Changing for Life: Using the Stages of Change to Support the Recovery Process

Transcription

1 Changing for Life: Using the Stages of Change to Support the Recovery Process Sara S. Johnson, Ph.D. Senior Vice President, Research & Product Development

2 Assessing your Readiness. How ready are you to use the Transtheoretical Model (TTM) in your work? Not planning to in the next 6 months Planning to in the next 6 months Planning to in the next month Have been using it for less than 6 months Have been using it for more than 6 months Ummmm What is the TTM?

3 SAMSHA 2011

4 SAMSHA s Working Definition of Recovery:

5 SAMSHA, 2011

6 Four dimensions that support a life in recovery Health Home Purpose Community

7 Problem People with mental and substance abuse disorders may die decades earlier than the average person mostly from untreated and preventable chronic illnesses like hypertension, diabetes, obesity, and cardiovascular disease that are aggravated by poor health habits such as inadequate physical activity, poor nutrition, smoking, and substance abuse.

8 Solution Integrated care The systematic coordination of general and behavioral healthcare Integrating mental health, substance abuse, and primary care services produces the best outcomes and proves the most effective approach to caring for people with multiple healthcare needs

9 OTPs as Health Homes Small number of states are making opioid treatment programs (OTPs) health homes under the Affordable Care Act (ACA) OTPs will help clients manage both their physical and behavioral health needs, including chronic conditions like obesity and diabetes A health home is for individuals with a chronic condition and a substance use disorder is included in the definition of a chronic condition We re not treating SUDs in isolation anymore. OTPs are trying to connect patients to treatment in the world of health services.^ ^

10 RI OTP as Health Homes Rhode Island has demonstrated that a health home approach can: Improve health Improve quality-of-life Decrease Medicaid costs The health home implements a whole-person oriented treatment plan ^ ^

11 Behavior Change Existing Contemplation Behavior New Behavior Precontemplation Preparation Action Maintenance What behavior change messages are most effective for those who need to change? Behavior has changed Key concepts Behavior change happens along a continuum Individually tailored messages have effects on those who are ready, getting ready, or not ready to change behavior Can have an impact on all participants and predict future change

12 White, W. The rhetoric of recovery advocacy: An essay on the power of language. Posted as In White, W. (2006). Let s Go Make Some History: Chronicles of the New Addiction Recovery Advocacy Movement. Washington, D.C.: Johnson Institute and Faces and Voices of Recovery, pp

13 Stages of Change

14 Precontemplation Not Yet Ready Have no intention to adopt the behavior in the next six months

15 Characteristics of Precontemplation Cons > Pros Defensive Resistant Change experienced as coerced Demoralized Denial From 30 to 85% of population at risk

16 SAMSHA, 2011

17 SAMSHA, 2011

18 Precontemplators might say Not now I won t I ought to I wish I could I should

19 Contemplation Getting Ready Intend to adopt the behavior in the next 6 months

20 Characteristics of Contemplation Pros = Cons Ambivalent Lack commitment Lack confidence Doubt Delay ( chronic contemplation) From 10 to 50% of population at risk

21 Contemplators might say Maybe I will I might When X happens

22 Preparation Ready to Take Action Intend to adopt the behavior in next 30 days Already taking small steps

23 Characteristics of Preparation Pros > Cons Have a plan Have taken small steps Decisive/committed More confident, but fear of failure Ideal participants From 5 to 35% of population at risk

24 Preparers might say I will I m ready to It is time to

25 Action Recently Changed Behavior Adopted the behavior less than 6 months ago

26 Characteristics of Action Individuals working to make change Individuals may experience strong urge to revert back to old behavior Recycling to earlier stage is common

27 Those in Action say I am I just started to

28 Maintenance Changed Behavior Adopted the behavior at least 6 months

29 Characteristics of Maintenance Higher self-efficacy Dynamic, not static Consolidating gains Improved coping skills

30 Those in Maintenance say I have been

31 Termination: Sustaining goals for more than five years

32 Characteristics of Termination: Home Free Full confidence Zero temptation New behavior has become a habit

33 Stage of Change Distribution: Smoking Stage of Change 20% 40% 40% Precontemplation Contemplation Preparation Velicer, WF., Fava, JL., Prochaska, JO., Abrams, DB., Emmons, KM., & Pierce, J. (1995). Distribution of smokers by stage in three representative samples. Preventive Medicine, 24,

34 Stage Profiles of Completers and Dropouts of Psychotherapy T-scores PC C A M Premature Termination Appropriate Termination Continuers Brogan, MM, Prochaska, JO & Prochaska, JM. (1999). Predicting termination and continuation status in psychotherapy using the transtheoretical model. Psychotherapy, 36,

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36 Stage Progression Precontemplation Contemplation Preparation Action Maintenance PC C P Moving forward at least one stage as much as doubles the chance that an individual will move to action in the next six months.

