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This is Marshall Poe on the editor of the new books network And I'd like to tell you that we have a new and improved website It has two new features that we think you'll love one of them is a vastly improved search engine So that when you type in keywords, you'll get a bunch of episodes really quick The other is the ability to create a listener account and in that listener account You can save episodes for later listening so you can create a kind of listening list We think these features are neat and we think you'll enjoy them. Please visit the site today. Hi, I'm dr. Robert Pearl former CEO of the permanent the medical group Kaiser Permanente a Stanford medical and business school professor a Forbes contributor and best-selling author of the book mistreated while we think we're getting good health care And why we're usually wrong And I am Jeremy core host of the new books and medicine podcast American health care is broken across the United States. There are over 200,000 patient deaths from medical error every year growing physician burnout outdated technology and inconvenient and delayed care for patients and on top of all of this skyrocketing drug prices and Increasingly unaffordable out-of-pocket patient expenses For decades our nation's political and medical leaders have talked about fixing the American health care system and yet the problems are now greater than in the past Every other industry that is inefficient and ineffective has experienced disruption Health care will be no different The question is whether the solutions will come from inside the health care system or be imposed on it We'd like to invite you to listen to our new podcast Fixing health care with dr. Robert Pearl and Jeremy core Each episode will feature one of the top leaders and innovative thinkers in health care today This shows format is simple the guests will present their roadmap for fixing American health care's biggest problems And from there German I will scrutinize the plan and help listeners separate Fixes that is the potential to succeed from simply the hype Our goal is that everyone from health care consumers to political and medical leaders will find value in the discussions on our show You may not agree with the different solutions offered, but you will never again conclude that nothing can be done We hope you will join us. Please subscribe via iTunes your favorite podcast software for more information visit our website at www.fixinghealthcarepodcast.com Welcome to a new books and alcohol drugs and intoxicants a podcast of the new books network. I'm your host Jen Wang This podcast features conversations and discussions with scholars and experts across diverse fields on the recently published books about substance use My goal for this podcast is to bridge the gap between academic and public knowledge on drugs and the implications for individuals and societies For more information about the podcast, please go to new books and alcohol drugs and toxicants calm Or follow us on tumblr at new books and drugs Thank you for tuning in and I hope you enjoy the podcast Today we have dr. Carlo de Clemente with us today's talk about his new book dr. Carlo de Clemente is a Presidential research professor in the Department of Psychology at the University of Maryland Baltimore County He also serves as director of the health and addictive behaviors lab at UMBC So his new book substance abuse treatment and the stages of change selecting employment interventions examines the latest research on the stages of change model in treating substance abuse and drug addiction Grounded and cutting-edge theory and research this volume is an ideal guy for practitioners and professionals who treat substance abuse across a broad range of settings So welcome dr. de Clemente. Thank you so much for being here Thank you Jennifer for having to be here And so can we start off by you telling us a little bit about your research and academic trajectory and how you came to study work You're studying currently Sure, when I was in graduate school actually I got started the research working on the smoking cessation and So I kind of started looking at addicted behaviors and that became a real interest of mine at the same time We were trying to look at a model for looking at how do people change and looking across different kinds of therapy theories and trying to figure out how How all of it fit together? So we came up with what we call the trans-theoretical model a lot of times It's a referred to as the stages of change model because it's got stages of change in it Which really kind of thinks about the process of change so we began working and researching in that we've done work in Smoking I've done work in alcohol. I ran an alcoholism treatment clinic and I've been using this model to try and help inform The clinical work that we do and help even some of the self change work. So we have a book changing for good That actually is a book for laypeople to kind of learn how to learn the model and learn how to apply in their own lives So that's that was the 30 some years ago, and I'm still kind of working on that and And working to help professionals and help individuals Kind of work their way through this process of change We do health behaviors, but we also do it at the behaviors Okay, that's great. Oh, yeah, and before I forget congratulations on your lifetime achievement award last November, right? Yes, it was last November the addiction group at the Earth the Association for Behavioral and Cognitive Therapy Was very nice and rewarded me that that's great. Yeah, congratulations. It's awesome Um, so do you mind talking a little bit about the different stages that you described in your model? No, that'd be great So the stages idea used to be that that when people thought about coming into treatment You had to bring your readiness with you. Okay So most of the time people say well, you know, if you're motivated come to treatment if you're not motivated get out into your motivators So what we did with the stages model was to say wait a minute There's a lot of parts of this process that we need to be thinking about not just action And what you can do once you're motivated, but what about pre-action? And so in the pre-action piece of this model we have three stages one stage called pre-contemplation Where the person just isn't thinking that it but that they really want to