THE STAGES OF CHANGE PRESENTERS: DR. CARLO DICLEMENTE & DR. STEPHANIE HUTTER-THOMAS - RCORP ...
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Regrounding Our Response:
The Stages of Change
Presenters:
Dr. Carlo DiClemente & Dr. Stephanie Hutter-Thomas
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Regrounding Our Response Overview 1. We can name stigma as an obstacle, but often don’t have the tools to impact the attitudes that sustain it. 2. Regrounding Our Response aims to build a multi-disciplinary network of trainers around the state to expand education on fundamental areas of public health that are necessary to help reduce stigma. 3. Unless we address the myths and misunderstandings around substance use, we will be limited in our readiness to embrace the strategies that are being shown to work – to save lives, save money, and help turn the tide in this crisis.
Regrounding Our Response Learning Objectives:
Seeks to reduce the stigma associated with responding to the overdose crisis along an educational
continuum
Comprehensive
Social Adverse Medication
Stages of Health Framework
Determinants Childhood for People Who Use Assisted
Experiences Change
of Health Drugs Treatment
• Define and identify the social • Review how trauma can
• Understand the burden of • Understand what comprises • Understand the prevalence
determinants of health affect brain architecture,
change Drug User Health of opioid use and the
• Understand how current US behavior and traits
differences between
drug policy undermine social
• Utilize ACE Score to • Understand how intentional • Learn about how stigma and substance use disorder and
determinants of health establish a common behavior change happens trauma impact health physical dependence
• Understand the role of the standard for traumatic
• Understand how harm • Review key harm reduction • Explain how medications for
social determinants of health childhood experiences
reduction strategies keep strategies and protective addiction treatment (MAT)
in the opioid crisis
• Recognize the connection people safe, build self- factors for infectious disease prevent opioid overdose and
• Analyze how harm reduction
between childhood trauma efficacy and support the provide effective long-term
strategies address the social • Review examples of drug
and substance use change process therapy
determinants of health at an user health frameworks and
individual level, which • Discuss protective factors • Learn how to support people strategies to apply the • Understand barriers to
improves community and how to build resilient, through the process of framework in your accessing medications for
outcomes self-healing communities change organization opioid use disorder (OUD)
Subject Matter Experts and
Primary Sources
Bridging Environments for Health
Social Determinants of Health
The Family Tree’s ACE Interface Initiative
Adverse Childhood Experiences with the Maryland Essentials for Childhood Initiative and
State Council on Child Abuse and Neglect
University of Maryland Baltimore County Center for Community
Stages of Change Collaboration
Comprehensive Health Framework NASTAD - National Alliance of State and Territorial AIDS
Directors
for People Who Use Drugs
MAT as Overdose Prevention Institutes for Behavior Resources and REACH health Services
Stages of Change 1- Hour Course:
Learning Objectives
• Understand the burden of change
• Understand how behavior change happens
• Understand how harm reduction strategies keep
people safe, build self-efficacy, and support the
change process
• Learn how to support people through the
process of change
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Stages of Change:
Learning Objectives
• Understand the burden of change
• Understand how behavior change happens
• Understand how harm reduction strategies keep
people safe, build self-efficacy, and support the
change process
• Learn how to support people through the
process of change
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The Burden of Change 8 Reasons Why Change Is Hard
Negative Emotional Motivation
All or None Thinking
Eating the Elephant All at Once
Neglecting the Right Tools
Trying to Change Too Much at Once
Underestimating the Change Process
Forgetting Failure Is Given
Not Making a Commitment to Change
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Barriers to Drug Use Behavior Change When 147 patients in urban United States Community Health Centers who misused drugs, but did not meet criteria for drug dependence, were asked to identify barriers patients believed inhibited drug use behavior change, six major reasons emerged: Needing drugs to alleviate mental or emotional distress 72 (49.0%) Proximity to people or places associated with drug use 61 (41.5%) Belief that drug use enhances quality of life or functioning 52 (35.4%) Needing drugs to alleviate physical pain or discomfort 40 (27.2%) Drug use being habitual/fearing consequences of stopping drug 30 (20.4%) use Drug use hard to stop due to challenges associated with 19 (12.9%) poverty, homelessness 10
Understanding Substance Use
Disorder
• DSM-5 definition
• Habitual patterns of intentional, pleasurable
behaviors
• Behavior becomes:
• Excessive
• Problematic – serious consequences across
various areas of life
• Difficult to modify and stop
11Substance Use Disorder & Change
• Development of and recovery from
addiction/SUDs require a personal
journey through an intentional change
process:
• Marked by personal decisions and
choices
• Influenced at various points by many
biological, psychological, and social
factors
• Follows a common path – marked by
set of tasks that must be completed to
move forward
12Stages of Change:
Learning Objectives
• Understand the burden of change
• Understand how behavior change happens
• Understand how harm reduction strategies keep
people safe, build self-efficacy, and support the
change process
• Learn how to support people through the
process of change
13Motivation and the Change Process
• People are NOT unmotivated!
