Dr. Carlo DiClemente Trains the Carrara Clinical Team on the Stages of Change

0:00 health behavior. His contributions include over 140 publications and influential books. He has been recognized with numerous honors to mention here and he continues to serve as a consultant, trainer and speaker influencing clinical practice and public health policy by translating cutting edge research into accessible practical strategies. So welcome, Dr. DiClemente, and please add or embellish. I got anything right or wrong. No, thank you. You got that right. Yeah, I am retired, kind of semi-retired, but more on the retired side than the semi-side at this point. OK. We want to welcome Richard just joined, Richard Taite, our founder. Hi, Richard. Listen, guys, I've got to do a podcast in a minute with another world-renowned doctor. But I want to thank you so much, Dr. DiClemente, for doing this for us.

1:01 For those of you that don't know, Dr. James Prochaska was a friend of mine, but he was a lifelong friend of Dr. DiClemente. And they wrote a textbook that is one of two textbooks that you actually have to read in order to become a therapist in this country. So it doesn't get better than this. It doesn't. And you know how everybody says in our industry, they say, we're going to meet you where they're at. But nobody knows what the hell that means. Nobody. Okay, it's a talking point. But this man knows what it means because he spent his life doing research to figure out how human beings actually create behavior change. So we know where they're at based on the theoretical model of behavior change, which by the way, if his work didn't exist, I'm not sober today. None of us are sitting here on this call. Okay, so doctor, I want to thank you so much for doing this for us today. I'm gonna let you guys go because I can't keep my mouth shut and I want them to be able to hear from you. We're very grateful. We're going to use this on our social media as well so that way we want to give this away. Other therapists, other treatment centers, you know, we all want to help whoever we can and so I want to make certain that this gets out to other people that want to know more about this so that your work isn't just academic, it's practiced. Okay?

2:43 Okay. Perfect. Thank you. I appreciate the intro and I'm glad to be here and be participating in this. Yes sir. Thank you. You got it. So for those of you who are here, I'm going to go through kind of looking at behavior change and the different kinds of pieces of the puzzle that we put together in the work that we've done over this past 40 years. I'm going to share a set of slides with you so we can go over those and I will stop. You know, if you have a question, I'm going to stop a couple of times through the presentation and talk so you can, you'll have a chance to kind of ask questions or think about how does this impact what you do and how you kind of are the work you're doing. Okay, so we're going to look at the pieces of the puzzle. So how did we find these pieces? Well, the real issue, I'm trying to get rid of this top part, all right. So how do we find these pieces with science and serendipity?

4:09 You always have to be ready when you're looking and understanding from clients' perspectives to discover something that you weren't ready to do, but you also need to kind of also scientifically evaluate it. So we've listened to changers and we've done quantitative data-driven stuff. We look at the concepts. We created the concepts, but we always tried to test them as well and to see how they fit into this process of change. And I've had a wonderful set of collaborators, colleagues, students, and of course my mentors in Rochester who died a couple of years ago. So let me give you a little background. Over the course of about 40 years ago, I began this journey into looking into change. And basically what it was spurred by in the 60s and 70s, most of you were too young to remember that. There were different treatments, but when they did these horse race studies where they went, okay, let's compare Gestalt with psychodynamic with cognitive treatments.

5:19 They would compare these treatments and most often they were equally successful. They were better than waitlist controls, but they were equally successful. That was pushing Jim working on this Systems of Psychotherapy book that he was working on when I was there at the university. The other thing was happening where there's like 250 types of therapy being identified. And it's kind of like, oh, there can't be that many types of therapy. So the search was for principles or processes of change that would be integrative and be across different theories of therapy. The other thing that happened that I think was just at this particular point in time, serendipitous, is that most smokers successfully quit on their own. And many other people made behavior changes even with addictive behaviors without treatment. And so we're trying to kind of figure out how to kind of study that.

6:19 So I kind of said, okay, I'm going to try and study this. I'm going to try and study this with smoking cessation. I didn't really want to do smoking cessation because I was smoking at the time. But basically, Jim convinced me that it was a good behavior to study because you could study the numbers. You could count the number of cigarettes, et cetera, et cetera, et cetera. So my dissertation really was about whether smokers who quit on their own and or with treatment used similar processes of change that Jim had been looking at and developing as he was developing the systems of psychotherapy. So I used two types of treatments, [unclear] and SmokEnders. And we had a group that quit on their own. So that was really helpful. We had three groups. And the answer, are there common processes of change? The answer was yes, for the most part. But what we did find, and that was the serendipity, is it's complicated.

7:19 And it needs some kind of a framework for different points in the change journey. Because the participants in the study kept asking, if I said, well, how important was this, and how important was doing this, and how important was doing this when you were getting free? Because all of them had been quit for at least two weeks. And they said, well, when do you mean? Do you mean before I came into the treatment program? Do you mean during the treatment program? Do you mean now that I've quit? And we realized that you can't understand the processes of change unless you know where the person is in their quick journey. So from that, we developed the Transtheoretical Model. And I know people talk about it as a stages of change model, but the stages of change are only one aspect of the model. The stages is the kind of the temporal dimension of this. And the processes of change are the mechanisms. These are the client mechanisms that drive people through the stages of change.

