Change Is a Process not a Product: Reflections on Pieces to the Puzzle

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Acknowledgments

This retrospective reflects not only my contributions but also those of a very large number of mentors, collaborators, colleagues, and wonderful graduate students and staff that have made my research and my contributions possible. I am also grateful to the many different funding sources that have supported this work including NCI, NIAAA, NHLBI, NIDA, SAMHSA, the Robert Woods Johnson Foundation, as well as other regional and local funders.

Notes

¹ The reader is asked to consider that with the advent of artificial science and its theoretical underpinnings (chaos, complexity, and uncertainty theories) it is now posited that much of human behavior is complex, dynamic, multi-dimensional, level/phase structured, non-linear, law-driven and bounded (culture, time, place, age, gender, ethnicity, etc.). “Human behavior change,” however it is defined and delineated, would be such processes. There are a number of important issues to consider and which are derived from this: (1) Using linear models/tools to study nonlinear processes/phenomena can and does result in misleading conclusions and can, therefore, also result in inappropriate interventions; and (2) the concepts prediction and control have different meanings and dimensions than they do in the more traditional linear ‘cause and effect’ paradigms. Uncertainty, unpredictability and the lack of real control, and not just attempts at influencing, are the dimensions of reality. (Buscema, M. (1998), Artificial Neural Networks, Substance Use & Misuse, 33(1-3)). Editor's note.

² Treatment can be briefly and usefully defined as a unique, planned, goal directed, temporally structured, multidimensional change process, of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bounded

(culture, place, time, etc.), associated with a range of stakeholders with agendas, and can be categorized into professional-based, tradition-based, mutual-help based (AA,NA, etc.) and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users— of whatever types and heterogeneities— which aren't also used with nonsubstance users. Whether or not a treatment technique is indicated, contraindicated, irrelevant for the targeted goal(s) or even iatrogenic in its outcomes, and what are its selection underpinnings (theory-based, empirically-based, “principle of faith-based, tradition-based, etc.), continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) and wellbeing treatment-driven models there are now new sets of goals in addition to those derived from/associated with the older tradition of abstinence driven models. Conflict-resolution models may stimulate an additional option for intervention. Each ideological model has its own criteria for success as well as failure as well as iatrogenic-related harms. Treatment is implemented in a range of environments; ambulatory as well as within institutions which can include controlled environments. Treatment includes a spectrum of clinician-caregiver-patient relationships representing various forms of decision-making traditions/models: (1) the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making which facilitates the collaboration between clinician and patient(s) in which both are active, and (3) the “informed model” in which the patient makes the decision(s). Editor's note.

³ A caveat is necessary. An inadvertent built-in “flaw” in treatment process and outcome semantics is relating to “success” and “failure” as static, predictable, binary categories, rather than as being ongoing, dynamic, multidimensional, nonlinear, “measurable,” and “nonmeasurables” at a given state of knowledge and technology, which may or may not be realistically achievable by the targeted, change-engaged, or unengaged person; i.e., necessary resources for changing which are all-too-often not considered and remain undocumented. Editor's note.

⁴ This ongoing “intake-assessment” entails our making necessary changes as we move from collecting targeted necessary, appropriate data, to interpreted information, (knowing) to derived knowledge (understanding) which adequately maps both the person's and the change system's available, timely accessible, and allotted resources. Viable, sustainable change represents interpenetrating, ongoing, encounters between such processes as awareness, expectations, perceptions, judgments, cognitions, affect, decisions which are or aren't implemented, learned from or not, integrated or not, ceased or not, begun again, etc., all of which operate under conditions of uncertainty and unpredictability in which a fellow human being, who also uses drugs, or not, is doing the best that s/he can at that time. Editor's note.

⁵ The reader is asked to consider that the term “recovery” is an overloaded container concept, catch-all-code, in the substance use-misuse intervention field, which is bounded by culture, time, place and stakeholder values, agendas, interests, and influences. Although there is no consensualized definition by a range of involved deliverers of care and services for its targeted populations recent definitions include the United States: (1) Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship. Sobriety refers to abstinence from alcohol and all other nonprescribed drugs. The Betty Ford Institute Consensus Panel, Journal of Substance Abuse Treatment 33 (2007) 221–228; and (2) the UK Drug Policy Commission: “Recovery is a process, characterized by voluntarily maintained control over substance use, leading toward health and wellbeing and participation in the responsibilities and benefits of society.” The UK Drug Policy Commission, Recovery Consensus Group Policy Report, July 2008; www.ukpc.org.uk, “Recovery” is most often associated with abstinence. Its dimensions, and the necessary internal and external, micro and macro level conditions for its achievement and sustainment, and the person's necessary enabling resources as well as interfering flaws and limitations, have yet to be delineated in treatment ideologies such as harm reduction, quality-of-life, and conflict resolution. Editor's note.

Additional information

Notes on contributors

Carlo C. DiClemente

Carlo C. DiClemente, Ph.D., ABPP, Professor, Department of Psychology, University of Maryland Baltimore County (UMBC), Director of the MDQUIT Tobacco Resource Center and the Center for Community Collaboration at UMBC. He oversees the HABITS laboratory assessing the process of smoking initiation and cessation, motivation and stages of change for a variety of health behaviors, understanding mechanism of change in alcohol and substance abuse, and creating integrative screening instruments to support client collaboration and integrated care. Dr. DiClemente is the codeveloper of the Transtheoretical Model of behavior change, and the author, co-author of numerous scientific publications and books on motivation and behavior change with a variety of health and addictive behaviors. Awards: Robert Woods Johnson Foundation, ASAM, APA Division 50 and the Addictive Behavior Special Interest Group at ABCT.