Transcript INSPIRATION FOR A CHANGE - Institute for Recovery

The Challenge of Change:
Creating a RecoveryOriented System of Care
Carlo C. DiClemente
Professor of Psychology
University of Maryland,
Baltimore County
www.umbc.edu/psych/habits
www.mdquit.org
Behavior Change is Critical to the Growth
and Development Organizations, Societies,
and Individuals

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
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

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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
HEALTH PROMOTION &
DISEASE PREVENTION
REQUIRE
CANCER PREVENTION
BEHAVIOR
CHANGE
INITIATION
CHRONIC ILLNESS MANAGEMENT
SAFETY AND INJURY
PREVENTION
MODIFICATION
MENTAL HEALTH
SUBSTANCE ABUSE
CESSATION
COMMUNITY & HEALTH
SERVICE DELIVERY
SYSTEMS
REQUIRE
NEW DISCOVERIES/PHILOSOPHIES
ORGANIZATIONAL
& INDIVIDUAL
BEHAVIOR CHANGE
INITIATION
CHRONIC ILLNESS MANAGEMENT
NEW POLICY OR PROCEDURES
MODIFICATION
CHANGES IN PROVIDERS
CHANGES IN FUNDING
SHIFTS IN MANAGEMENT
CESSATION
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
WHAT DO WE NEED TO
CHANGE?
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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
WHY DON’T PEOPLE OR
ORGANIZATIONS CHANGE?

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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
HOW PEOPLE CHANGE
Other Models of How to get
People to 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
Stage of Change Tasks
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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
Understanding Barriers to Change and the Tasks of
the Stages of Change
UNMOTIVATED
Precontemplation
UNWILLING
Contemplation
Preparation
UNABLE
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-Revaluation
Environmental Reevaluation
Emotional Arousal/Dramatic Relief
Social Liberation
Self-Liberation
Counter-conditioning
Stimulus Control
Reinforcement Management
Helping Relationships
CONTEXT OF CHANGE
1.
2.
3.
4.
5.
Current Life Situation
Beliefs and Attitudes
Interpersonal Relationships
Social Systems
Enduring Personal Characteristics
MARKERS OF CHANGE
Decisional Balance
Self-Efficacy/Temptation
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

WHAT INDIVIDUALS OR
ORGANIZATIONS HAVE TO
REALIZE

MY BEHAVIOR IS
PROBLEMATIC/EXCESSIVE

MY DRUG USE IS CAUSING
PROBLEMS IN MY LIFE
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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
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
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. Decisionmaking.

GOAL: A considered evaluation that
leads to a decision to change.
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Decisional Balance Worksheet
NO CHANGE
CHANGE
PROS (Status Quo)
_______________
_______________
_______________
CONS (Status Quo)
_______________
_______________
_______________
CONS (Change)
_______________
_______________
_______________
PROS (Change)
_______________
_______________
_______________
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

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
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.

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
WILLING TO MAKE CHANGE
 COMMITMENT
TO TAKE ACTION
 SPECIFIC ACCEPTABLE ACTION PLAN
 TIMELINE FOR IMPLEMENTING PLAN
 ANTICIPATION OF BARRIERS
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).