37 Percentage Abstinent Over 18 Months for Smokers (n=570) Percentage PC C P/A 10 0 Pretest Assessment Periods Prochaska, JO, Velicer, WF, Fava, Jl, et al. (2001). Evaluating a population-based recruitment approach and a stage-based expert system intervention for smoking cessation. Addictive Behavior, 26,

38 Decisional Balance Benefits Barriers

39 Stage of Change Transitions The pros & cons of changing across stage for 48 behaviors Hall, K. L. & Rossi, J. S. (2008). Meta-analytic examination of the strong and weak principles across 48 health behaviors. Preventive Medicine, 46,

40 Decisional Balance of Drug Addiction Treatment Across Stage T-Scores PC C PR A/M Stage Pros Cons

41 Perceived Coercion and Choice Over Participating In Drug Addiction Treatment Across Stage Choice Coercion T-Scores PC C PR A/M Stage

42 Decisional Balance Across the Stages Precontemplation Contemplation Preparation Action Maintenance Increase the Pros Reduce the Cons Keep the Pros Above the Cons

43 Self-Efficacy Confidence Degree to which individuals believe they can achieve their goals

44 Self-Efficacy DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF. The Process of Smoking Cessation: An Analysis of Precontemplation, Contemplation, and Preparation Stages of Change. J Consult Clin Psychol. 1991; 59:

45 Processes of Change HOW people change Experiential and behavioral strategies and techniques used to change behavior Facilitate transitions between stages Processes of Change Used as basis of intervention to facilitate stage progression 2011 Pro-Change Behavior Systems, Inc. All Rights Reserved.

46 Processes of Change: Experiential Processes of Change Consciousness Raising (Become Informed): Learning new facts, ideas and tips that support the healthy behavior change Dramatic Relief (Increase Emotional Awareness): Experiencing negative emotions (fear, anxiety) that go along with the old behavior or the positive emotions (e.g., inspiration) that go along with behavior change Environmental Reevaluation (Consider Others): Realizing the negative impact of one s behavior and the positive impact of change on others 2011 Pro-Change Behavior Systems, Inc. All Rights Reserved.

47 Processes of Change: Experiential Processes of Change Self-Reevaluation (Create a New Self Image): Realizing that the behavioral change is an important part of one s identity Social Liberation (Notice the Public Effort): Realizing that social norms are changing to support the healthy behavior 2011 Pro-Change Behavior Systems, Inc. All Rights Reserved.

48 Processes of Change: Behavioral Processes of Change Helping Relationships (Get Support): Seeking and using social support to make and sustain changes Counter-Conditioning (Use Subsitutes): Substituting healthy alternative behaviors and thoughts for unhealthy ones Reinforcement Management (Rewards): Increasing the intrinsic and extrinsic rewards for healthy behavior change and decreasing the rewards for old behaviors 2011 Pro-Change Behavior Systems, Inc. All Rights Reserved.

49 Processes of Change: Behavioral Processes of Change Stimulus Control (Manage Environment): Removing reminders or cues to engage in the old behaviors, and using cues to engage in the new healthy behavior Self-Liberation (Make a Commitment): Believing in one s ability to change and making a commitment to change based on that belief 2011 Pro-Change Behavior Systems, Inc. All Rights Reserved.

50 Integration of Stages & Processes of Change Precontemplation Contemplation Preparation Action Maintenance Become Informed Consider Others Increase Emotional Awareness Notice the Public Effort Create New Self-Image Make Commitment Get Support Use Substitutes Rewards Manage Environment Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9),

51 Outcomes: Depression Prevention In a clinical trial of the TTM based depression prevention program among 809 proactively recruited participants: Treatment group was significantly more likely to experience a reliable and clinically significant improvement in depression (unadjusted OR=1.79, 95% CI= ). Treatment group was significantly less likely to develop major depression during follow-up (OR=0.63, CI= ). For patients with major depression, the intervention associated with greater improvement in physical functioning Levesque, D. A., Van Marter, D., Schneider, R. J., Bauer, M. R., Goldberg, D. N., Prochaska, J. O. et al. (2008). Computerized Intervention for Depression in Primary Care: A Randomized Trial Under Review.

