1. Addiction and Change: Understanding Initiation and Promoting Recovery
Carlo C. DiClemente, Ph.D. ABPP
University of Maryland, Baltimore County

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. Etiology of Addictions
Conditioning
Social Influences
Genetics
Abuse
Physiology
Personality
Initial Use
Self-RegulatedUse
Coping/Expectancies
Environment
Dependence
Reinforcement
All of these factors can have arrows to initial experience and then to any or all of the three patterns of use. Most could have arrows that demonstrate linear or reciprocal causality as well

5. 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 offers a developmental, task oriented, learning based view that can be useful to clinicians and researchers using a variety of traditional etiological and cessation models
Chassin and Colleagues; Jessor and Colleagues; Schulenberg et al.,
Dennis Wholley Courage to Change
Anne Fletcher, Sober for Good

6. Happens over a Period of Time Has a Variable Course
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 treatments
Consists of self change and/or treatment
Involves changes in other areas of psychosocial functioning

8. Addiction and Change
Both acquisition of and recovery from an addiction require a personal journey through an intentional change process
Journey influenced at various points by many of the factors identified in the previously reviewed etiological models

9. A LIFE COURSE PERSPECTIVE ON ADDICTION
Cross sectional views and brief follow up studies offer confusing data about predictors and outcomes of prevention and cessation of addiction
Multiple biological, social, individual, environmental factors influence transitions into and out of protective and problematic health behaviors
Understanding initiation and cessation of these behaviors requires a life course and a process of change perspective

10. Motivation
Motivation can be considered the tipping point for making change happen
Not a simple or single construct or best thought of as an “on-off” switch
Most of the time it is defined post hoc: if you are successful, you were motivated

11. Motivation There are various models to explain motivation
“Push” Models of internal dynamic forces or drives
“Pull” Models of reinforcement, goals, values
“Persuasion” Models of influence, social forces
“Process” Models of readiness and tasks
The Process Model changes the conversation from the “what” of motivation to the “how” of motivation

12. Motivation and the Change Process
Clients are not unmotivated! They either
are just motivated to engage in behaviors that others consider harmful and problematic or
are not ready to begin behaviors that we think would be helpful.
People who seem to have everything to gain from changing a behavior or doing some activity to relieve negative feelings or consequences do not do these things
Excellent and effective self-management techniques are not used even after they are taught to people who come voluntarily for help
DiClemente. 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)

13. Motivation is Personal
Motivation belongs to clients and their process of change.
However, motivation can be enhanced or hindered by interactions with others (including providers) and events in the life context of the clients.
Motivation is best viewed as the client’s readiness to engage in and complete the various tasks outlined in the Stages of Change for a specific behavior change.

14. Motivation Is Critical for Successful Change
Both brief interventions and alcoholism and substance abuse treatment research indicate a key role for patient motivation
In many drinking reduction studies motivation predicts decreases (Delta study of Shock Trauma patients)
Project MATCH client initial motivation measured by multidimensional stage measures predicted drinking out to 3 years post-treatment for outpatients
Bullets 2 and 4 have no verbs—a little unclear.
CSAT Treatment Improvement Protocol Number 35. Enhancing Motivation for Change in Substance Abuse Treatment. 1999;DHHS no. (SMA) Project MATCH Research Group. Alcohol Clin Exp Res. 1998;22:1300.

15. WHY ARE PEOPLE NOT MOTIVATED TO CHANGE?
NOT CONVINCED OF THE PROBLEM OR THE NEED FOR CHANGE – UNMOTIVATED
NOT COMMITTED TO MAKING A CHANGE – UNWILLING
ACTUAL OR PERCEIVED ABILITY TO MAKE A CHANGE – UNABLE
DIFFERENT PARTS OF A PROCESS
These are different phenomena and indicate that there are different parts or aspects of making a successful behavior change