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
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.
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TASKS: Sustaining change over time
and across a wide range of situations.
Avoiding going back to the old pattern of
behavior.
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GOAL: Long-term sustained change of
the old pattern and establishment of a new
pattern of behavior.
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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
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
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
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
Theoretical and practical considerations related to
movement through the Stages of Change
Motivation
Precontemplation
Personal Environmental
Organizational
Concerns Pressure
Decision-Making
Self-efficacy
Contemplation
Preparation
Action
Decisional
Cognitive
Behavioral
Balance
(Pros & Cons)
Experiential
Processes
Processes
Recycling
Maintenance
Relapse
Stages of Change Model
Precontemplation
Increase awareness of need to change
Contemplation
Motivate and increase confidence
in ability to change
Relapse
Preparation
Assist in Coping
Negotiate a plan
Maintenance
Encourage active
problem-solving
Termination
Action
Reaffirm commitment
and follow-up
STAGES OF CHANGE AND INTERVENTION TASKS
PRECONTEMPLATION
Raise doubt - Increase the client’s perception of
risks and problems with current behavior
CONTEMPLATION
Tip the decisional balance - Evoke reasons for
change, risks of not changing; Strengthen client’s
self-efficacy for change of current behavior
PREPARATION
Help the client to determine the best course of
action to take in seeking change; Develop a plan
ACTION
Help the client implement the plan; Use skills;
Problem solve; Support self-efficacy
MAINTENANCE
Help the client identify and use strategies to
prevent relapse; Resolve associated problems
RELAPSE
Help the client recycle through the stages of
contemplation, preparation, and action, without
becoming stuck or demoralized because of relapse
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
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
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
Multiple Problems
Complicate the Process of
Change
The Context of Change:
A Figure Ground
Perspective
CONTEXT OF CHANGE
I. SITUATIONAL RESOURCES AND PROBLEMS
II. COGNITIONS AND BELIEFS
III. INTERPERSONAL RESOURCES/PROBLEMS
IV. FAMILY & SYSTEMS
V. ENDURING PERSONAL CHARACTERISTICS
Typical Complications for
Individual and Organizations
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Symptom/Situation
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– Inadequate facilities
– Financial
– Psychiatric
– Financial
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Beliefs
– Religious views
– Cultural beliefs
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– Self-Esteem
Systemic
– Funding Sources
– Political forces
– Subgroup conflicts
Systemic
Intrapersonal
Interpersonal
– Leadership Conflicts
– Employment
– Family/Children
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Beliefs
– Only one right way
Interpersonal
– Marital
Situation
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Institutional
– Traditions
– Organizational Culture
PROBLEM FOCUS
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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
Multiple Problems Need an
Integrated Approach to Care
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Stages by Context Analysis
PreC
Cont
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Action Maint
I Sit
II Cog
III Rel
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V Per
Experiential
Processes
Behavioral Processes
Evaluating Client Problems

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
Intervention Strategies
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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
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 multicomponent interventions
 Re-evaluate regularly the change process

PROCESS OF
FORMAL
INTER
CHANGE
VENTIONS
Application to
Organizations that Deal
with Co-Occurring
Disorders
Some Final thoughts
Addictions, Mental Illness and the
Process of Change
 Both
Mental Illness and Addictions are
frustrating and fascinating behavior
problems involving
–Social influences, support and policies
–Physiology, biology, genetics, and
chemistry
–Psychological and motivational factors
 Comprehensive and multidimensional
models to understand them and to
provide care
Facing the Challenge
 Mental
Illness and Addictions
challenge courts, treatment
providers, educators, families, social
services and society to create
– policies
– prevention programs
– treatments
– harm reduction strategies
that hinder initiation and facilitate
recovery
Organizational Challenges for
Change for Addiction Interventions
Dual Diagnosis: Addiction and Mental
Health – a conceptual integration
 Integrating treatments among multiple
providers for multi-problem patients
 Legal Sanctions and Treatment Decisions
 Implementing Empirically Based
Treatments
 Burnout and Turnover

THE CHALLENGE FOR
PROVIDER ORGANIZATIONS
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To Create Successfully Sustained
Organizational Change to Meet the Needs
of Clients, Organization, and Society
To Use a Process Perspective as opposed
to a simply a Content Perspective
The Content or Product to Change in a
Change Enabling Organization can be
SERVICES, SAFETY, EDUCATION,
RESEARCH, OR POLICY
WHAT IS NEEDED:
ORGANIZATIONAL LEADERSHIP
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THAT INSPIRES, MOTIVATES, AND PROVIDES
INCENTIVES FOR EXCELLENCE AND CHANGE
NOT ONE THAT ORDERS, IMPOSES, AND
PUNISHES TO ENFORCE IMPOSED CHANGE
SETS A TONE, AN EXPECTATION THAT THE
CHANGE IS VALUED
MODELS BEHAVIORS, VALUES, ETHICS THAT
SUPPORT THE CHANGE
CREATING A SHARED VISION TO
SUPPORT CHANGE
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A VISION OF WHAT WE CAN BE AND WHAT WE
CAN DO
A VISION THAT CREATES HIGH BUT ACHIEVABLE
OUTCOME AND EFFICACY EXPECTATIONS
A VISION THAT STRIVES FOR EXCELLENCE AS
APPROACHED NEVER ACCOMPLISHED
A VISION SHARED AT ALL LEVELS OF THE
ORGANIZATION
CREATING AND SUSTAINING
CHANGE REQUIRES A TEAM