change in the near term So in some ways we asked you know, are you seriously thinking about quitting smoking in the next six months? If somebody says no to that they're in pre-contemplation So then we have once you say yes, you still have to kind of say okay. Well, we're so now you're in contemplation You're thinking about doing it and and in pre-contemplation the challenge is getting people interested and concerned enough to move into thinking about it and and making some kind of a Risk-award analysis across benefits analysis doing some of the decision-making work that that once you do that You're you finished the contemplation stage So contemplation is a stage of decision-making and then the third stage is really preparation even after you've made it this decision you still have tasks to do you've got a Think about what's what's my level of commitment to doing this and so you have to increase commitment and you have to develop a plan so what you want to try and do during that is really develop a What I call the effective accessible and acceptable plan something that you know can work You can access all the things you need to make that plan work And you can It's acceptable to you Because I think a lot of plans that people are given aren't all from acceptable So those are the three Pre-action stages and then you move into action where you start kind of implementing the plan you start making the change And you're trying to build a new habit. That's what the action stage is really kind of getting you to create a new pattern of behavior So if it was using cocaine in action what I'm trying not to do is to not use cocaine But also to build a life that keeps cocaine on the sidelines And and a lot of times the plans that we build to do that don't always work So one of the key things in action is to revise make sure you revise the plan when you need to do so because Otherwise what people normally do is if the plan isn't working. What do people normally do with the change? Just give up. I give up and so instead of revising the plan they throw out the change So the action stage one of the key tasks is really staying with it sticking with it building yourself confidence overcoming obstacles If you skip kind of getting right back on and kind of not not allow that To kind of disrupt the whole process until you really create we think this takes Maybe three to six months Until you really create a new pattern of behavior and then the final stage kicks in where now the challenge is To sustain that over time To make sure that now this is becoming Not something that I have to work so hard to do but something that's becoming normal So you could you create a new normal? You know where now my life, I live my life. I enjoy doing this. I enjoy doing that and cocaine is not a part of it Or I you know, it's smoking. I'm kind of enjoying myself I'm kind of breathing exercise and doing other kind of things and smoking is now not a part of it And you're not thinking about smoking all the time. You're not Really having to put a whole lot of effort in you still have to put an effort though. You still have to avoid relapse There's always a challenge to going back to something dramatic happens So the maintenance stage is really kind of sustaining change and and making it become manageable part of your lifestyle Okay, and our individuals would you say they're in maintenance or in life? Well, that's a good question. I Don't think of it that way. We have another piece where I think that it's not a stage of change But it's an exit. So I talk about people being in termination Mm-hmm, so that once you've maintained it for a long time where you're no longer thinking about it. You're totally confident. You have No temptation essentially to go back. You're in you've terminated the process of change And why that's important is that there's We have a lot of things without a change and change takes effort So you you have to kind of terminate a few things so you can actually move on and do some of the others That you need to change. So for example, I'm I'm quick smoking for oh gosh 20 More than 20 years Yeah, so so I I spoke for 10 years, but I'm quick for 2025 years. I'm I'm not in maintenance anymore. I'm in termination and the difference for me is For me now, I could go back to cigarettes before any quicker than anybody else who hasn't done it But for me it would be more like kind of a Re-inertiation rather than a relapse Initiation so differentiating between re-inertiation and relax right because now I would have to kind of go through the stages of initiation We also have stages of initiation as well as the stages of recovery I would have to go through those stages somewhat and and kind of get convinced that it's a good idea Make a decision that okay. I'm gonna try and start again and then kind of go in and start messing with it and then finally get hooked by nicotine again and and move on so That's where I think The distinction has to be why I make a distinction between relapse and And re-inertiation and the station between maintenance and termination Okay, yeah, I think these distinctions are really important to Kind of differentiate too. And also I'm curious as to what you think about How to best define the target goal of the behavioral change? So I know a lot of times people advocate total abstinence, you know when it comes to alcohol or drug use But there's also some harm reduction kind of programs So would that be something that would be considered an ideal outcome as well? Well, that's a really good question. So In in the book we talk about both of those when you think about the stages of change the stages are really Behavior-specific So if I am thinking about cutting down on things Versus stopping them I could be in different stages for the two different goals So and a lot of times you are I mean if I'm in action for cutting down on alcohol and think I'm This is my goal. I'm going to really kind of moderate my drinking. I'm going to never pick specifically drink. I'm going to do this Then I'm usually in pre-contemplation for abstinence And so that's really how I think about it really depends on the goal the individual wants and how I'm going to work towards it Now, I believe harm reduction is a really good thing But oftentimes it's not as stable as absolutes Because you know any time so here's my view is really about Harm reduction actually takes more self-regulation sometimes than abstinence Because