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Addiction and Change:Understanding Initiation andPromoting RecoveryCarlo C. DiClemente, Ph.D. ABPPUniversity of Maryland, Baltimore Countywww.umbc.edu/psych/habitswww.mdquit.org

What are Addictions? Habitual patterns of intentional,appetitive behaviorsBecome excessive and produceserious consequencesStability of these problematicbehavior patterns over timeInterrelated physiological andpsychological componentsAddicted individuals have difficultymodifying and stopping them

Traditional Models forUnderstanding Addictions Social/Environmental ModelsGenetic/Physiological ModelsPersonality/Intra-psychic ModelsCoping/Social Learning xcessive BehaviorModelsIntegrative Bio-Psycho-SocialModels

Etiology of AddictionsConditioningGeneticsSocial InfluencesAbusePhysiologyPersonalityInitial ependenceReinforcementAll of these factors can have arrows to initial experience and then to any orall of the three patterns of use. Most could have arrows that demonstratelinear or reciprocal causality as well

Change the Integrating PrincipleNo single developmental model orsingular historical path can explainacquisition of and recovery fromaddictions A focus on the Process of Changeand how individuals change offers adevelopmental, task oriented,learning based view that can beuseful to clinicians and researchersusing a variety of traditionaletiological and cessation models

BECOMING ADDICTED Happensover a Period ofTime Has a Variable Course Involves a Variety ofPredictors that can be bothRisk and Protective Factors Involves a Process ofChange

SUCCESSFUL RECOVERYFROM ADDICTIONS Occursover long periods of time Often involves multiple attemptsand treatments Consists of self change and/ortreatment Involves changes in other areasof psychosocial functioning

Addiction and ChangeBoth acquisition of and recoveryfrom an addiction require apersonal journey through anintentional change process Journey influenced at variouspoints by many of the factorsidentified in the previouslyreviewed etiological models

A LIFE COURSE PERSPECTIVE ONADDICTION Cross sectional views and brief follow upstudies offer confusing data aboutpredictors and outcomes of preventionand cessation of addictionMultiple biological, social, individual,environmental factors influencetransitions into and out of protective andproblematic health behaviorsUnderstanding initiation and cessation ofthese behaviors requires a life courseand a process of change perspective

Motivation Motivation can be considered thetipping point for making changehappenNot a simple or single construct orbest thought of as an “on-off”switchMost of the time it is defined posthoc: if you are successful, you weremotivated

Motivation There are various models to explain motivation “Push” Models of internal dynamic forces ordrives “Pull” Models of reinforcement, goals, values “Persuasion” Models of influence, socialforces “Process” Models of readiness and tasksThe Process Model changes the conversationfrom the “what” of motivation to the “how” ofmotivation

Motivation and the Change Process Clients are not unmotivated! They either are just motivated to engage in behaviors thatothers consider harmful and problematic or are not ready to begin behaviors that we thinkwould be helpful.People who seem to have everything to gainfrom changing a behavior or doing some activityto relieve negative feelings or consequences donot do these thingsExcellent and effective self-managementtechniques are not used even after they aretaught to people who come voluntarily for helpDiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; 2003.CSAT Treatment Improvement Protocol Number 35. Enhancing Motivation for Change in Substance Abuse Treatment.1999;DHHS no. (SMA) 99-3354.

Motivation is Personal Motivation belongs to clients and theirprocess of change.However, motivation can be enhancedor hindered by interactions with others(including providers) and events in thelife context of the clients.Motivation is best viewed as the client’sreadiness to engage in and completethe various tasks outlined in the Stagesof Change for a specific behaviorchange.

Motivation Is Critical forSuccessful Change Both brief interventions and alcoholismand substance abuse treatment researchindicate a key role for patient motivationIn many drinking reduction studiesmotivation predicts decreases (Deltastudy of Shock Trauma patients)Project MATCH client initial motivationmeasured by multidimensional stagemeasures predicted drinking out to 3years post-treatment for outpatientsCSAT Treatment Improvement Protocol Number 35. Enhancing Motivation for Changein Substance Abuse Treatment. 1999;DHHS no. (SMA) 99-3354.Project MATCH Research Group. Alcohol Clin Exp Res. 1998;22:1300.

WHY ARE PEOPLE NOTMOTIVATED TO CHANGE? NOT CONVINCED OF THE PROBLEMOR THE NEED FOR CHANGE –UNMOTIVATEDNOT COMMITTED TO MAKING ACHANGE – UNWILLINGACTUAL OR PERCEIVED ABILITY TOMAKE A CHANGE – UNABLEDIFFERENT PARTS OF A PROCESS

HOW PEOPLE CHANGE

The Transtheoretical Model of Intentional Behavior ChangeSTAGES OF CHANGEPRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCEPROCESSES OF s RaisingSelf-RevaluationEnvironmental ReevaluationEmotional Arousal/Dramatic ReliefSocial lus ControlReinforcement ManagementHelping RelationshipsCONTEXT OF CHANGE1.2.3.4.5.Current Life SituationBeliefs and AttitudesInterpersonal RelationshipsSocial SystemsEnduring Personal CharacteristicsMARKERS OF CHANGEDecisional BalanceSelf-Efficacy/Temptation

How Do People Change? People change voluntarily only when They become interested andconcerned about the need for change They become convinced the changeis in their best interest or will benefitthem more than cost themThey organize a plan of action thatthey are committed to implementingThey take the actions necessary tomake the change and sustain thechange

Stage of Change Labels and Tasks Precontemplation Not interestedContemplation ConsideringPreparation PreparingAction Initial changeMaintenance Sustainedchange Interested, concernedand willing to considerRisk-reward analysisand decision makingCommitment andcreating a plan that iseffective/acceptableImplementing planand revising asneededConsolidating changeinto lifestyleDiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; 2003.DiClemente. J Addictions Nursing. 2005;16:5.

