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The Challenge of Change: Creating a Recovery- Oriented System of Care

The Challenge of Change: Creating a Recovery- Oriented System of Care. Carlo C. DiClemente Professor of Psychology University of Maryland, Baltimore County www.umbc.edu/psych/habits www.mdquit.org. Organizations and societies must adapt their practices in order to survive and thrive

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The Challenge of Change: Creating a Recovery- Oriented System of Care

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  1. The Challenge of Change:Creating a Recovery- Oriented System of Care Carlo C. DiClemente Professor of Psychology University of Maryland, Baltimore County www.umbc.edu/psych/habits www.mdquit.org

  2. Organizations and societies must adapt their practices in order to survive and thrive Even very successful organizations must continue to change to survive (GM, IBM, Rolls Royce) Key questions are what, whether, and how to change Individuals must constantly change behaviors in response to shifting demands of the life context Failure to change is often a sign of stagnation, pathology and decline Key questions are what, whether and how to change Behavior Change is Critical to the Growth and Development Organizations, Societies, and Individuals

  3. HEALTH PROMOTION & REQUIRE BEHAVIOR DISEASE PREVENTION CHANGE CANCER PREVENTION INITIATION CHRONIC ILLNESS MANAGEMENT SAFETY AND INJURY MODIFICATION PREVENTION MENTAL HEALTH SUBSTANCE ABUSE CESSATION

  4. COMMUNITY & HEALTH ORGANIZATIONAL SERVICE DELIVERY REQUIRE & INDIVIDUAL SYSTEMS BEHAVIOR CHANGE NEW DISCOVERIES/PHILOSOPHIES INITIATION CHRONIC ILLNESS MANAGEMENT NEW POLICY OR PROCEDURES MODIFICATION CHANGES IN PROVIDERS CHANGES IN FUNDING CESSATION SHIFTS IN MANAGEMENT

  5. A Broader Process Perspective • The process of intentional behavior change is relevant for understanding • Multiple Health and Protective Behaviors • Individuals and Organizations • Providers and Patients • Leaders and Those They Lead • Policy Makers and Program Developers

  6. WHAT DO WE NEED TO CHANGE? • CHANGE IS DISRUPTIVE • PEOPLE, PROGRAMS AND SOCIETIES DO NOT WANT TO CHANGE EVERYTHING and, AT TIMES, ANYTHING • CHANGE IS MOST OFTEN BEHAVIOR SPECIFIC; FEW SEEK TO CHANGE EVERYTHING AT ONCE • DEFINING EXACTLY WHAT IS TO BE CHANGED IS CRITICAL TO UNDERSTANDING THE CHALLENGE

  7. WHY DON’T PEOPLE OR ORGANIZATIONS CHANGE? • 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

  8. HOW PEOPLE CHANGE

  9. Other Models of How to get People to Change

  10. How Do People Change? • People change voluntarily only when • They become interested andconcernedabout 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 • Theytake the actions necessary to make the change and sustain the change

  11. Precontemplation Not interested Contemplation Considering Preparation Preparing Action Initial change Maintenance Sustained change Interested and Concerned Risk-Reward Analysis & Decision making Commitment & Creating an Effective/Acceptable Plan Implementation of Plan and Revising as Needed Consolidating Change into Lifestyle Stage of Change Tasks

  12. Understanding Barriers to Change and the Tasks of the Stages of Change UNMOTIVATED UNWILLING UNABLE Precontemplation Contemplation Preparation Action Maintenance

  13. 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

  14. 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

  15. 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 WHAT INDIVIDUALS OR ORGANIZATIONS HAVE TO REALIZE

  16. Key Issues and Intervention Considerations • 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

  17. Tasks and goals for each of the Stages of Change • 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.

  18. Decisional Balance Worksheet NO CHANGE PROS (Status Quo) _______________ _______________ _______________ CONS (Change) _______________ _______________ _______________ CHANGE CONS (Status Quo) _______________ _______________ _______________ PROS (Change) ______________________________ _______________

  19. Key Issues and Intervention Considerations • 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 and complicate

  20. MOTIVATED TO CHANGE • 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

  21. Tasks and goals for each of the Stages of Change • 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.

  22. Key Issues and Intervention Considerations • 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

  23. WILLING TO MAKE CHANGE • COMMITMENT TO TAKE ACTION • SPECIFIC ACCEPTABLE ACTION PLAN • TIMELINE FOR IMPLEMENTING PLAN • ANTICIPATION OF BARRIERS

  24. Tasks and goals for each of the Stages of Change • 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).

  25. Key Issues and Intervention Considerations • 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

  26. 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 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.

  27. Key Issues and Intervention Considerations • 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

  28. ABLE TO CHANGE • Continued Commitment • Skills to Implement the Plan • Long-term Follow Through • Integrating New Behaviors into Lifestyle or Organization • Creating a New Behavioral Norm

  29. Relapse and Recycling - Slipping Back to Previous Behavior and Trying to Resume Change 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

  30. Key Issues and Intervention Considerations • 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

  31. 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 Organizational Concerns Pressure Balance Experiential Processes (Pros & Cons) Processes Recycling Relapse

  32. Stages of Change Model Precontemplation Increase awareness of need to change Contemplation Motivate and increase confidence in ability to change Relapse Assist in Coping Preparation Negotiate a plan Maintenance Encourage active problem-solving Action Reaffirm commitment and follow-up Termination

  33. STAGES OF CHANGE AND INTERVENTION 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. WHO IS THE CLIENT • 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

  35. Important Considerations about System Change • Usually when you change a system everyone needs to make changes • 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

  36. Some Examples • HIV/AIDS Compliance enhancement • Trauma Unit Screening and Interventions for Risky Drinking • Peoplesoft at UMBC • Think of some of your examples of when changes went well and when they failed. What contributed to success or failure

  37. Multiple Problems Complicate the Process of Change The Context of Change: A Figure Ground Perspective

  38. CONTEXT OF CHANGE I. SITUATIONAL RESOURCES AND PROBLEMS II. COGNITIONS AND BELIEFS III. INTERPERSONAL RESOURCES/PROBLEMS IV. FAMILY & SYSTEMS V. ENDURING PERSONAL CHARACTERISTICS

  39. Symptom/Situation Psychiatric Financial Beliefs Religious views Cultural beliefs Interpersonal Marital Systemic Employment Family/Children Intrapersonal Self-Esteem Situation Inadequate facilities Financial Beliefs Only one right way Interpersonal Leadership Conflicts Systemic Funding Sources Political forces Subgroup conflicts Institutional Traditions Organizational Culture Typical Complications forIndividual and Organizations

  40. PROBLEM FOCUS • Since change goals and motivations are often behavior specific, it is critical to be specific about the focus of interventions • We need to evaluate in collaboration with the client what is the primary target behaviors that needs to be changed and the client goals • Target behavior is figure and additional problems become the ground or context for that change

  41. Multiple Problems Need an Integrated Approach to Care

  42. Stages by Context Analysis Experiential Processes Behavioral Processes

  43. How serious is the problem? Not Evident Not Serious Serious Very Serious Extremely Serious 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 Evaluating Client Problems

  44. Intervention Strategies • SEQUENTIAL – start with initial symptom or situation and try to resolve that and work way down. • KEY AREA OR LEVEL – Find problem or area where you have the most leverage or client or system 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

  45. Approaches that Pay Attention to the Process of Change • Clearly identify the target behavior and the contextual problems • Evaluate stage of readiness to change • Evaluate beliefs, values 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 change process

  46. PROCESS OF FORMAL INTER VENTIONS CHANGE

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