I still I'm engaging in the behavior all the time and now I have to keep watching myself I have to moderate I have to kind of make sure that I'm not going to success So I'm really working hard to make sure that I have this under self-regulatory control Yeah Yeah, so in abstinence a lot of times you can you can almost forget about you know, I don't drink anymore So I don't have to worry about them and if I say I don't drink anymore, then I you know people say you aren't good now I don't drink and so there isn't the Struggle I mean there's still temptation to drink and there's still all those kind of things. I'm not saying it's always easier But what I'm saying is sometimes it requires a little less once you kind of have a lifestyle now that does not include drinking You can move on and you can do other things and you know, you just are It's it's part of your lifestyle not to drink and not to order drinks and not to be in bars and in places where you go to drink And that's protective But if I'm still going to bars and still doing all those things and need to keep working on doing the reduction It takes a little more effort energy and and vigilance To do that so I think there's different goals and and you know, that's really the challenges I think between the harm reduction and the And the abstinence People can get back in and some of them have been successful and doing harm reduction and doing that for years and years and years After they've had a significant problem Being able to do that others They just are not successful doing that harm reduction thing until they actually get so Going, you know, I think I need to do stop this completely Yes, also different outcomes as well. I think it has important to address too. I think in treatment because I think a lot of times The clinicians might advocate one perspective, you know So maybe complete abstinence, but maybe the clients are completely ready yet for that Well, that's the issue and again that part of the book is really you've got to be on the same page with your client If you're gonna work with them. I mean, you can believe that abstinence is the best thing for this client But if this client is totally convinced that all they're gonna do is reduce And you're gonna push them to To abstain and what you're gonna get is a lot of resistance because they're in pre-contemplation for abstaining They're in preparation or action for Reducing so you're gonna say no that's not good enough. You're gonna have to go back And so you're gonna go into the pre-contemplation piece and you have to then move them forward and get them interested in concerned enough that Maybe I do need to quit completely So you've got a selling job to do Whereas you have lots of a selling job to do if you're gonna stay with their goal of reducing and again if you If they get a sense that you're criticizing their goal a lot of times You're gonna get some more resistance where you're gonna get some sense of wait a minute. Yeah, I can't work with you because you don't You don't believe what I'm saying you don't understand your honesty where I'm coming from. Yeah Yeah, and I think throughout the book on you guys made a really good case for Stating that you know, it really is the client's perspective You know in the end that's the most important one in achievement process Well, yeah, because I think and that's again reflected in the book that the the mechanisms of change from my perspective are in the client Mm-hmm. I mean, it's really great to have good therapies and effective therapies and that's really important and we teach good skills and whatever but The person that's got to go around and with these so that the mechanisms of change aren't really in the therapies. They're in the client That's one of the key elements. I think of the transvertical model and the and then the book in terms of how we're looking at it So what you're always trying to do is engage those Important processes have changed the mechanisms that they need to use to accomplish the task to move forward in the process And if you're fighting them then there's those processes those mechanisms are getting engaged and working there they're now now focused on fighting you or Going against you not on moving forward in the change process Yeah, and I think this is this is important to you address - I think there's a lot of times you have court mandated You know Subsequent abuse treatment where a lot of times the people might not really want to change, but they have to by the court Well, they don't have to change They have to stop what they're doing sometimes Okay, and that's something that again, we have a talk about a little bit of the book But also it's important to we've done some research on People can stop behaviors without changing them. Mm-hmm, right. Yeah, and that's I think an important realization That we've learned actually with pregnant women smokers that a number of women when they're pregnant quit smoking and we go, okay Well, actually really quit smoking and naturally great and they're off for like six months or eight months and then after they give birth the relapse rates are as almost the same as if you kind of Have people who had just quit the day before Yeah, it's crazy So you kind of go so we did a study and I said, you know, these aren't these people aren't quitting. They're only stopping So when we think about me, there used to be pregnancy smoking cessation So we wrote an article called pregnancy smoking cessation a case of mistaken identity Because these women did not look like women who were trying to quit they were not using the processes They were totally confident and the reason for not smoking during the pregnancy was about 95% for the baby Not for themselves for the baby not for themselves for the baby so postpartum They can protect the baby in other ways. So they would always say oh, no, I'm still protecting the baby I'm smoking outside. I don't smoke in the room with the baby I go away and smoke over here, but I needed to manage my stress and I need to manage all the other things so Basically what they what they did most of them were really just putting their smoking on hold And you know people do the same thing with drinking. I mean a lot of people are probation go. I'm not drinking Oh, so you quit drinking. No, I'm not drinking for the next six months cuz I'm on probation And if they catch me I'm going to get in big trouble So people can do that. I mean we