52 Percent Experiencing Reliable and Clinically Significant Change in Level of Depression Depression in Primary Care: Percent Experiencing Reliable and Clinically Significant Improvement in Depression at 9 Months Follow-Up Expert System + Guide Usual Care Percent Major Depression Subclinical Depression Baseline Level of Depression Levesque et al., 2008

53 Gender 30 Point Prevalence Abstinence Assessment (Month) Male Female Velicer, WF, Redding, CA, Sun, X, & Prochaska, JO. (2007). Demographic variables, smoking variables, and outcome across five studies. Health Psychology, 26,

54 Age Point Prevalence Abstinence Assessment (Months) <= Velicer, WF, Redding, CA, Sun, X, & Prochaska, JO. (2007). Demographic variables, smoking variables, and outcome across five studies. Health Psychology, 26,

55 Proactive Cessation With Adolescents in Primary Care Tailored Intervention Assessment Only 23.9% 11.4% Hollis, JF, Polen, MR, Whitlock, EP; Lichtenstein, E., Mullooly, JP, Velicer, W.F., & Redding, C.A. (2005). TEEN REACH: Outcomes from a randomized controlled trial of a tobacco reduction program among teens seen in primary medical care. Pediatrics, 115,

56 Race Point Prevalence Abstinence White Black Assessment (Month) Velicer, WF, Redding, CA, Sun, X, & Prochaska, JO. (2007). Demographic variables, smoking variables, and outcome across five studies. Health Psychology, 26,

57 Hispanic Point Prevalence Abstinence Assessment (Month) No Yes Velicer, WF, Redding, CA, Sun, X, & Prochaska, JO. (2007). Demographic variables, smoking variables, and outcome across five studies. Health Psychology, 26,

58 Smoking Program: Inpatient Psychiatry Sample RCT of Pro-Change Smoking Cessation Program vs usual care in 224 participants recruited from acute inpatient psychiatry unit 16% were in Preparation Intervention included: On-unit Smoking Cessation Session, printed report, and guide Access to NRT minute cessation counseling session Letter mailed to outpatient provider Follow-up Smoking Cessation Sessions 3 & 6 months 10-weeks of NRT post-discharge Prochaska, J.J., Hall, S.E., Delucchi, K., & Hall, S.M. (2012). Efficacy of Initiating Tobacco Dependence Treatment in Inpatient Psychiatry: A Randomized Clinical Trial. American Journal of Public Health. doi: /AJPH

59 Cessation Rates in Inpatient Psychiatry Sample % Quit Intervention Usual Care months 6 months 12 months 18 months Prochaska, J.J., Hall, S.E., Delucchi, K., & Hall, S.M. (2012). Efficacy of Initiating Tobacco Dependence Treatment in Inpatient Psychiatry: A Randomized Clinical Trial. American Journal of Public Health. doi: /AJPH

60 Re-hospitalization in Inpatient Psychiatry Sample Prochaska, J.J., Hall, S.E., Delucchi, K., & Hall, S.M. (2012). Efficacy of Initiating Tobacco Dependence Treatment in Inpatient Psychiatry: A Randomized Clinical Trial. American Journal of Public Health. doi: /AJPH

61 SAMSHA, 2011

62 SAMSHA, 2011

63 Adding TTM-tailored Interventions to Midwife Counseling with Pregnant Smokers Adding TTM-tailored interventions produced 8.2 times the impacts of midwife counseling alone Increased Recruitment Increased Retention Increased Efficacy Decreased Mis-reporting Lawrence,T, Aveyard, P, Cheng, K, Griffin, C, Johnson, C, & Croghan, E. (2005). Does stage-based smoking cessation advice in pregnancy result in long-term quitters? 18-month postpartum follow-up of a randomized controlled trial. Addiction, 100 (1),

64 Percentage of Not-on-Track Cases Meeting Criteria for Clinically Significant Outcome at Termination Outcome Classification Treatment as Usual Treatment & Feedback Deteriorated 21.3% 13.4% Reliable or clinically significant change 21.0% 34.9% Lambert, et al. (2005)

65 Computerized Stage-Based Intervention for Adult Male DV Offenders 492 offenders recruited from four Rhode Island domestic violence agencies at program intake Computer sessions were offered as an adjunct to mandated group treatment Computer randomly assigned participants to: 1. Treatment group manual + computer sessions and reports at intake, 2 and 5 months follow-up 2. Placebo control group computer assessments and one-size-fits-all reports at intake and 5 months follow-up

66 Demographics Average age 33.7 years 70% white non-hispanic, 8% black non-hispanic, 14% Hispanic, 7% other 54% single, never married, 19% married, and the remainder separated, divorced or widowed 61% had at least a high school degree 53% were employed full-time 35% had attended a prior DV program 34% had prior arrests for other violence

67 Victim Reports Victim Report Violence and Threats Control Treatment Any violence 1 st six months Any violence 2 nd six months Any threats 1 st six months Any threats 2 nd six months 37% 16% 16% 13% 61% 47% 61% 32%

68 Self-Reports in 5-Month Assessment Self-Reported Help-Seeking Control Treatment Talked to Clergy 9% 23% Talked to Med Professional 26% 40% Couples Counseling 11% 22% Other Group Counseling 19% 34%

69 Coaction refers to the increased probability that individuals who adopt a health behavior will adopt another health behavior.

