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Download INSPIRATION FOR A CHANGE - Institute for Recovery
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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 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 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? 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? 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 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 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. 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. 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. 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 Symptom/Situation – Inadequate facilities – Financial – Psychiatric – Financial Beliefs – Religious views – Cultural beliefs – Self-Esteem Systemic – Funding Sources – Political forces – Subgroup conflicts Systemic Intrapersonal Interpersonal – Leadership Conflicts – Employment – Family/Children Beliefs – Only one right way Interpersonal – Marital Situation Institutional – Traditions – Organizational Culture PROBLEM FOCUS 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 C Emergency Shelter n ou Me ty l nta He n Ge h alt era l tan sis As V Community Living Residential Treatment Multi-Service Center ce ra ete Su b ’ ns ce rvi Se eA nc sta V b s en atm e r eT us a on ati oc lR So eh il ab cia t ita e lS ri cu Multi-Service Center Crisis Residential HHISN H ele om n tio ss ty ce rvi Se Homeless Encampment Multi-Service Center Day Rehabiliation Sheltered Employment s Stages by Context Analysis PreC Cont Prep Action Maint I Sit II Cog III Rel IV Sys 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 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 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 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 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 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