think that's not possible with the diction and sometimes that's that's true I mean sometimes people are are so obsessed and so Driven by the desire to kind of use that they can't even stop for a few days Yeah But most people if you give them a convincing reason They'll stop for a little bit of time, especially if there's some serious consequences related to But the people who can't stop are probably the people who are the most dependent Yeah, and have the largest problems of course so even with a mandated client coming in You still have a choice and they still have a choice You know, I mean we're doing drug courts now and You know, people are kind of screened and said, okay, you're eligible for drug court Which means you have to kind of meet with the judge on a regular basis and go to treatment and come back and we have a probation officer and we have a treatment provider and we all meet and talk about you and But you don't have to go to jail There's a number of people who choose jail Yeah, let's have a little too complicated. I'm gonna go to jail. How long is jail three months? Okay? I'll do my three months and I'll get out So even with mandated you sometimes have choices and I think the challenge for the clot for the provider is to kind of Try and engage the person in their personal process of change and and you Not to believe that the mandated change is changed, but to get there a person to make the change for themselves So more intrinsic than extrinsic and exactly exactly that makes sense So which stage do you think might be the hardest or client both clients and therapists have the most difficulties with do you think oh? I think I think it's contemplation. Really? Yeah Well because that's where I mean, you know all the MI motivational interviewing kind of work Talk to that ambivalence because that's the hardest thing for therapists to deal with and You know people are ambivalence people are you have reasons on both sides people kind of Even after they decide one week the next week. They're kind of going on. I'm not sure that that's really what I want to do so I do think that contemplation is one of the hardest stages because People can stay in contemplation for long periods of time Even if they make a brief foray into action they oftentimes slide back into contemplation and kind of end up back there for a while You know they try and they make a half-hearted attempt and they go oh well, it's really hard for me So then they go back and it's well, you know, I don't know. I mean, I'd really like to not be smoking They're using heroin, but but I don't know. It's just such a It it just grabbed me. I mean, it's just so much part of my life. I'm not sure I can really give it up So so I do think that's some of the most frustrating parts for the provider because You know, sometimes as soon as the provider hears well, I really you know, I'd really like to give it up You don't you know, they get all excited and go. Oh, they're really ready to change. I'm going out. I'm painting just that's just a That's a desire Don't get too excited. You have to kind of wait make sure that you got the rest of that on there and and that they're making a really good Decision so that that will be able to support commit And not what you're really looking at is And we have to do research there strength of commitment is really important But that's really supported by a solid decision and and so so that I mean, yeah, sounds strange sometimes So it sounds like there's Successful completing all the tasks and specific stages are needed before you can really move on to the next stage So I think that's true. I mean, I do think that people can sometimes Move quickly through these stages And be successful. I also think sometimes people Rush and and go, you know from pre-contemplation somebody goes, you know, look, you just got a DUI. Oh, yeah, okay I'm really gonna come come quitting drinking. Yeah, that's it. I got a DUI. I'm gonna quit drinking I'm done and they rush through but they really haven't made a decision the decision is all based on the extended Kind of reasons. They really don't mean they have a commitment not to get in trouble But I'm not sure there's commitment is actually to stop drinking or to modify their drinking in a way that it's not problematic So They rush forward and then they relapse and then they kind of go. We'll see I can't do it Well, if you don't have each of the tasks done well enough, I think that's what happens when you relapse Yes, and and the beauty of the relapse piece is We left this in the stage. We've got to do that Yeah, I talk about that in the book. He's playing a little bit on that so We we used to think about we got such a stage, but as we look at the pope folks the The numbers on the kind of attitudes and stuff just never matched up that they were totally a separate group When people relapse what happens to them is they go back into one of the earlier stages so So I'm trying to Quit cocaine, and then I start using again. Mm-hmm. Well, yeah, I start using that but the question then becomes Well, where are you now about quitting smoke quitting cocaine? And so some people go back into pre-contemplation and say well, I'll tell you what I mean, I tried I can't do it. It's impossible for me. I'm not even thinking about quitting Other people will go back in and say, you know, I know it's good for me I failed this time. It's not clear to me that I can do it, but but I'm still thinking about it And they're back in contemplation. So other people will kind of go back and say, you know, I Really screwed up this time. I know it. I'm gonna really make a firm decision And and I need to figure out exactly what's a better plan my plan wasn't that good? So I'm gonna just get back on build a better plan and move forward and those people are in preparation So what we call is this is there's a recycling process People go from relapse back and cycle back into some of the early stages and and I think part of that Making sure you get all the tasks done well enough Mm-hmm if they're not done well enough, you're gonna trip somewhere down the road And a lot of people think about it. Oh, well, it's really it's really about the The action. I mean people found that you got a cue in action that they just couldn't feel where Somebody came up to them and said, you know, you want to use here. I got some cocaine. Don't you want to use it? And he'll say oh see that what happened they were