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The Challenge of Change: Creating a Recovery Oriented System of Care

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Title: The Challenge of Change: Creating a Recovery Oriented System of Care


1
The Challenge of Change Creating a Recovery-
Oriented System of Care
  • Carlo C. DiClemente
  • Professor of Psychology
  • University of Maryland, Baltimore County
  • www.umbc.edu/psych/habits
  • www.mdquit.org

2
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

3
HEALTH PROMOTION REQUIRE
BEHAVIOR DISEASE PREVENTION
CHANGE
CANCER PREVENTION
INITIATION CHRONIC ILLNESS
MANAGEMENT SAFETY AND INJURY

MODIFICATION PREVENTION MENTAL HEALTH
SUBSTANCE ABUSE
CESSATION

4
COMMUNITY HEALTH ORGANIZATIONAL SERVICE
DELIVERY REQUIRE
INDIVIDUAL SYSTEMS BEHAVIOR
CHANGE
NEW DISCOVERIES/PHILOSOPHIES
INITIATION CHRONIC ILLNESS MANAGEMENT NEW
POLICY OR PROCEDURES
MODIFICATION CHANGES IN PROVIDERS CHANGES
IN FUNDING
CESSATION SHIFTS IN MANAGEMENT

5
(No Transcript)
6
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

7
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

8
WHY DONT 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

9
HOW PEOPLE CHANGE
10
Other Models of How to get People to Change
11
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

12
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

13
Understanding Barriers to Change and the Tasks of
the Stages of Change
UNMOTIVATED UNWILLING UNABLE
Precontemplation Contemplation
Preparation Action Maintenance

14
The Transtheoretical Model of Intentional
Behavior Change
STAGES OF CHANGE PRECONTEMPLATION ?
CONTEMPLATION ? PREPARATION ? ACTION ?
MAINTENANCE
PROCESSES OF CHANGE COGNITIVE/EXPERIENTIAL BEH
AVIORAL   Consciousness Raising Self-Liberatio
n Self-Revaluation Counter-conditioning Envir
onmental 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
15
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

16
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

17
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

18
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.

19
Decisional Balance Worksheet
NO CHANGE PROS (Status Quo) _______________ _____
__________ _______________ CONS
(Change) _______________ _______________ _________
______
CHANGE CONS (Status Quo) _______________ ________
_______ _______________ PROS (Change) ___________
____ _______________ _______________
20
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

21
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

22
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23
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.

24
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25
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

26
WILLING TO MAKE CHANGE
  • COMMITMENT TO TAKE ACTION
  • SPECIFIC ACCEPTABLE ACTION PLAN
  • TIMELINE FOR IMPLEMENTING PLAN
  • ANTICIPATION OF BARRIERS

27
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).

28
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

29
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.

30
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

31
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

32
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33
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

34
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

35
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
36
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
37
STAGES OF CHANGE AND INTERVENTION TASKS
Raise doubt - Increase the clients perception of
risks and problems with current behavior
PRECONTEMPLATION
Tip the decisional balance - Evoke reasons for
change, risks of not changing Strengthen
clients self-efficacy for change of current
behavior
CONTEMPLATION
Help the client to 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 the stages of
contemplation, preparation, and action, without
becoming stuck or demoralized because of relapse
RELAPSE
38
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

39
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

40
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

41
Multiple Problems Complicate the Process of Change
  • The Context of Change
  • A Figure Ground Perspective

42
CONTEXT OF CHANGE
I. SITUATIONAL RESOURCES AND PROBLEMS
II. COGNITIONS AND BELIEFS
III. INTERPERSONAL RESOURCES/PROBLEMS
IV. FAMILY SYSTEMS
V. ENDURING PERSONAL CHARACTERISTICS
43
Typical Complications for Individual and
Organizations
  • Situation
  • Inadequate facilities
  • Financial
  • Beliefs
  • Only one right way
  • Interpersonal
  • Leadership Conflicts
  • Systemic
  • Funding Sources
  • Political forces
  • Subgroup conflicts
  • Institutional
  • Traditions
  • Organizational Culture
  • Symptom/Situation
  • Psychiatric
  • Financial
  • Beliefs
  • Religious views
  • Cultural beliefs
  • Interpersonal
  • Marital
  • Systemic
  • Employment
  • Family/Children
  • Intrapersonal
  • Self-Esteem

44
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

45
Multiple Problems Need an Integrated Approach to
Care
46
Stages by Context Analysis
Experiential Processes
Behavioral Processes
47
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

48
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

49
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 multi-component
    interventions
  • Re-evaluate regularly the change process

50
PROCESS OF
VENTIONS
FORMAL
INTER
CHANGE
51
Application to Organizations that Deal with
Co-Occurring Disorders
  • Some Final thoughts

52
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

53
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

54
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

55
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

56
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

57
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

58
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

59
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

60
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

61
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
62
Some Final Thoughts
  • Treating those needing to change as consumers who
    can choose to use our services
  • The reality of recovery

63
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

64
Two Sides of the Coin
  • Treatment Services
  • Programs
  • Types of Services
  • Treatment Strategies and types
  • Development of New Approaches and Medications
  • Consumer
  • Motivation
  • Change mechanisms
  • Adherence
  • Hope
  • Efficacy
  • Managing co-existing problems

65
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 2002201.
66
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

67
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

68
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
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