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CREATE A TEAM OF INDIVIDUALS WHO
HAVE THE RESPONSIBILITY AND
AUTHORITY TO ENGAGE IN THE PROCESS
AND ATTAIN THE GOALS
THESE ARE THE INDIVIDUALS WHO
PERFORM THE BEHAVIORS ARE THE
CHANGE TARGET
LONE RANGERS RARELY CREATE
EXCELLENT, SUSTAINABLE
ORGANIZATIONAL CHANGE
CREATING THE TEAM
 GET
AND KEEP THE RIGHT PEOPLE
 USE INCENTIVES (RECOGNITION,
RESPECT, REINFORCEMENT)
 TRUST AND MONITOR
 PLAN AND IMPLEMENT
 BUILD NORMS & SUPPORT SYSTEMS
 SHARE RESPONSIBILITY AND
AUTHORITY
IN MAKING AN INDIVIDUAL OR
ORGANIZATIONAL CHANGE
 Pick
a target behavior or
constellation of behaviors
 Make a solid decision
 Prioritize and Prepare
 Make a plan and revise as needed
 Keep going and do not get
discouraged
 Find and build a network of support
 Make the change a new norm
Built to Last: Successful Habits of
Visionary Companies
Be a clock builder –an architect- not a
time teller
 Embrace the “Genius of the AND”
 Preserve the core values/stimulate
progress
 Seek consistent alignment of core values
and purpose with current practice and
future goals
 Key Concepts

– Core ideology, values, purpose
– Envisioned Future: Big Hairy Audacious Goals
Collins JC & Porras, JI (1994) Harper Business Books
Some Final Thoughts
 Treating
those needing to change as
consumers who can choose to use
our services
 The
reality of recovery
What is a Consumer?
A person who has the power to buy, to
choose from among options, to demand
service, to decide, and to manage their
choices and lives
 Individuals with an array of interests,
values, tastes, opinions, attitudes and
intentions
 A valued commodity to those who offer
products and services
 Not just an alternate or politically correct
term for client or patient

Two Sides of the Coin

Consumer
– Motivation
– Change
mechanisms
– Adherence
– Hope
– Efficacy
– Managing coexisting
problems

Treatment Services
– Programs
– Types of Services
– Treatment
Strategies and
types
– Development of
New Approaches
and Medications
A Consumer Perspective
A Consumer Perspective shifts the emphasis
from an intense concentration on our
treatments to a unique focus on our
consumers and their processes
 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.
The Challenge
 Meet
our consumers where they are
 Understand their needs, preferences,
and perspectives
 Develop products and services that
are attractive and effective
 Engage the consumer in the creation
of the options
 Plan to be there for the long term
The Reality of Recovery

Change is not only possible, it is a reality.
– There are over 40 million former smokers in
the U.S.
– Many individuals with serious psychiatric
disorders are working in government and
business, in education and entertainment and
leading productive lives
– Large numbers of alcohol and drug addicted
individuals from varied level of socioeconomic
status are in recovery and provide models and
support for those whose journey of change lies
ahead of them
– Providers must be careful not to engage in a
self-fulfilling prophecy
Thank You
 My
contribution to helping you to
create a recovery based system of
care for individuals suffering from
mental illness and addictions
 Each person you reach and help to
manage these problems affects the
lives of many others
 Your work and efforts are
appreciated