pressured into doing it. Mm-hmm, but I don't I don't think that's the whole story I think that was the occasion and they did get some pressure But the decision wasn't firm enough to commitment wasn't firm enough. The plan wasn't good enough for them to really say no So when you go back you got to go through that again and and get it all right and I think that's really what the challenge is for The process of change for all of us. That's true for exercise. It's true for diet. It's true for cocaine. It's true for smoking Yeah, and it sounds like people can really swing between these different Attitudes a lot of times so they can be really committed You know on Monday that they really really really do want to quit completely But then maybe by Wednesday kind of go back into ambivalence and think well, maybe not completely Right. It seems like that's one of the difficulties too Right. No, I think there's so what I say is there's regression people go forward, but they also go backwards There's recycling And then there's also kind of just being stuck There's some people kind of just gets stuck in the stage So some people just stay in pre-compromation. They go, no, I'm not thinking that I don't think I want to do it. I'm not thinking about it. They get a lot of pressure, but they're gonna go, nope but I'm not doing it and They just stick there and hang out there and sometimes they hang out there for years Others hang out in contemplation. We did a study in front of our first studies was followed in groups of smokers in these different students started out in these different stages and And one group we followed them for two years One group that actually was a pretty sizable group of folks who started out in contemplation stayed in contemplation for whole two years Every time they said I'm seriously thinking about quitting in the next six months They didn't do anything the next six months. We say are you seriously buddy. They say yes I'm serious you think about quitting suppose in the next six months, so they were always thinking about it But they couldn't get beyond that So we call that group the chronic contributors Because they they do seem to get stuck and that's true for a lot of people, you know, I mean look around at your friends How many people say no, I know I should really do I mean I really want to do more exercise I mean, I am I'm thinking about doing some exercise stuff and next year there's come the January 1st and the years of vision. I'm really I just here. I'm really gonna do more exercise This is where I'm gonna go and do more exercise and sometimes they try and and don't always get through and sometimes they don't even try They never really get to the gym. They never get to the action Criterion, maybe you think about action as going to the gym three days a week or walking After supper for at least three nights a week or something like that Even though they wanted to do it. They're in they they're interested in doing it. They never really kind of get to Actually complete that behavior Yeah, and do you think that's because of a lack of commitment or a week commitment or is it more that they just don't know how you know what I mean I feel like a lot of times people when it comes to the new year they seem really really really motivated To do it this once like ones and for all they're gonna start exercising in the morning, you know, yeah Well again, I think motivation is not a single dimension motivation has a lot of components to it So I do think they're motivated in the sense that they've got a desire to do this Mm-hmm. They want to do this They think they need to do this So they're there's a variety of things that they they believe about themselves But they don't necessarily get to the firm decision that says no, this is really in my best interest I really think that took costs really The benefits really outweigh the costs I'm going to make a firm decision and do this and then have the level of commitment to follow through and and and the commitment to follow through is really a commitment to deal with all the reasons why not to do this There's a lot of them because you can really okay. I'm not feeling well today now. We got to keep going. Oh Well today is you know, I mean this week. I'm really busy and work. I've got to work until seven o'clock at night Doesn't matter. You don't find some time to get in there and go exercise you know, it's walking around so You've got to be able to overcome all of those obstacles, and that's why you need that kind of commitment You know down the road I mean people say oh, you'll feel better when you when you're When you exercise, but that's not really true First days that you exercise. You don't feel better. Thank you. You usually saw or other kind of stuff traveling and so You know, you need a lot of commitment to get over that. Otherwise you give up you go wait Oh, I didn't think it would be this on And and that's really you know what's happening. So that's why people are trying to engineer a round change So that's where you have diets now. Let's say no, it will provide you with food Right, but you can only eat one of these. Okay, you can't eat all of them. This is your dinner. This is your lunch So that you don't have any free choice. So the less choice you have they figure the more the better off the better possibility is That you will stay Even what you're supposed to eat Probably not gonna last long Realistically Well, I think at some point you've got to be making sure either you've got to stay eating what they give you or you're Gonna have to figure out how to do it on your own and And then that's the reason that we know so in the book we talked a little bit about Individual therapy group therapy. We talked about settings. So inpatient residential and and you know The good thing is when people really need a lot of support residential Inpatient Therapy the communities all of those are really important But your stay inside those places where you're protected has got to teach you about what to do outside Yeah Right otherwise You you can get really confident when you're in the hospital and we saw that in solar research people get really confident They have high self-efficacy. I'm gonna really do this and then they go out and they're confident Thomas because in the real world when you're facing all the cues and all the situations that are there It it's a lot harder to be confident and you may not be prepared for some of