A Client/Consumer perspective A Consumer Perspective to Carenecessitates a shift in emphasis from aconcentrating only on our treatments tofocusing on our consumers and theirmotivation and mechanisms of changeMost treatment services provide good,effective action-oriented treatmentsMany of our consumers are unmotivated,overwhelmed with multiple problems,feeling hopeless, or simply not interestedor engaged by our servicesDiClemente & Velasquez. Motivational interviewing and the stages of change. In: Miller & Rollnick, eds. Motivational Interviewing, 2nd ed. NY:Guilford Publications; 2002:201.

Motivation is Multidimensional Motivation is best understood as thereadiness and ability to accomplish thetasks needed to move individualssuccessfully through the stages of changeThese tasks require self-regulation skillsthat enable the person to engage in theprocesses of change needed to accomplishthe tasks and move the markers of changeThere are facilitating and hinderingpersonal and environmental factors thataffect movement through each of thestages

Understanding Motivation and Movement throughthe Stages of ationPreparationUNABLEActionMaintenanceThis Process is as relevant for organizations and service providers as it is forIndividuals with mental health and addiction problems.

Tasks and Goals for each of the Stagesof Change PRECONTEMPLATION - The state inwhich there is little or no consideration ofchange of the current pattern of behaviorin the foreseeable future.TASKS: Increase awareness of need forchange and concern about the currentpattern of behavior; envision possibility ofchangeGOAL: Serious consideration of changefor this behavior

WHAT INDIVIDUALS or ORGANIZATIONSMUST REALIZE MY BEHAVIOR ISPROBLEMATIC OREXCESSIVEMY DRUG USE ISCAUSINGPROBLEMS IN MYLIFEI HAVE OR AM ATRISK FOR SERIOUSPROBLEMSMY BEHAVIOR ISINCONSISTENTWITH SOMEIMPORTANT VALUESMY LIFE IS OUT OFCONTROL WHAT WE ARE DOINGIS NOT EFFECTIVE INMEETING THE NEEDSOF OUR CLIENTSOUR APPROACH ISCOSTING TOO MUCHFOR THE OUTCOMESWE ARE GETTINGTHERE ARE SERIOUSPROBLEMS IN OURPROCEDURES,PROGAMMMING,ORPRODUCT

Key Issues and InterventionConsiderations Coercion or Courts cannot do it aloneConfrontation breeds ResistanceMotivation not simply Education isneededIntrinsic and Extrinsic MotivationsProactive versus ReactiveApproachesSmaller versus Larger goals andMotivation

Tasks and goals for each of the Stagesof Change CONTEMPLATION – The stage wherethe individual or society examines thecurrent pattern of behavior and thepotential for change in a risk – rewardanalysis.TASKS: Analysis of the pros andcons of the current behavior patternand of the costs and benefits of change.Decision-making.GOAL: A considered evaluation thatleads to a decision to change.

Decisional Balance WorksheetNO CHANGECHANGEPROS (Status Quo)CONS (Status Quo)CONS (Change)PROS (Change)

Key Issues and InterventionConsiderations Decisional Considerations are PersonalIncrease the Costs of the Status Quo andthe Benefits of ChangeChallenge and Work with AmbivalenceEnvision the ChangeEngender Culturally RelevantConsiderations that are MotivationalSee how families and larger organizationscan influence change by providingincentives or putting up barriersMultiple problems or issues interfere andcomplicate

MOTIVATED TO CHANGE Admit that the status quo isproblematic and needs changingThe pros for change outweigh theconsChange is in our own best interestThe future will be better if we makechanges in these behaviorsBut this is only the first two stepstoward making a change happen

Tasks and goals for each of theStages of Change PREPARATION – The stage inwhich the individual ororganization makes a commitmentto take action to change thebehavior pattern and develops aplan and strategy for change.TASKS: Increasingcommitment and creating achange plan.GOAL: An action plan to beimplemented in the near term.

Key Issues and InterventionConsiderations Effective, Acceptable and AccessiblePlansSetting Timelines forImplementationBuilding Commitment andConfidenceCreating IncentivesDeveloping and Refining SkillsNeeded to Implement the PlansTreatment Plan and Change Plan

WILLING TO MAKE CHANGE COMMITMENT TO TAKE ACTIONSPECIFIC ACCEPTABLE ACTIONPLANTIMELINE FOR IMPLEMENTINGPLANANTICIPATION OF BARRIERSBUT YOU STILL HAVEN’T DONE ITYET

Tasks and goals for each of theStages of Change ACTION – The stage in which theindividual or organization implements theplan and takes steps to change the currentbehavior pattern and to begin creating anew behavior pattern.TASKS: Implementing strategies forchange; revising plan as needed;sustaining commitment in face ofdifficultiesGOAL: Successful action to changecurrent pattern. New pattern establishedfor a significant period of time (3 to 6months).

Key Issues and InterventionConsiderations Flexibleand ResponsiveProblem Solving Support for Change Reward Progress Create Consequences forFailure to Implement Continue Development andRefining Skills Needed toImplement the Plan

Tasks and goals for each of theStages of Change MAINTENANCE – The stage where thenew behavior pattern is sustained for anextended period of time and isconsolidated into the lifestyle of theindividual and society.TASKS: Sustaining change over timeand across a wide range of situations.Avoiding going back to the old pattern ofbehavior.GOAL: Long-term sustained changeof the old pattern and establishment of anew pattern of behavior.