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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?. 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

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  1. ADDICTION AND CHANGE:Understanding and Intervening in the Process Carlo C.DiClemente, Ph.D. ABPP UMBC Psychology www.umbc.edu/psych/habits

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. The “Five R’s” of How and Why People Stay in Precontemplation • Reveling • Reluctant • Rebellious • Resigned • Rationalizing

  14. 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.

  15. Decisional Balance Worksheet NO CHANGE PROS (Behavior) _______________ _______________ _______________ CONS (Change) _______________ _______________ _______________ CHANGE CONS (Behavior) _______________ _______________ _______________ PROS (Change) ______________________________ _______________

  16. 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.

  17. 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).

  18. 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.

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

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

  25. THE COURSE OF ADDICTION DEPENDENCE ABUSE REGULAR USE REGULAR USE CASUAL USE CASUAL USE EXPERIMENTATION EXPERIMENTATION

  26. 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

  27. 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

  28. PREVENTION OF INITIATION OF ADDICTION PC - C C - PA PA - A A - M ALREADY AFFLICTED AT- RISK PREVENTION POPULATION PREVENTION

  29. A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLEN 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

  30. 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

  31. 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

  32. 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

  33. STAGES OF CHANGE AND THERAPIST TASKS 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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)

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