1. Tailoring Interventions to Client Motivation and Mechanisms of Change
Carlo C. DiClemente, Ph.D. ABPP
UMBC Psychology

2. 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

3. 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

4. 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?

5. 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

6. 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

7. 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

8. 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?

9. 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)

10. 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

11. 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)

12. 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

13. Baseline Predictors of Drinking at Months 4-15

14. Predictors of Drinking at 3-year Follow-Up

15. 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.

18. 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

19. Post treatment(Week 16) Profiles
Drinking at Week 68
The Parallelism Hypothesis was rejected-F(4.46, )=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).

20. 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)

21. 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?

22. 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

23. 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)