70 Coaction Studies demonstrate that coaction may not be a naturally occurring phenomenon given that it occurs much more in groups receiving tailored behavior change treatments. -Johnson, et al Coaction in Odds Ratio Control Group TTM Intervention Group Johnson, S. S., Paiva, A., Mauriello, L., Prochaska, J. O., Redding, C. A., & Velicer, W. F. (2014). Coaction in Multiple Behavior Change Interventions: Consistency across Multiple Studies on Weight Management & Obesity Prevention. Health Psychology, 13,

71 Well-being Rath & Harter, Well-being: The Five Essential Elements

72 Dimensions of Support in Recovery SAMSHA, 2012

73 Improvements in Well-Being Overall Individual Domains Prochaska, J.O., Evers, K.E., Castle, P.H., Johnson, J.L., Prochaska, J.M., Rula, E.Y., Coberley, C., & Pope, J.E. (2012). Enhancing Multiple Domains of Well-being by Decreasing Multiple Health Risk Behaviors: A Randomized Clinical Trial. Population Health Management, 15 (5),

74 Well-Being Trial Behavioral Outcomes Vs. Control *p <.05 **p <.01 ***p <.001 Prochaska, J.O., Evers, K.E., Castle, P.H., Johnson, J.L., Prochaska, J.M., Rula, E.Y., Coberley, C., & Pope, J.E. (2012). Enhancing Multiple Domains of Well-being by Decreasing Multiple Health Risk Behaviors: A Randomized Clinical Trial. Population Health Management, 15 (5),

75 Well-Being Please imagine a ladder with steps numbered from zero at the bottom to ten at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you. On which step of the ladder would you say you personally feel you stand at this time? On which step of the ladder do you think you will stand about five years from now? Thriving Struggling Suffering Based on the Cantril Self-Anchoring Striving Scale (Cantril, 1965) & GALLUP 75

76 Well-Being: Change Over Time Prochaska, J.O., Evers, K.E., Castle, P.H., Johnson, J.L., Prochaska, J.M., Rula, E.Y., Coberley, C., & Pope, J.E. (2012). Enhancing Multiple Domains of Well-being by Decreasing Multiple Health Risk Behaviors: A Randomized Clinical Trial. Population Health Management, 15 (5),

77 Inclusive Care Inclusive Research Inclusive Practice Inclusive Care

78 What Do You Do with Precontemplators? Goal: Engage them in the change process Key Strategy: Increase the Pros Encourage participant to list their own benefits Point out additional benefits specific to them Provide a list of benefits Encourage them to look for more

79 What Do You Do with Contemplators? Goal: Overcome ambivalence Key Strategy: Make the Pros Outweigh the Cons Ask participant to name most significant con(s) Acknowledge changing does have costs, but avoid debate about whether change is worth it Ask participant to shrink cons by: Comparing them to growing list of pros Asking how important they are relative to pros Challenging themselves to counter the cons

80 More About Contemplation Don t encourage Contemplators to take action but rather to start to prepare Encourage small steps

81 Key Behavior Change Strategy for Preparation Goal: Help the patient move to Action Key Strategy: Encourage participant to make strong commitment by: Setting a specific start date, rather than wait for a magic moment Sharing commitment with others Creating a specific Action Plan Writing down the plan, start date, etc.

82 Key Behavior Change Strategy for Action Goal: Keep it up!! Key Strategy: Encourage participant to get support by: Seeking support from others Being as specific as possible about the type and amount of encouragement they need Seeking out professionals as needed

83 Key Behavior Change Strategy for Maintenance Goal: Make the new behavior a life-long habit Key Strategy: Use Substitutes Encourage participant to: Replace negative thoughts with positive thoughts Plan ahead to deal with difficult situations Have a plan for dealing with slips rather than giving up

84 Recap Recovery occurs via highly personalized pathways as individuals are unique and have distinct needs Helping people move just one stage increases likelihood of successful action Redefine success Stage movement decisional balance self-efficacy stage-matched processes of change 84

85 Re-Assessing your Readiness. How ready are you to use the Transtheoretical Model (TTM) in your work? Not planning to in the next 6 months Planning to in the next 6 months Planning to in the next month Have been using it for less than 6 months Have been using it for more than 6 months