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The Process of Human Behavior Change
Carlo C. DiClementeProfessor of Psychology
University of Maryland, Baltimore Countywww.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 & REQUIRE BEHAVIORDISEASE PREVENTION CHANGE
CANCER PREVENTION
CHRONIC ILLNESS MANAGEMENT
MENTAL HEALTH
MEDICATION ADHERENCE
HEALTH PROTECTION
SUBSTANCE ABUSE
INITIATION
MODIFICATION
CESSATION
COMMUNITY HEALTH ORGANIZATIONALSERVICE DELIVERY REQUIRE & INDIVIDUALSYSTEMS BEHAVIOR CHANGE
NEW DISCOVERIES
CHRONIC ILLNESS MANAGEMENT
NEW POLICY OR PROCEDURES
CHANGES IN PROVIDERS
CHANGES IN FUNDING
SHIFTS IN MANAGEMENT
INITIATION
MODIFICATION
CESSATION
Different Patterns of Behavior Change
Initiation, Modification, Cessation
Moderated and Self-Regulated Behavior Pattern
EXCESS
ABSENCE
HEALTH BEHAVIORS*
• MULTIPLE• MULTIDIMENSIONAL• VARY IN FREQUENCY• VARY IN INTENSITY• REQUIRE DIFFERING LEVELS OF
MOTIVATION• CAN BE INTEGRATED INTO DIFFERENT
LIFESTYLES TO VARYING DEGREES
*Includes Mental Health Behaviors
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
Most Models of Change are Multidimensional
• There are many models of change that identify separate and distinct aspects of behavior change:
• Health Belief Model – Vulnerability, Beliefs, Efficacy
• Theory of Reasoned Action or Planned Behavior – Action Intention, Decision, Implementation Intention, Efficacy
• Social Learning – Norms, Beliefs, Outcome and Efficacy Expectancies, Cues to Action
• Behavior Modification – Reinforcement History, Value and Schedules
Clear Difference Between Pre Action and Action Stages
The Key Link
Pre ActionStages
ActionStages
What do individuals have to do in Pre Action Stages to be successful in Action Stages? What do they have to do in the Action stages to sustain success?
Behavior Change Requires a Multidimensional Set of Explanatory Variables
• When making the transition from status quo to status quo how can I organize these influences
• Different tasks and hurdles that need to be accomplished or overcome
• Cognitions complicate Behavior Change Transition Probabilities and are less observable
• Single dimensions seem inadequate to explain the complexity and diversity of the behavior change process
• Self-Regulation is an integral part of the behavior change process
What Drives the Behavior Change Transition?
• Intentions• Expectancies• Change Language• Decision Making• Skills• Goals• Development
• Relationships• Reinforcements• External Pressure• Life Events• Family• Consequences• Teachable
Moments
All have been involved on some of the changes I have seen in therapy and research
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
Important Steps in Making Behavior Changes that Last
• THINK• DECIDE• PREPARE• COMMIT• IMPLEMENT• SUSTAIN
These seem to be different parts of a process of intentional behavior 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 UNWILLING UNABLE
Precontemplation Contemplation Preparation 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-LiberationSelf-Revaluation Counter-conditioningEnvironmental Reevaluation Stimulus ControlEmotional Arousal/Dramatic Relief Reinforcement ManagementSocial Liberation Helping Relationships
CONTEXT OF CHANGE
1. Current Life Situation2. Beliefs and Attitudes3. Interpersonal Relationships4. Social Systems5. 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 AND ORGANIZATIONS MUST 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. Decision-making.
• GOAL: A considered evaluation that leads to a decision to change.
Decisional Balance Worksheet
NO CHANGE
PROS (Status Quo)_____________________________________________
CONS (Change)_____________________________________________
CHANGE
CONS (Status Quo)_____________________________________________
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 with 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 Decision-Making Self-efficacy
Precontemplation Contemplation Preparation Action Maintenance
Personal Environmental Decisional Cognitive Behavioral OrganizationalConcerns Pressure Balance Experiential Processes
(Pros & Cons) Processes
Recycling Relapse
PrecontemplationIncrease awareness of need to change
ContemplationMotivate and increase confidence
in ability to change
ActionReaffirm commitment
and follow-up
Termination
Stages of Change Model
RelapseAssist in Coping
MaintenanceEncourage activeproblem-solving
PreparationNegotiate a plan
Theoretical and Practical Considerations Related to Movement Through the Stages of Change
Motivation
Precontemplation Contemplation Preparation Action Maintenance
PersonalConcerns
What would help or hinder completion of the tasks of each of the stages and deplete the self-control strength needed to engage in the processes of change needed to complete the tasks?
