Tailoring Interventions to Client Motivation and Mechanisms of Change Carlo C. DiClemente, Ph.D. ABPP UMBC Psychology www.umbc.edu/psyc/habits

Understanding the Process of Change over the Past 30 years There have been many advances in our understanding of recovery and of the process of change involved in addiction and recovery and substantial shifts in our understanding of the role of interventions in recovery My work focuses on how people change using the Transtheoretical Model of Intentional Behavior Change (TTM) The current conceptual and research contribution focus on key mechanisms of change – understanding the engines that make behavior change happen in addictions and health behaviors. Understanding the Process of Change over the Past 30 years

Searching for Mechanisms of Change Mechanisms - elements that are primary causative factors, essential to explaining part of the change (engine, gas, driver?) Moderators - variables that facilitate or hinder the change taking place but only secondarily causative (Flat tire; road construction; engine oil) Markers - indicators that various mechanisms or moderators are occurring (Speedometer; Air pressure) Mediation – Statistical mediation has often be used to support interpretation of a mechanism but this is limited and fails to account for interactive elements Mediation: Necessary but not sufficient; Linear types of relationships not reciprocal; David MacKinnon and validity of mediation and causation

Intervention/Treatment (therapy theory or strategies, alliance, dose, type) Provider (therapist characteristics, alliance, skill, empathy) – New Focus on Interaction Attribute x Treatment interactions (matching) Environmental mechanisms (social, peer, policy, physical (built), enforcement, technology, reinforcement) Person (personality, demographics) New Focus on Neuroscience and Personal Change Process Where Have We been looking to Understand Recovery and Mechanisms of Change?

How Do People Change? People change voluntarily only when They become interested and concerned about 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 They take the actions necessary to make the change and sustain the change

Transtheoretical Model STAGES OF CHANGE Precontemplation - Contemplation - Preparation - Action - Maintenance PROCESSES OF CHANGE Experiential Processes Behavioral Processes Consciousness Raising Self-Reevaluation Dramatic Relief Environmental Reevaluation Social Liberation Self-Liberation Counterconditioning Stimulus Control Reinforcement Management Helping Relationships DECISIONAL BALANCE SELF-EFFICACY

THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY Dependence PC C PA A M PROCESSES, CONTEXT AND MARKERS OF CHANGE PA A M PC C Dependence Sustained Cessation RECOVERY Stages: Precontemplation, Contemplation, Preparation, Action, Maintenance DiClemente, Addiction and Change (in press) second edition 7

Theoretical and Practical Considerations Related to Movement Through the Stages of Change Motivation Self-efficacy Decision Making Precontemplation Contemplation Preparation Action Maintenance Personal Concerns Environmental Pressure Decisional Balance Cognitive Experiential Processes Behavioral Processes How can we help case managers understand where the client is with regard to a specific problem and change that is needed. If the action is to become employed, where is the client in this process. Precontemplation because they believe they cannot get a job. Ambivalent and unable to make a decision to seek it. Trying to get jobs without skills needed or a proper plan?. Recycling Relapse What would help or hinder completion of the tasks of each of the stages and sustain or deplete the self-control strength needed to engage in the processes of change needed to complete the tasks?

Evidence for Personal Process of Change in Alcoholism Treatment Patient intention/motivation Pre-treatment motivation predicts drinking outcomes up to 3 years post treatment (PMRG, 1997, 1998; COMBINE, UKATT, Heather et al., 2009)) Patient goals predict outcomes in psychosocial and pharmacotherapy ( Hall et al., 1991, Penberthy et al, 2011, DeMartini et al,2014) Natural, Un-aided or Self-Change “Spontaneous recovery” and self-guided change produce significant changes and support personal change mechanisms like decision making, commitment, self reevaluation, behavioral coping (DiClemente, 2006; Tucker et al., 2004; Sobell et al., 1993) Placebo responding (inert ingredient; expectation; significant changes) (Wager et al, 2004; Wager & Atlas, 2015; Shafer, Colloca, Wager, 2015)

Evidence for Personal Process of Change in Alcoholism Treatment Importance of patient behavior during treatment Commitment language (Amrhein et al.) Patient to therapist talk ratio (Moyers et al.) Setting a data for change Patient evaluations of strengths and vulnerability Temptation and Craving (PMRG, 1997b; Anton et al.,2006) Self Efficacy (PMRG, 1998; DiClemente et al., 2001) Temptation minus Confidence (PMRG, 1998; Shaw & DiClemente, 2016) Awareness and acknowledgement of consequences