the temptations and the Cues that are going to come your way Yeah, so it sounds like there really has to be a very comprehensive and detailed plan to kind of Force see these possible scenarios outside the treatment center the treatment situation. I Think that's true for a lot of people. I mean I do think that most people need a good plan of how I'm going to go about doing this and how I'm going to deal with you know, Uncle George who Drink a lot when I'm around him and that kind of is a key for me to kind of start drinking again and getting back on this or You know this kind of situation or that kind of situation So I do think that the planning is It's important you can't be naive and go out there. Okay. Well, I'm just gonna quit and that's going to be it Because there's going to be a lot of challenges out there to your change Yeah, so you really do need like a really strong planner really strong commitment and I think you said in the book that Even though commitment is really important and you know the commitment to follow through is really important on the action plan A lot of times clinicians are not really given a lot of training and that aspect Is that right? That's true. I think you know commitment enhancement is not something that we really are taught a lot. We taught a lot of the We were taught some decision-making stuff for talks and things about action, but but really how do you? Create commitment is a challenge because that is I mean the commitment is obviously the task of the Client of the person making the change. Mm-hmm, but but how do you actually enhance commitment? It's not something that we're taught a lot So yeah, I think that's something that that's a little weakness in the training piece Right so what I'm training my students now. We kind of we're looking at some of the social psychological literature of persuasion Mm-hmm trying to think about that as a commitment enhancing Mm-hmm We look at you know, what are some? Indicators of commitment so we talk about commitment language Can you make a distinction between the kind of language in person's using to find that commitment and and measure that commitment? We actually When I talk to clinicians, I say you know you actually go go to your car salesman and Learn how to increase commitment Because those are the people who really that's what their job is they live on Creating commitment from people who are somewhat ambivalent Everybody goes into the car. I don't know if I really want this one. I don't know if I really want that one I don't know. Oh, that's too much money and and they have a lot of techniques to try and Get people to kind of make a decision Mm-hmm and help them to kind of come to decision making and and committing to kind of writing it writing down and writing a check And and doing the kind of things that says okay, I'm signing this contract That's it. That's a pretty strong commitment right there. Yeah following through with it. I think yeah Yeah, so do you think self-regulation plays a role in that as well and commitment to follow through oh Sure, I think self-regulation plays a role in all of these pieces of the change process You know if someone really has Still pretty intact self-regulation and and you know, I think I think self-regulation is several things I mean we talked about it as kind of Executive cognitive functioning so people who have kind of decision-making kind of Impact decision-making pretty good solid decision-making processes that seem to work when we talk about affect regulation because that's certainly one of the things that Addicts are not really good at a lot of times meaning that they lose affect of regulation control either before or if not while you're using drugs because the drugs kind of hijack the The pleasure centers and so it makes it more difficult to regulate your your affect But that's certainly another piece and then the self-control mechanism so in the ability to kind of Manage yourself to say no, I'm not doing this to be able to get the strength to kind of Resist the temptation so all of those I think are really important pieces as you go along I mean, if you've got a lot of impairment in Your executive cognitive functioning decision-making processes week If you know, you have a lot of affective turmoil, it's hard to build commitment Right, you know, you're really kind of over here. I'm totally depressed I'm totally anxious. I'm totally, you know, it's really hard when you're hit that when you're experiencing that Those extreme levels and you can't modulate those levels of affect To build commitment or do planning or other kinds of things like that And then so all along the way, I think that that whole self-regulation piece plays a role Yeah, because you know, I think you're right. I think a lot of times a lot of the people who do abuse Substances or who have problems with substances probably already have some problems with self-regulation to first place You know, so I think it's probably even more difficult for them to have to exert The self-regulation during treatment as well. So yeah, this commitment piece I guess is especially something that I'm really interested in Yeah, I think that's what I think that's true Yeah, and do you think Virgin quitters, so you know quitters that have never really quit before have a harder time moving from The first stage, you know, pre-competition to the next stage compared to comic quitters So quitters that have put many many times before but it relapse every single time Do you think which group do you think might have an easier time or harder time? Well, it's interesting if you think about the the modal kind of response I mean Very few people actually quit the first time they try And I don't know if that's because they're not totally convinced there hasn't been enough consequences yet Or they're just not They don't they think it's gonna be easy And so oh, I'm gonna quit doing this and then they realize oh it isn't as easy as I thought it was going to be so I do think that the The first attempt a lot of times is not always gonna work out and for a lot of people I think there are some people who maybe You know they they experience a very dramatic consequence and that just kind of moves them through this process even though it's the first time it moves into the process so Quickly and so so substantively that they go that bit But I think you know the people who have the hardest times are the people who are constantly