• Rather, they are either…
• Motivated to engage in behaviors that
may be harmful and problematic
~OR~
• Not ready to begin behaviors that may
be helpful.
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
14 Abuse Treatment. 1999;DHHS no. (SMA) 99-3354.Understanding Intentional
Behavior Change
People change voluntarily only when:
• They become interested in or concerned about the need for change
• They become convinced that the change is in their best interest or will
benefit them more than cost them
• They organize a plan of action they are committed to implementing
• They take the actions that are necessary to make the change and sustain
the change
15Recipe for Successful Change:
Ready, Willing, & Able
Successful intentional behavior change
happens when one is…
• Ready: Sufficiently motivated to
change in the near future
• Willing: Has made a firm personal
decision to change
• Able: Believes in their ability to
change/that they have what they
need in order to make a change
16Remember:
“ Change is a process… NOT an event. ”
~ James Prochaska
• Major behavior changes don’t happen overnight!
• The process of change can be thought of as moving through
different stages of change that begin before a person decides
to make a change.
• Each stage represents important tasks that the person
needs to accomplish in order to successfully change.
17The Stages of Change Model
Precontemplation
Not thinking about changing
Contemplation
Considering change
Preparation
Making decision/s for change
Relapse Action
Lapse Commitment and beginning to change
Studies show that people progress & recycle Maintenance
through the stages on their way to achieving long- Change has become integrated with life
term behavior changes.
18Key Tasks for Each Stage
STAGES KEY TASKS
Precontemplation
◦ Not interested in change Increase interest and concern
Contemplation Risk-reward analysis and decision
◦ Considering change making
Preparation Commitment and creating an
◦ Preparing for change effective/acceptable plan
Action Implementation of plan and revision
◦ Initial change as needed
Maintenance
◦ Sustained change Integrating change into lifestyle
19 DiClemente, 2018; 2005Readiness for Change Is Behavior
Specific
• Readiness is behavior specific.
• One key behavioral goal (e.g., changing alcohol use, weight loss)
involves important behaviors related to that goal:
• Cutting down vs. Abstaining
• Dietary change vs. Exercise
• Broad change goals involve the process of changing multiple
behaviors
20It Is Possible to Be at Different Stages
of Change for Related Behaviors
Behavior Stage of Change
PC C PA A M
Quitting Cigarettes X
Carrying Narcan X
Quitting Heroin X
Quitting Alcohol X
Using Sterile Syringes X
21Encouraging Movement Through
the Stages of Change
READY WILLING ABLE
Motivation Decision-Making Self-efficacy
Precontemplation Contemplation Preparation Action Maintenance
Personal Environmental
Concerns Pressure
Recycling Relapse
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DiClemente, 2003; 2005; 2018Stages of Change:
Learning Objectives
• Understand the burden of change
• Understand how behavior change happens
• Understand how harm reduction strategies keep
people safe, build self-efficacy, and support the
change process
• Learn how to support people through the
process of change
23Current Landscape for People
Who Use Drugs
Public Health: Law Enforcement: Public Health:
Prevention Arrest Treatment
Incarceration
24Reimagined Landscape for People
Who Use Drugs
Public Health: Harm Reduction
Public Health: Law Enforcement Public Health:
Prevention Assisted Diversion Treatment
(LEAD)
25Harm Reduction Defined
Provision of services to people who are actively using drugs:
• Comes with no expectation that they stop using
• Is delivered in a non-judgmental and non-
stigmatizing manner
• Acknowledges harms of drug use
• Presents accurate information about ways to reduce
these harms
• Focused on promoting any positive change.