Evidence for Personal Process of Change in Alcoholism Treatment Significant drinking reductions occur after brief interventions in opportunistic settings (Bernstein et al., , Monti et al., Gentiello et al., Soderstram et al.,) and in routine settings (Babor et al., Fleming et al., Ockene et al.) There are developmental periods and events (job, marriage, pregnancy, aging) that trigger change for many individuals (Leonard & Homish, 2008) Processes of Change promote behavior change (Velasquez, Crouch, Stephens, & DiClemente, 2015; Norcross, Krebs, & Prochaska, 2011) Success profiles at the end of treatment from Project MATCH involve personal process variables (Carbonari & DiClemente, 2000)

Project MATCH Tested 3 distinct alcohol treatments Cognitive Behavioral Treatment (CBT) (12/12 wks) Twelve Step Facilitation (TSF) (12/12 wks) Motivational Enhancement Therapy (MET) (4/12 wks) No long term significant differences between these Examined 21 hypothesized matching effects and over 30 baseline predictors of drinking Only a couple of significant matches 9 centers, over 20 sites and 75 therapists with 952 outpatients and 774 aftercare patients Project MATCH Research Group. J Stud Alcohol. 1997;58:7. Babor & Delboca, 2002

Baseline Predictors of Drinking at Months 4-15

Predictors of Drinking at 3-year Follow-Up

Success Profiles From Project MATCH TSF, CBT, and MET treatments produced similar drinking outcomes No Significant TX differences at EOT for Stage of Change Subscales, Working Alliance, Temptation to Drink, Abstinence Self Efficacy, Experiential and Behavioral Processes of Change. What happens to process dimensions during treatment and how do they relate to long-term drinking outcomes? Process dimensions discriminated post treatment drinking outcome groups Success Profiles From Project MATCH Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

The Combining Medications and Behavioral Interventions for Treatment of Alcoholism trial (COMBINE) was a project which evaluated the use of two medications, acamprosate and naltrexone, coupled with a low intensity medication management intervention and/or a higher intensity behavioral intervention, CBI. Clients received treatment for 16 weeks, and then were followed until 68 weeks after baseline. The clients were divided into three groups based on their drinking behaviors since the prior assessment, abstinent, lighter, and heavier drinking. The drinking levels were based on the median percent days abstinent for each time period. Treatment group was not significantly related to TTM profile scores. The COMBINE Study

Post treatment(Week 16) Profiles Drinking at Week 68 The Parallelism Hypothesis was rejected-F(4.46, 2098.593)=49.498, p<.001, (N=944) so drinking groups had different shaped profiles. The Levels Hypothesis was rejected-F(2, 941) =9.903, p<.001 meaning that the profiles overall levels of the variables was significantly different regardless of shape. Follow up analyses found that the measures of confidence (F(2, 941)=60.75 p<.001), temptation (F(2, 941)=70.66 p<.001), Experiential POC (F(2, 941)=5.76 p=.003), and Behavioral POC (F(2, 941)=22.32 p<.001) were significantly different between the three groups. Post hoc tests found significant mean difference between the heavier drinking group and moderate drinking group(p=.004), and between the heavier drinking group and the abstinent group (p<.001).

Self- Efficacy and Drinking Outcomes Bandura’s concept of Self-Efficacy is an important predictor and mediator of drinking outcomes (Kadden & Litt, 2011) Recent analyses of relapse after at least one week of abstinence at EOT indicated that the gap between self-reported T minus SE highly tempted predicted time to first drink and number of drinks consumed on first day (Shaw & DiClemente, 2016)

How Does Treatment Work? Client Therapist Adherence Treatment Environment Recovery Focus on What provider does Relationship Empathy Working Alliance Active Ingredients Manuals Treatment Combinations & Matching Relapse Prevention Mutual Support How Does Treatment Work?

What about looking at it another way? Focus on What Client Does Treatment: A Mediator or Moderator of Client Processes Environment/ Biology Client Process Motivation Efficacy Self Regulation Pressures from policy, others teachable moments Treatment Client Processes Engagement Self-Regulation Self-Efficacy Support Systems Multiple problems Support Support systems Multiple Problems Recovery What about looking at it another way? Focus on What Client Does

Summary Motivation (variously defined) seems an important piece of the mechanisms of change puzzle. Motivation clearly acts as a predictor and often acts as a moderator and/or mediator of drinking outcomes. Needs complex statistical models (MacKinnon) Client coping activities and self-evaluations clearly are important probably more important than static characteristics and even treatment and therapist Many of these mechanisms are related to changes in brain activation so connect with neuroscience is critical (NIH Harnessing Neuroplasticity for Behavior Change 2013)