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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

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Addiction and change understanding and intervening in the process

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
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
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
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
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
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
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
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
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 CHANGE

COGNITIVE/EXPERIENTIALBEHAVIORAL

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


Model components stages
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
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
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 change1
Tasks and goals for each of the Stages of Change Precontemplation

  • 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 Precontemplation

NO CHANGE

PROS (Behavior)

_______________

_______________

_______________

CONS (Change)

_______________

_______________

_______________

CHANGE

CONS (Behavior)

_______________

_______________

_______________

PROS (Change)

______________________________

_______________


Tasks and goals for each of the stages of change2
Tasks and goals for each of the Stages of Change Precontemplation

  • 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 change3
Tasks and goals for each of the Stages of Change Precontemplation

  • 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 change4
Tasks and goals for each of the Stages of Change Precontemplation

  • 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 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

Stage of Change Tasks


Regression relapse and recycling through the stages
Regression, Relapse and Recycling through the Stages Precontemplation

  • 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
Reasons for Relapse Precontemplation

  • 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 Behavioral

Concerns Pressure Balance Experiential Processes

(Pros & Cons) Processes

Recycling Relapse


Stages of Change Model through the Stages of Change

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
THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY through the Stages of Change

ADDICTION

Dependence

PC

C

PA

A

M

PROCESSES, CONTEXT AND MARKERS OF CHANGE

PC

C

PA

A

M

Sustained

Cessation

Dependence

RECOVERY


The course of addiction
THE COURSE OF ADDICTION through the Stages of Change

DEPENDENCE

ABUSE

REGULAR USE

REGULAR USE

CASUAL USE

CASUAL USE

EXPERIMENTATION

EXPERIMENTATION


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/ Behavioral

Concerns Pressure Balance Experiential Processes

(Pros & Cons) Processes

Experimentation Casual use Regular Use Dependence


Implications for acquisition and prevention
Implications for Acquisition and Prevention Prevention and Stages of Initiation

  • 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
PREVENTION OF INITIATION OF ADDICTION Prevention and Stages of Initiation

PC - C

C - PA

PA - A

A - M

ALREADY

AFFLICTED

AT- RISK

PREVENTION

POPULATION

PREVENTION


A stage by addictive behavior perspective on allen
A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLEN Prevention and Stages of Initiation

TYPE OF

BEHAVIOR

STAGE OF INITIATION

PC

C

PA

A

M

X

ALCOHOL

X

NICOTINE

X

MARIJUANA

X

HEROIN

X

COCAINE

X

AMPHETAMINES

X

LSD

X

GAMBLING

X

EATING DISORDER


Key issues in prevention
Key Issues In Prevention Prevention and Stages of Initiation

  • 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
The Well-Maintained Addiction Prevention and Stages of Initiation

  • 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 through the Stages of Change

Raise doubt - Increase the client’s perception of

risks and problems with current behavior

PRECONTEMPLATION

Tip the decisional balance - Evoke reasons for

change, risks of not changing; Strengthen client’s

self-efficacy for change of current behavior

CONTEMPLATION

Help the client to determine the best course of

action to take in seeking change; Develop a plan

PREPARATION

Help the client implement the plan; Use skills;

Problem solve; Support self-efficacy

ACTION

Help the client identify and use strategies to

prevent relapse; Resolve associated problems

MAINTENANCE

Help the client recycle through the stages of

contemplation, preparation, and action, without

becoming stuck or demoralized because of relapse

RELAPSE


Key issues in interventions
Key Issues In Interventions through the Stages of Change

  • 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 through the Stages of Change

  • 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
Special Issues for Drug Courts and Mandated Assessment & TX through the Stages of Change

  • 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
Approaches that Pay Attention to the Process of Change through the Stages 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 through the Stages 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 change1
Processes of Change through the Stages 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
Transtheoretical Model: Experiential Processes of Change through the 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


Transtheoretical model behavioral processes of change
Transtheoretical Model: Behavioral Processes of Change through the Stages 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)


PROCESSES OF CHANGE by STAGE through the Stages of Change

STAGES

PC C PA A M

P

R

O

C

E

S

S

E

S

Consciousness raising

Self-reevaluation

Dramatic relief

Helping relationship

Self- liberation

Contingency

management

Counter-

conditioning

Stimulus control


Context of change
CONTEXT OF CHANGE through the Stages 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
Stages by Context Analysis through the Stages of Change

ExperientialProcesses

BehavioralProcesses


Transitions through the stages of addiction for allen potential complicating problems
TRANSITIONS THROUGH THE STAGES OF ADDICTION FOR ALLEN: through the Stages of Change Potential Complicating Problems

STAGE OF CHANGE TRANSTIONS

CONTEXT OF

CHANGE

PC C

C PA

PA A

A M

SPECIFIC BEHAVIORAL &

SITUATIONAL ISSUES

Multiple

Addictions

Religious

beliefs

Soft vs. Hard Drugs

Sex &

alcohol

BELIEFS &

EXPECTANCIES

Girlfriend/

Intimacy

INTER

PERSONAL

School

success

Parental

smoking

SOCIAL SYSTEMS

(Family, Employment, Social)

Brother &

Peers

Peers

Risk

taking

ENDURING PERSONAL

CHARACTERISTICS


Transitions through the stages of recovery for allen potential complicating problems
TRANSITIONS THROUGH THE STAGES OF RECOVERY FOR ALLEN: through the Stages of Change Potential Complicating Problems

STAGES OF CHANGE

CONTEXT OF

CHANGE

PC C

C PA

PA A

A M

Seeking

Help

SPECIFIC BEHAVIORAL &

SITUATIONAL ISSUES

Multiple

Addictions

Sex &

alcohol

BELIEFS &

EXPECTANCIES

Soft vs. hard drugs

Girlfriend/

Intimacy

INTER

PERSONAL

AA

SOCIAL SYSTEMS

(Family, Employment, Social)

Peers

Brother &

Peers

Work

ENDURING PERSONAL

CHARACTERISTICS

Impulsive


Difficult clients and client difficulties a ttm analysis
Difficult Clients and Client Difficulties: A TTM Analysis through the Stages of Change

  • 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

Project MATCH: Alcohol Impairment at Baseline through the Stages of Change



PROCESS OF (Outpatient)

FORMAL

INTER

VENTIONS

CHANGE


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