26Interventions
• Overdose Education and Naloxone Distribution
• Syringe Services Programs (sterile syringes and injection
equipment)
• Law Enforcement Assisted Diversion (LEAD)
• Harm Reduction Peer Work
• Mobile, Low Barrier Wound Care Services
• Medication-Assisted Treatment (MAT)
• HCV Testing and Treatment for PWUD
• Targeted Case Management
• Peer support groups (NA, AA, SMART Recovery)
27Rationale for Harm Reduction
• Reduces overdose deaths (Seal et al., 2005; Tobin et al.,
HARM
2009)
• Increases entry into drug treatment (Hagan et al.,
2009; Strathdee et al., 1999)
• Reduces prevalence of sexually-transmitted
infections/infectious diseases (STIs/IDs) (Des
Jarlais et al., 2014; Institute of Medicine, 2017; van den Berg et al.,
2007; Wodak & Cooney, 2006; Wodak & Maher, 2010)
28Rationale for Harm Reduction
• Promotes respect, compassion, and understanding toward people who
use substances
• Meets people where they are & everyone can benefit! (Marlatt, 1996)
• Applies commonly used HR principles to substances – e.g., sex ed.,
sober rides, legalizing sex work/drugs (Leslie, 2008; Rekart, 2006)
29Benefits of Harm Reduction
Consider sharing these key messages:
Harm reduction programs can:
• Establish trust between people who use opioids and the public
health sector.
• Make it easier for people who use to seek help when they’re
ready.
• Reduce the costs and harms related to using.
• Promote positive change with respect to harmful use of
substances.
30Stages of Change:
Learning Objectives
• Understand the burden of change
• Understand how behavior change happens
• Understand how harm reduction strategies keep
people safe, build self-efficacy, and support the
change process
• Learn how to support people through the
process of change
31How Can We Use This Model?
Meeting People Where They Are
• Identify stages of change and understand implications of being in each
stage
• Focus on the tasks of these stages and what you can do when you
encounter individuals who use opioids or other substances
• Consider how to keep people safe during the pre-Action stages (Harm
Reduction)
32Role of Self-Efficacy in the Process
Self-Efficacy = Degree of confidence individuals have in their ability
to perform a specific behavior.
• Precontemplation and Contemplation: Self-efficacy is lower
than temptation to engage in the problem behavior.
• Movement from Preparation to Action: Gap between temptation
and confidence closes, and behavior changes.
• Action to Maintenance: Self-efficacy = Key predictor of Action
and of long-term success.
33Precontemplation Tasks & Goals
• PRECONTEMPLATION: The state in which there is little or no
consideration of changing 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.
34The “Five R’s”: How & Why People
Stay in Precontemplation
• Reveling: “I like it the way it is.”
• Reluctant: “Not now… not ever.”
• Rebellious: “It’s my life… MYOB.”
• Resigned: “The damage is done…there’s no use.”
(Hopeless; helpless)
• Rationalizing: “At least I’m not doing…XYZ.”