16. HOW PEOPLE CHANGE

17. PRECONTEMPLATION  CONTEMPLATION  PREPARATION  ACTION  MAINTENANCE
The Transtheoretical Model of Intentional Behavior Change
STAGES OF CHANGE
PRECONTEMPLATION  CONTEMPLATION  PREPARATION 
ACTION  MAINTENANCE
PROCESSES OF CHANGE
COGNITIVE/EXPERIENTIAL BEHAVIORAL
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
The perspective I use to help understand the personal process of change that I have been researching for the past 20 plus years is the Transtheoretical Model. This model tries to identify critical dimensions that seem to impact behavior change and describe these dimensions and interactions among these dimensions. This is not presented as if these were the only dimensions but in my work they seem to be relevant and important ones. It matters if while I am trying to change one behavior and engage in the processes that would help me complete the tasks of each of these stages well enough to make progress there are other problems or resources in various areas of my life that would help me or hinder me in engaging in the processes and completing the tasks. The Markers are signposts that seem to be important at different parts of the process. Not clear if they should be called moderators, mediators, mechanisms or simply markers of the change process. Again these are not the only ones possible, they are just ones we have studied.

18. 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

19. Stage of Change Labels and Tasks
Precontemplation
Not interested
Contemplation
Considering
Preparation
Preparing
Action
Initial change
Maintenance
Sustained change
Interested, concerned and willing to consider
Risk-reward analysis and decision making
Commitment and creating a plan that is effective/acceptable
Implementing plan and revising as needed
Consolidating change into lifestyle
DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; DiClemente. J Addictions Nursing. 2005;16:5.

20. A Client/Consumer perspective
A Consumer Perspective to Care necessitates a shift in emphasis from a concentrating only on our treatments to focusing on our consumers and their motivation and mechanisms of change
Most treatment services provide good, effective action-oriented treatments
Many of our consumers are unmotivated, overwhelmed with multiple problems, feeling hopeless, or simply not interested or engaged by our services
DiClemente & Velasquez. Motivational interviewing and the stages of change. In: Miller & Rollnick, eds. Motivational Interviewing, 2nd ed. NY: Guilford Publications; 2002:201.

21. Motivation is Multidimensional
Motivation is best understood as the readiness and ability to accomplish the tasks needed to move individuals successfully through the stages of change
These tasks require self-regulation skills that enable the person to engage in the processes of change needed to accomplish the tasks and move the markers of change
There are facilitating and hindering personal and environmental factors that affect movement through each of the stages

22. Understanding Motivation and Movement through the Stages of Change
UNMOTIVATED UNWILLING UNABLE
Precontemplation Contemplation Preparation Action Maintenance
This Process is as relevant for organizations and service providers as it is for
Individuals with mental health and addiction problems.

23. 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

24. WHAT INDIVIDUALS or ORGANIZATIONS MUST REALIZE
MY BEHAVIOR IS PROBLEMATIC OR 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
MY 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

25. 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
Mandated treatment produces modest outcomes similar to “voluntary” clients but treatment system must be trained to motivate the mandated.
Promise only what you will do, do what you promise
Consequences teach but foxhole motivation is ephemeral
New motivational approaches show great promise to promote change
Harm reduction needs to be done in a manner that promotes motivation to change
Smaller versus larger goals represents issue of harm reduction or in organizations the get what you can while trying to get what you want.

26. 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.

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

28. 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
Personal values,family influences, and important events are critical in the individual’s consideration of change.
Consequences can teach but first must reach the individual where he or she lives.
Values clarification and finding meaningful goals
Ambivalence is normal
Providing a vision of the possible that seems realistic
Cultural competence needed to reach the personal considerations for each substance abuser. Programs for Native Americans using sweat lodges, for African Americans using a culturally sensitive engagement strategy, family values emphasis for Hispanic clients

29. 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
But this is only the first two steps toward making a change happen

31. Tasks and goals for each of the Stages of Change
PREPARATION – The stage in which the individual or organization 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.