recycling Yeah, I make sense who who are going and trying and failing and trying and failing and trying and failing and And a lot of times with those people That there's something else going on. So I think it's a failure of the process To some degree, but it may also be that there's other there are other problems interfering So for substance use for example People who who try and fail try and fail try and fail and doesn't look like I mean I see relapse and recycling as a learning process Mm-hmm, and and with these folks it doesn't look like they're learning anything. Mm-hmm. They're just kind of going around circles Repeating that yeah, so once you have somebody doing that you have to stop and step back and kind of go wait a bit What's happening and a lot of times in substance area you find that role? There's a mental health problem here Hmm and that's really interfering with the process and it's interfering with the success that we need to treat the mental health Problem as well. Otherwise, we may not be both so integrated and and so Yeah complicated. They're mutually complicating conditions, but you've got a Really work at Kind of getting both a feeling with both of them. Mm-hmm, and so that's why we come up with you'll diagnose the truth Because he'll say okay, you gotta deal with both of these things you can't if you deal with just one you're not you're not going to be successful So a lot of times when people are just kind of spinning their wheels or kind of going in circles I think there's something else going on or there's something in the context of their lives Maybe their environment. I mean they're trying to get off and then every time they go back into this environment is It's so heavily saturated with cocaine or heroin or alcohol or tobacco that it's almost impossible to kind of stay clean Yeah So relapse could be a learning experience, but it could also be a sign that something Something is wrong something needs to be addressed. Yes. Yes I think multiple relapses are certainly a sign if they're relapsing over and over again that somebody needs to take a bigger picture look Somebody needs to kind of step back and and look at the whole The whole person and the whole environment. You should be doing that anyway, but but a lot of times you miss some things Yeah, people kind of get a little bit too focused sometimes. I mean from the detail or something Yeah Yeah, and I found it really interesting that even though we have all these different kinds of treatment, you know, yeah a a you have harm reduction all these different kinds, but it seems like These different types of treatments kind of influenced the whole process of change in a very similar way Yeah, it does seem like there's some I mean I see the process of changes the common pathway So that's the individual path But the that's that's the path that the individual needs to go through everybody goes through it a little bit differently They go through different ways and that treatment really works to facilitate that process of change to to kind of get that process of change activated moving forward doing some of those kind of things that that I think is really Important to dare, but it doesn't look like there's only one way to do this That's the real challenge You can probably do this in a number of ways, I mean You know, it may be that, you know that you go to 12 steps and I go to Rational recovery or you go to CBT and I go to an MIT program So we did run that we did that with project match we ran three different treatments and very different treatments But the outcomes were very similar So I I think it's it's you know, well, there's You know what I said one thing, you know, there are different strokes for different folks But they all seem to be swimming in the same stream So they're all kind of moving along that same stream, but there's different there's different influences that seem to move them along Mm-hmm Yeah, because it seems like people sometimes are very divided, you know, we have different camps where you know, the spot recovery people really Hate the whole AA model and like vice versa, and I think you hear a lot of these debates all the time But which ones are really effective and which ones are like a waste of time When reality seems like it might be more Efficient to kind of put aside these differences in focus and how they kind of change the individual so to speak Through these common pathways. Yeah Well someone much wiser than I said, you know, the either or is always a challenge that there's wisdom in the both And I think that you know a lot of times I mean I think why practitioners need to adhere to some One thing that they do and that they get good at is is probably important to them because they have to have some grounding They need a focus and they need something that they believe in that they can teach their clients. Mm-hmm So I think he you know, that's good But when you get rigid about that and say, you know, but it's only this way That you can do this. I think there's enough evidence to say out there. That's not really true That there's lots of different ways that people can get to make this change Mm-hmm And people are using alternative medicine and I had One anchor who was doing a TV program with us on the smoking cessation down in Houston kind of said Well, I'm kind of embarrassed to say how I quit smoking. They will why why? Well, actually somebody put a staple in my ear And I quit And I quit smoking because I know there's not pretty much evidence for this But for me it worked And well, that's true. I mean, you know, you know, but what is that that somebody who's committed enough? To making this change that they went and allowed somebody to put staples in their ear. Yeah So and they believe that this is going to help overcome craving and so basically they have a support They go out. They make good. They are they're committed to making this change This thing gives them some support and some sense of confidence that they can really overcome all kinds of cravings And they go and they become successful Yeah So but but for me it's the person who's making this change not necessarily the The treatment because every treatment also has its failures. Right. Yeah So if they all want our treatment the failure. Yeah based on those feet. It didn't work this time for those people And then and what's funny is that every program wants to be the last treatment that the person gets