(Harm minimization)
35Supporting People in
Precontemplation:
Not Interested in Change Right Now
• Encourage them to start • With permission, provide
thinking about change motivating information
• Be sure to emphasize that it • Assist them in identifying and
is their choice emphasizing possible benefits of
• Ask open-ended questions change
• Avoid sustain talk • Reduce harmful behaviors
• Reflect change talk
36Contemplation Tasks & Goals
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:
• Analyzing 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
37Supporting People in Contemplation:
Ambivalent About Making a Change
• Promote Harm Reduction • Use double-sided reflections
• Help support them in making a • Highlight change talk w/ reflections
decision • Encourage them to make the
• Explore important reasons for arguments for change
change • With permission, share important
• Assist them in identifying their information
most important values • Support their self-efficacy /
• Explore ambivalence and the confidence
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pros and cons of changeProgression from Contemplation
to Preparation
Beliefs/decisions that promote progression from contemplation
to preparation:
• Decide that the current behavior is problematic and needs
changing
• The pros for change outweigh the cons.
• Change is in my own best interest.
• The future will be better if I make changes in these
behaviors.
39Preparation Tasks & Goals
• PREPARATION: The stage in which the individual
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
future.
40Supporting People in Preparation:
Planning for Change
• Continue promoting Harm • Support the plan with your
Reduction help/resources
• Assist them in preparing • Encourage them to set a
well to make the change
timeline or date to begin/make
• Help them develop an the change
effective and acceptable
plan • Help them to identify possible
• Make it a collaborative barriers and plan for
plan – You cannot do it for overcoming these
them!
41Action: Tasks & Goals
• ACTION: The stage in which the individual or society implements the
plan, takes steps to change the current behavior pattern, and begins
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).
42Action: Key Issues & Intervention
Considerations
• Flexible and responsive problem solving
• Support for change
• Reward progress
• Continue development and refining skills needed to
implement the plan
43Supporting People in Action:
Starting to Make the Change
• Support the change and help • Use summaries to help reflect
spot possible problems in the their experiences
plan
• Highlight when there is support
• Encourage them to reward for change
themselves as they make strides
• Assist with breaking down
• Check in with them about any barriers (e.g., no transportation)
difficulties they are having
• Help them to revise the plan
when needed
44Maintenance: Tasks & Goals
• MAINTENANCE: The stage where the new behavior pattern is
sustained for an extended period and is consolidated into the
lifestyle of the individual.
• 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
45Maintenance: Key Issues &
Intervention Considerations
• It’s not over ‘til it’s over
• Support and reinforcement
• Availability of services or resources to address other life issues / areas of
functioning
• Offering valued alternative sources of reinforcement
• The “change” becomes the new norm
46Supporting People in Maintenance:
Sustaining the Change Over Time
• Support them in creating • Support their self-efficacy /
an environment that confidence
supports sustained • Encourage them to watch out for
change as much as events that can disrupt change
possible
• Help them to address any
• Continue helping them to remaining barriers
identify and emphasize
benefits of change
47Maintaining Change Requires… • Continued commitment • Skills to implement the plan • Long-term follow-through • Integrating new behaviors into lifestyle • Creating a new behavioral norm 48
Review: Helping People Progress Through
The Stages of Change
STAGES TASKS OF THE HELPER
Precontemplation
Increase person’s awareness of risks,
◦ Not interested in change
problems, and need for change
Contemplation Encourage person to voice reasons for change
◦ Thinking about change and risks of not changing; help tip the balance
of pros and cons
Preparation
◦ Preparing for change Help develop a personalized change plan
Action Help the person to develop relapse prevention
◦ Initial change strategies; adjust change plan as needed
Maintenance Help person identify strengths for long-term
◦ Long-term change change; provide support
49 DiClemente, 2003; 2005; 2018Relapse & Recycling 50
Change is NOT a Linear Process:
Understanding Relapse & Recycling
51Relapse Triggers
• Cravings, Urges, Temptations
• Social Cues and Situations
• Pleasure and Positive Reinforcement
• Testing Control
• Significant Others
• Stress, Negative Mood
• LIFE
52Relapse & Recycling
• Relapse shouldn’t be seen as a problem of substance abuse or
substance use disorders – relapse and recycling are a natural part
of the process of behavior change.