33. 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
Action takes 3 to 6 months
Revising the plan needs responsive treatment options
Making sure there is support for change in the environment or seeking alternative environments when the natural environment is saturated with drugs and alcohol.
When some of the issues that were in the Background become foreground, providing resources and options for assistance to protect the action stage activity. Multisystemic Family Therapy.
Bringing the family into the treatment whenever that is feasible and reasonable. It is particularly important to include any significant other that is in the picture. SO substance abuse is the most potent relapse predictor.
Contingency management has shown great promise if used well. Payments for clean urines, contingencies for housing, increasing social support, addressing the network.
Contingencies include consequences, loss of privileges, etc.

34. WILLING TO MAKE CHANGE COMMITMENT TO TAKE ACTION
SPECIFIC ACCEPTABLE ACTION PLAN
TIMELINE FOR IMPLEMENTING PLAN
ANTICIPATION OF BARRIERS
BUT YOU STILL HAVEN’T DONE IT YET

35. Tasks and goals for each of the Stages of Change
ACTION – The stage in which the individual or organization 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).

36. 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
Action takes 3 to 6 months
Revising the plan needs responsive treatment options
Making sure there is support for change in the environment or seeking alternative environments when the natural environment is saturated with drugs and alcohol.
When some of the issues that were in the Background become foreground, providing resources and options for assistance to protect the action stage activity. Multisystemic Family Therapy.
Bringing the family into the treatment whenever that is feasible and reasonable. It is particularly important to include any significant other that is in the picture. SO substance abuse is the most potent relapse predictor.
Contingency management has shown great promise if used well. Payments for clean urines, contingencies for housing, increasing social support, addressing the network.
Contingencies include consequences, loss of privileges, etc.

37. 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.

38. 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
Maintaining change requires a long-term perspective
Unrealistic expectations from residential, inpatient, and intensive programs that last anywhere from 1 to 12 weeks.
Resolving associated problems and other life context problems critical to support the change.
Life must become different.

39. ABLE TO CHANGE Continued Commitment Skills to Implement the Plan
Self Control Strength that is not exhausted by other problems
Long-term Follow Through
Integrating New Behaviors into Lifestyle or Organization
Creating a New Behavioral Norm
Now you are getting there

40. The reality of relapse must be incorporated into the programs and policies for treatment of substance abuse.
Relapse is not a problem of substance abuse; it is a problem of behavior change
A learning perspective of successive approximation rather than one trial learning is needed.

41. 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

42. Regression, Relapse and Recycling through the Stages
Regression represents movement backward through the stages
Slips are brief returns to the prior behavior that represent a some problems in the action plan
Relapse is a return or re-engaging to a significant degree in the previous behavior after some initial change
After returning to the prior behavior, individuals Recycle back into pre-action stages (precontemplation, contemplation, or preparation).

43. Key Issues and Intervention Considerations
Blame and Guilt Undermine Motivation for Change
Determination despite delays and defeats
Support Re-engagement in the Processes of Change
Recycling or just Spinning Wheels
Hope and a Learning Perspective is Needed
Disappointment leads to blame and guilt
Abstinence must be seen as a goal but not treated as a sacred state. It must become second nature and part of an entire lifestyle rather that a constantly sought after state.
Don’t restrict recycling but there is a difference between someone who is truly recycling and those who are simply spinning their wheels because there is some singificant flaw in the process of change.
Hope is not foolhardy. Lessons from smoking cessation

44. 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

45. 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

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

48. Expectancies/Beliefs Decision-Making Self-efficacy
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

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

50. A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE ON ALLEN
TYPE OF
BEHAVIOR
STAGE OF INITIATION PC C PA A M
ALCOHOL X
NICOTINE X
MARIJUANA X X
HEROIN X
COCAINE
AMPHETAMINES X X
LSD
GAMBLING X
EATING DISORDER X