Right, of course Because then they fail with success But the issue is the person to success not necessarily But the program helped that person achieve that success So we should be proud of ourselves for helping that person, but we shouldn't take all the credit Right, it really comes down to the person to the individual person in the end But don't you think it's also important to kind of differentiate between I just feel like there's a lot of Kind of the pseudo science kind of right like quackery kind of There's so many like groups out there that are trying to Curidy people of addiction disorders and a lot of times I think they're really dangerous even if you believe it Yeah, people want to separate people from their money not from their addiction So, yes, you do have to be really careful about that. I would really be Careful looking at the credentials of the group Looking at what they do Looking up to what they do Get listed in kind of the best practices kind of lists of things that people do And there are things out there. I mean, there are a lot of reviews of that look at best practices and you know find a practitioner who's You know good, but and and solid and is using ethical practices That you can also work with Mm-hmm and that that's critical, but you do have to be careful. I mean people have used, you know Hospitalized people who didn't need hospitalization just because they wanted 28 days of that person's coverage So you do have to be careful about that and I would say everybody has to be kind of skeptical But if you look around and you do your homework in terms of there's a lot of stuff you can find online Some of the information is good. So it's not so good, but I would keep looking for more objective Kind of reports Just like you do for consumer reports on your Looking for cars or something like that Looking for treatment programs Yeah in one of the challenge really is Trying to get the general polo to understand the implications of your research, you know to make them aware of programs that are based on research Yeah, I think that's important to address as well Because some people are suffering, you know, even they just want to stop But it's really hard sometimes that they can't find of actually effective treatments Right And do you have I mean, I Guess last concluding remarks that you want our listeners to take away from I mean the focus varying It's very comprehensive So maybe not just one message, but if you have to say right, I mean again I think that you know I think the message in the book or the books content is tell your treatments to your clients to the client's motivation to the client's characteristics to the client's context Where they live and how they live and do that and and if you're doing that I think you're at least helping them engage in this process of change and that's really what what the what the solution is really does But engaging that personal process of change and they're helping people be successful Mm-hmm. And are you optimistic about people's ability to really change? Oh, yeah, well, I am I do smoking cessation research and when people say people don't change addictions. I have data Wait a minute We were 42 percent of the population smoked in 1964 and only 19 or 18 percent smoke now there are 45 million something like that people in the United States who quit quit nicotine addiction Yeah So when you if I give you those numbers you can't tell me that people can't quit addictions and and that's true Is it hard? Yes. Do some people not quit and die before they quit? Yes But do people change? Yes, there's a whole recovery community out there. That's strong and and vibrant and filled with people with the courage to change So even though it seems like it really is it is a lot of work, you know, it is a lot of work There's a lot of failure. I thought there's also a lot of success And I think we focused on the failure and not the success part of it. Definitely. Yeah And we've given addictions a bad rap I mean, we think relapse is part of addictions, but it's actually part of behavior change There's as many people who fail diets and fail to fail quitting cocaine Yeah, actually more Okay, diet third diets are really bad There's people who fail doing exercise, you know More than people who fail quitting cigarettes or alcohol. Mm-hmm So Relaxes is a process is a problem of change not a problem of addictions. That's a really important message. I think yeah Well, do you want to talk a little bit before we run out of time about when you're working on next or where you're working on right now Okay, well, I'm actually revising my book on addiction and change And we'll be doing that over the next year just the contract for that and then You know very the last is and I and a couple of the colleagues are revising the group therapy manual for treatment And then I'm doing a lot of training in the community working with people in the community to Build their capacity to their to work on this change process teach them about the change process and teach them how they're kind of Use that in their in their practices That's great really busy. I am I am a little busy. That's for sure I'm sure it's very rewarding. You're gonna have to keep me updated on all your new books and everything okay Great. Well, thank you so much for being here and thank you listeners for tuning in today. Thank you. Yeah Thanks for tuning in and I hope you enjoyed the show for more information about this podcast Please go to new books and alcohol drugs and toxicants.com and please feel free to write us on iTunes. Thank you You (upbeat music) [BLANK_AUDIO]
In this episode, I talk with Carlo C. DiClemente, a Presidential Research Professor in the Department of Psychology at the University of Maryland- Baltimore County, about his co-authored book, Substance Abuse Treatment and the Stages of Change: Selecting and Planning Interventions (Guilford Press, 2013). We examine the stages-of-change model (also known as the transtheoretical model) in behavioral change, particularly in substance abuse and drug addiction treatment. We discuss the complexity involved in substance abuse, and the need to consider stage status in effective treatment. We talk about relapse and its implications for individuals’ recovery trajectories. The importance of the individual client as the central mechanism of change is emphasized throughout our discussion.
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