : Accepting responsibility for and committing to make a behavior change Stimulus Control : Creating, altering or avoiding cues/stimuli that trigger or encourage a particular behavior Counter-Conditioning : Substituting new, competing behaviors and activities for the “old” behaviors Reinforcement Management : Rewarding sought after new behaviors while extinguishing (eliminating reinforcements) from the status quo behavior Helping Relationships : Seeking and Receiving support from others (family, friends, peers)

P R O C E S S E S PROCESSES OF CHANGE by STAGE STAGES PC C PA A M Consciousness raising Self-reevaluation Dramatic relief Helping relationship Self- liberation Contingency management Counter conditioning Stimulus control

CONTEXT 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 Analysis

1. Sit PreC Cont Prep Action Maint 2. Cog 3. Rel 4. Sys 5. Per

TRANSITIONS THROUGH THE STAGES OF ADDICTION FOR ALLEN: Potential Complicating Problems CONTEXT OF CHANGE STAGE OF CHANGE TRANSTIONS PC C C PA PA A SPECIFIC BEHAVIORAL & SITUATIONAL ISSUES BELIEFS & EXPECTANCIES Soft vs. Hard Drugs INTER PERSONAL SOCIAL SYSTEMS School (Family, Employment, Social) success ENDURING PERSONAL CHARACTERISTICS Religious beliefs Brother & Peers Sex & alcohol Girlfriend/ Intimacy Peers Risk taking A M Multiple Addictions Parental smoking

TRANSITIONS THROUGH THE STAGES OF RECOVERY FOR ALLEN: Potential Complicating Problems CONTEXT OF CHANGE STAGES OF CHANGE PC C C PA SPECIFIC BEHAVIORAL & Multiple SITUATIONAL ISSUES Addictions BELIEFS & EXPECTANCIES Soft vs. hard drugs INTER PERSONAL SOCIAL SYSTEMS (Family, Employment, Social) Peers ENDURING PERSONAL CHARACTERISTICS Sex & alcohol Girlfriend/ Intimacy Brother & Peers

Impulsive

PA A

Seeking Help AA

A M

Work

Difficult Clients and Client Difficulties: A TTM Analysis  Target Problem and Contextual Problems  Stage of Change for Each Problem  Identifying Key Processes of Change  Finding Appropriate Strategies to Engage Processes  Recycling and Learning from the Past  Accomplishing Stage Tasks Adequately

Project MATCH: Alcohol Impairment at Baseline

Percent of Days Abstinent Drinks per Drinking Day No. of SCID Symptoms Prior IP Alcohol Treatment Number of Participants Outpatient 34.3

13.5

5.77

45.0% 952 Aftercare 26.8

20.5

6.79

58.3% 774

100 90 80 70 60 50 40 30 20 10 0 Mean Percent Days Abstinent as a Function of Time (Outpatient) -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 TTM Variables Conf Temp

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 TTM Variables Exp Beh

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 TTM Variables Conf Temp

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 TTM Variables Exp Beh

Abstinent Moderate Heavier

CLIENT PROCESS OF INTENTIONAL BEHAVIOR CHANGE THERAPIST TREATMENT

PROCESS OF

FORMAL INTER VENTIONS

CHANGE