51. Stage Based EpidemiologyPC M PC C M C A PA A PA

52. 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

53. Stages of Change and Therapist’s 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 behavior change
Contemplation
Help the client 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 stages of
contemplation, preparation, and action, without
becoming stuck or demoralized because of relapse
Relapse
CSAT Treatment Improvement Protocol Number 35. Enhancing Motivation for Change in Substance Abuse Treatment. 1999: DHHS no. (SMA)

54. How Do Interventions Work?
INDIVIDUAL
Static Interaction Model

55. How Do Interventions Work?
Dynamic Model: Stepping into a Flowing Stream

56. How Do Interventions Work?
Individual’s Status on Developmental and Change Process Factors During Course of Drinking
18 yo college student
weekend binge
drinking
23 yo graduate
experimenting with
recreational drugs
while binge drinking
34 yo, new father
occasional heavy drinking following
7 years of sobriety
46 yo executive,
recently divorced,
Depressed,
4-5 drinks a night
Please note the additions to this slide. It follows the history of a theoretical individual. Does it capture what you were looking for?
Intervention
Intervention

57. 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)
Examined 21 hypothesized matching effects and over 30 baseline predictors of drinking
Comprised 9 centers with over 20 sites and 75 therapists
Included 952 outpatients and 774 aftercare patients
Project MATCH Research Group. J Stud Alcohol. 1997;58:7.

58. Percentage Days Abstinent: Baseline to 36-Month Follow-up Across MATCH Therapies (Outpatient Sites)
There is an extra set of data points. We will need to adjust.
Timeline relative to treatment window
Project MATCH Research Group. Alcohol Clin Exp Res. 1998;22:1300.

59. Success Profiles From Project MATCH
TSF, CBT, and MET treatments produced similar drinking outcomes
However, the dimensions of the process of change were important in discriminating between the various outcomes in Project MATCH
What happens to them during treatment?
How do they relate to long-term drinking outcomes?
Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

60. End-of-Treatment-Process Profiles Predict Outcomes
Client status during follow-up period:
Abstinent
Moderate drinking
Heavier drinking
Client profile on Stage of Change subscales, temptation to drink, abstinence, self-efficacy, experiential and behavioral processes of change
Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

61. TTM Profile: Outpatient PDA Baseline
-0.8
-0.6
-0.4
-0.2
0.2
0.4
0.6
0.8
TTM variables
Standard scores
Abstinent
Moderate
Heavier
Pre
Con
Act
Main
Conf
Temp
TTM = Transtheoretical model
Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

62. TTM Profile: Outpatient PDA Post-treatment
Abstinent
Moderate
Heavier
0.8
0.6
0.4
0.2
Standard Scores
-0.2
-0.4
-0.6
Pre
Con
Act
Main
Conf
Temp
Exp
Beh
-0.8
TTM Variables
PDA = percent days abstinent
Carbonari, JP & DiClemente, CC. J Consult and Clin Psych. 2000; 68:810.

63. TTM Profile: Aftercare PDA Baseline
-0.8
-0.6
-0.4
-0.2
0.2
0.4
0.6
0.8
TTM variables
Standard scores
Abstinent
Moderate
Heavier
Pre
Con
Act
Main
Conf
Temp
Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

64. TTM Profile: Aftercare PDA Post-treatment
-0.8
-0.6
-0.4
-0.2
0.2
0.4
0.6
0.8
Pre
Con
Act
Main
Conf
Temp
Exp
Beh
TTM variables
Standard scores
Abstinent
Moderate
Heavier
Carbonari & DiClemente. J Consult Clin Psychol. 2000;68:810.

65. CLIENT THERAPIST TREATMENT
PROCESS OF
INTENTIONAL
BEHAVIOR
CHANGE
CLIENT
THERAPIST
TREATMENT

66. Where Do We Go From Here? Stepped care approaches
Matching techniques of treatment to client problem and process of change dimensions
Integrating formal and self-help approaches as well as different treatment approaches
Client-titrated treatment
Treatment shifts from being reactive and regimented to becoming proactive and personalized
DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; 2003.