Carlo C DiClemente PhD ABPP UMBC Psychology wwwumbcedupsychabits 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 unders ID: 655509
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Slide1
Tailoring Interventions to Client Motivation and Mechanisms of Change
Carlo C. DiClemente, Ph.D. ABPP
UMBC Psychology
www.umbc.edu/psyc/habitsSlide2
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
. Slide3
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 elementsSlide4
Where Have We been looking to Understand Recovery and Mechanisms of Change?
I
ntervention/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 ProcessSlide5
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 changeSlide6
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
Transtheoretical ModelSlide7
THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY
ADDICTION
RECOVERY
Sustained
Cessation
Dependence
PROCESSES, CONTEXT AND MARKERS OF CHANGE
Dependence
PC
C
PA
A
M
PC
C
PA
A
M
DiClemente, Addiction and Change (in press) second edition
Stages: Precontemplation, Contemplation, Preparation, Action, MaintenanceSlide8
Theoretical and Practical Considerations Related to Movement Through the Stages of Change
Motivation
Precontemplation Contemplation Preparation Action Maintenance
Personal
Concerns
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?
Decision Making
Self-efficacy
Relapse
Environmental
Pressure
Decisional
Balance
Cognitive
Experiential
Processes
Behavioral
Processes
RecyclingSlide9
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)Slide10
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 vulnerabilityTemptation 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 Slide11
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)Slide12
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 theseExamined 21 hypothesized matching effects and over 30 baseline predictors of drinkingOnly a couple of significant matches9 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 Slide13
Baseline Predictors of Drinking at Months 4-15Slide14
Predictors of Drinking at 3-year Follow-UpSlide15
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
Carbonari & DiClemente.
J Consult Clin Psychol.
2000;68:810. Slide16Slide17Slide18
The COMBINE Study
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.Slide19
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).Slide20
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)Slide21
How Does Treatment Work?
Relationship
Empathy
Working Alliance
Active Ingredients
Manuals
Treatment Combinations & Matching
Relapse Prevention
Mutual Support
Focus on What provider doesSlide22
What about looking at it another way? Focus on What Client Does
Recovery
Treatment: A Mediator or Moderator of Client ProcessesSlide23
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)