Decision Making Self-efficacy
Relapse
EnvironmentalPressure
Decisional Balance
CognitiveExperiential Processes
Behavioral Processes
Recycling
TASK COMPLETION AND MOVEMENT BETWEEN STAGES
PC CON PREP ACT MAIN
INTERESTCONCERN
RISK/REWARDDECISION
COMMMITMENTPLANNINGPRIORITIZING
IMPLEMENTTHE PLANREVISE
LIFESTYLEINTEGRATIONAVOIDRELAPSE
The Smoker’s Journey
Satisfied Dependentor CasualSmoker
Dissatisfied but ambivalent
Decided toMake a QuitAttempt
ChoosingA MethodNRT, TX, Cold Turkey,Quitline
QuitAttempt
ShortTermSuccess
LongTermSuccess
RelapseAndRecycling
Policy
Price
Social pressure
SmokingIn
Network Tobacco Advertising
Beliefs & Myths
Quitting History
PersonalConcerns
SpecialEvents
PsychiatricConditionsAnd Other
Life Problems
Promotion
SocialSupport
Products&
Services
STAGES OF CHANGE AND INTERVENTION TASKS STAGES OF CHANGE AND INTERVENTION TASKS
RELAPSE
CONTEMPLATION
PRECONTEMPLATIONRaise doubt - Increase the client’s perception of risks and problems with current behavior
Tip the decisional balance - Evoke reasons for change, risks of not changing; Strengthen client’s self-efficacy for change of current behavior
PREPARATIONHelp the client to determine the best course of action to take in seeking change; Develop a plan
ACTIONHelp the client implement the plan; Use skills; Problem solve; Support self-efficacy
MAINTENANCEHelp the client identify and use strategies to prevent relapse; Resolve associated problems
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
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
Some Examples
• Initiation and Recovery from Addiction
• Medication & HIV/AIDS Compliance enhancement
• Trauma Unit Screening and Interventions for Risky Drinking
• Group Therapy Manual
Addiction and Change
• Both acquisition of and recovery from an addiction require a personal journey through an intentional change process that is influenced at various points by a host of factors.
• Involve a Process of Change
THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY
ADDICTIONADDICTION
RECOVERYRECOVERY
SustainedCessation
Dependence
PROCESSES, CONTEXT AND MARKERS OF CHANGE
Dependence
PC C PA A M
PC C PA A M
Implications for Acquisition and Prevention
• If there is a common but unique pathway, we can better understand where individuals are in this process of change for each addictive behavior
• We can distinguish between prevention and treatment better
• We can target interventions to the process of change
Adolescents, Emerging Adults and Recovery
• Precontemplation• Contemplation• Preparation• Action• Maintenance• Relapse
• Fewer Consequences• Developing Self-
Regulation• Impulsivity• Poor Planning• Abstinence Forever• Social Pressures
Multiple Problems Complicate the Process of
Change
The Context of Change:A Figure Ground Perspective
Typical Complications forIndividual and Organizations
• Symptom/Situation– Psychiatric– Financial
• Beliefs– Religious views– Cultural beliefs
• Interpersonal– Marital
• Systemic– Employment– Family/Children
• Intrapersonal– Self-Esteem
• Situation– Inadequate facilities– Financial
• Beliefs– Only one right way
• Interpersonal– Leadership Conflicts
• Systemic– Funding Sources– Political forces– Subgroup conflicts
• Institutional– Traditions– Organizational Culture
Challenging Populations and the Process of Change
• Multiple Addictions– Multiple
motivations– Comprehensive or
sequential strategies
• Criminal Justice– Restricted Access
to target behaviors– Process of Change
• Dually Diagnosed– Same Process
of Change– Integrated
Treatment• Homeless
– Not helpless– Housing First
Difficult Clients Necessitate Managing Client Difficulties: A TTM Analysis
• Target Problem and Contextual Problems
• Stage of Change for Each Problem• Identifying Key Processes of Change• Finding Appropriate Strategies to
Engage Processes• Recycling and Learning from the Past• Accomplishing Stage Tasks Adequately
Motivating Movement through the Early Stages of Change
• Critical tasks of the early stages are eliciting concern, dealing with ambivalence regarding change, decision-making, creating commitment, careful and comprehensive planning.
• Motivational Interviewing/Enhancement approaches are important strategies to engage and work with clients helping them successfully complete these tasks.
Motivating Movement through the Later Stages of Change
• Critical tasks of the later stages involve commitment, effective planning, sustained implementation, using behavioral skills, sustaining change despite obstacles, coping with slips and relapse.
• Cognitive/Behavioral approaches and engaging support systems are important strategies to help clients successfully complete these tasks.
Job Corps Challenges
• Target and Contextual Problems• When to work with which problem• Self-Regulation Challenges• Building effective and acceptable
action plans• Sustaining Change• Collaboration and Coordination of
Care with Other Providers
How Do Interventions Work?
INDIVIDUAL INTERVENTION
Static Interaction Model
How Do Interventions Work?
Dynamic Model: Stepping into a Flowing Stream
PROCESS OF INTENTIONAL
BEHAVIOR CHANGE
CLIENT
PROVIDER
TREATMENT
Concluding Thoughts
• Change is a complicated process
• Need a roadmap
• Need both an Overview of the larger process as well as a Focused view of a particular client
• Negotiating Change and Entering the Client’s Change Process requires patience and persistence; optimism and realism; and the belief in the potential for change