• Most successful changers make repeated efforts to get it right that
are part of a learning process to correct for inadequate completion
of stage tasks.
53This Photo by Unknown Author is licensed under CC BY-SA
Regression, Relapse, & Recycling Through
the Stages
• Regression represents movement backward through the stages.
• Slips are brief returns to the prior behavior that represent 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.
55“If at first you don’t succeed, try, try, try again.”
~ William Edward Hickson
56What types of support help people
change?
Keys to Successful Recycling Examples of support
• Persistent efforts
• Housing stability
• Repeated attempts
• Helping individuals take the next step • Employment status
• Enhance motivation and support self- • Family connection
efficacy • Self-worth
• Support for impaired self-regulation
• Personal freedom
(scaffolding)
• Match intervention to current stage of
changeCyclical Model of Change
• Most individuals with SUDs will recycle through
multiple quit attempts and multiple interventions
in order to accomplish each stage task well
enough to support recovery.
• Helpful to consider each “lapse” or “relapse” to be
a learning opportunity – much like falling while
learning to ride a bike.
58Keys to Successful Recycling
• Blame and guilt undermine motivation for change.
• Support re-engagement in the process of change:
• Persistent efforts
• Repeated attempts
• Helping individuals take the next step – matching strategy to stage of
change
• Talking to the person in an encouraging way that increases their
motivation to give it another shot
59Relapse Is NOT a Substance Abuse
Problem
Relapse is…
• A problem of starting and sustaining any
behavior change.
• A problem of not completing the critical tasks
of the stages of change adequately.
60Relapse is NOT the opposite
of recovery.
61Concluding Thoughts:
Regrounding Our Response With
the
Stages of Change
62Successful Recovery From SUDs
• Occurs over long periods of time
• Often involves multiple attempts and treatments
• Consists of self-change and/or brief interventions or treatments
• Often involves changes in other areas of the person’s life (social
aspects, coping more effectively with stress/negative mood, etc.)
There are many pathways to recovery.
63 Bishof et al., 2001; Sobel et al., 2001; Vailliant, 2003SAMHSA’s Working Definition of Recovery
From Mental Disorders and/or Substance
Use Disorders
A process of change through which
individuals improve their health and wellness,
live a self-directed life, and strive to reach
their full potential.
64Concluding Thoughts: Helping
Change Happen
• Understand that change is a difficult, complex
process.
• Identify where a person is in the change process
and how harm reduction strategies may provide
support and build self efficacy
• Have conversations about change, focusing on
important personal values and the possibility of
change
65Concluding Thoughts: Helping
Change Happen
• Help to identify and address current
challenges/barriers
• Keep in mind that supporting the
individual’s change process
requires:
• Patience
• Persistence
• Optimism
• Realism
66Worker Burnout/Compassion Fatigue
• Burnout is a special type of work-related stress – a state of physical
or emotional exhaustion that also involves a sense of reduced
accomplishment and/or a loss of personal identity.
• Signs/Symptoms:
• Increased cynicism
• Low energy
• Mood fluctuations
• Disturbed sleep
• Difficulty concentrating or focusing
• Unexplained physical symptoms
• Changes in eating or drinking habits
67 (Mayo Clinic, 2018)Coping With Burnout/Compassion Fatigue
• Seek support from others.
• Increase engagement in relaxing activities
(walking, yoga, meditation, gardening,
etc.).
• Make sure to get enough sleep.
• Eat well and stay hydrated.
• Exercise regularly.
• Take time off when you need it.
• Try being gentle with yourself!
68 (Mayo Clinic, 2018)Submitting Questions and Comments
Submit questions by using the Q&A feature.
To open your Q&A window, click on the
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69Thank you
The purpose of RCORP is to support treatment for and prevention of
substance use disorder, including opioid use disorder, in rural counties at the
highest risk for substance use disorder.
Dr. Carlo DiClemente
diclemen@umbc.edu
Dr. Stephanie Hutter-Thomas
shuttert@umd.eduYou can also read