8:19 And you need to engage those, or they need clients to engage those to move forward. When we realized that we were just focused on smoking, people were critical and said, OK, well, you're just talking about smoking. And so we said, well, no, wait a minute. If you think about all change happens in the context of an individual's life. And so we brought it around these current life situations, beliefs and attitudes, interpersonal relationships, social systems and personal characteristics. So, in the context of all of those things, that's how change happens. And all of these things influence use of the processes and movements for those stages. And there were two markers of change that we included from the very beginning that weren't really our concepts, but the decisional balance that Janis and Mann had talked about, decision-making was really a balancing of pros and cons. And then there was self-efficacy. Bandura had just published some work in the 70s on self-efficacy, and we included that in my dissertation, but I also included it. We also included it in the model. And efficacy is really a marker. Decisional balance is a marker of early change and self-efficacy and temptation, a marker of later change.

9:41 So that's the larger model that I work from. So what was the first piece of the puzzle? Well, it was understanding how these array of coping activities function requires that we know when and where these activities occur in the person's change process. What we noted in a lot of the work that people were doing is we had a lot of therapies that were action oriented. So we had things we could give people to do. The problem was that we don't have clients who were action oriented. They were in earlier stages of change. So the idea is the complex, the change is a complex multi-dimensional process involving temporal, motivational, and behavioral dimensions. So the stages, you know, benefiting from the work of a lot of other people, which always, you know, science builds on the people that before. We divided the change process into five stages reflecting the different parts of the change process and labeling them, precontemplation and contemplation, determination at the very beginning that was decision making. Now we've changed that into preparation, action and maintenance. And that was our first one of our original articles and the original book on the Transtheoretical approach is not in press anymore, but it was published in 1984. So quickly, I'm just going to do a thought experiment with you. In a large multisite study, researchers from the Cancer Institute have discovered that watching television more than one to two hours a week causes brain cancer. How many of you and how many of the people who you told this to would stop watching TV for more than two hours a week immediately. You could unmute and say what you would do. Would any of you do this immediately? Probably not. Right and that's the response that I get mostly to this is that no I don't know I mean I want to know more about the study. I need to kind of, well it's too late now. I already have, I mean I have brain cancer, I've watched TV for many years, you have to go some way, maybe I could figure out a way to get around this, maybe I could stream it on my computer instead of watching the TV or maybe somebody is going to create a helmet that you could wear while watching TV that could rock out the rays.

12:16 But the whole idea is that when people are confronted with you need to make a change, most of us are not ready to do that and really would work around that or think about that and figure out how we might be able to get around it rather than go through it. So how do people change? If this was a real study and I was going to try and convince people that you need to know television really is that problematic and watching it is that problematic, I would have to get you interested and concerned about the need for change. I'd have to get you convinced that the change is in your best interest and it's going to benefit you more than it costs you. And that's what I've heard from some people. It's not cost is too high. You can't even watch a football game in two hours. So no, I'm not doing this. Once they make a decision, they have to organize a plan of action and get committed to implementing the plan. And then finally, And now we have to take the actions that are necessary to make the change and sustain the change.

13:20 And that's really what the stages of change are. The stages of change are labels. We have the labels that I just told you about. And, you know, it's, oh, they're not interested. They're considering. They're preparing. They're making the initial change. And they're maintaining the change. But the most important part about the stages are the tasks. If I have somebody in front of me in precontemplation, I need to get them interested and concerned about the need for change and maybe the possibility of change. If I have somebody in contemplation, I need to do a risk-reward analysis and help them with their decision making. Once they make a decision to make a change, I have to help them with their commitment and help them creating what I call an effective, acceptable, and accessible plan. If the plan doesn't have all three of those things, it usually won't be done. And then finally, you have to implement the change and take the action. It's great for you to join the gym in preparation, but if you never go to the gym, you never get into action.

14:23 You got to do it. So you implement the plan, and no plan is perfect. So it's important in the action phase, we think action takes three to six months, And I'll show you why when we look at the relapse curves. Basically, you have to implement the plan and revise it, because no plan is perfect. If you don't revise it, people just abandon the change. And that happens a lot. And then finally, you have to consolidate the change, so that no longer is it something that I'm really, I have to work on it, but as I get more and more into the change, it becomes more and more part of my lifestyle. And I have to use less and less energy and focus to really kind of make this happen. So those are the stages of change. There are misconceptions. It's a logical sequence. And it would say, OK, well, you just go from precontemplation, you move all the way up, and you go into maintenance. But that's not the way it's followed.

15:23 There's regression. Just because somebody goes into contemplation thinking about it doesn't mean they're going to go forward. They could decide not to do it. People get stuck in various stages. A contemplation is one that a lot of people always thinking about stuff, but never totally doing it. We did a first study, was following people for two years without doing an intervention. One group of people, a relatively large group, were in contemplation every time we kind of reached them over the two years. They'd say, oh yeah, are you seriously thinking about quitting smoking in the next six months? And they'd say yes. Six months later, they would say yes. all the way through the two years, but they never did anything. They never made a change of time. And then there's also the recycling that we'll talk about in a minute, a few minutes. The other thing about the stages are they're behavior and goal specific. And I'll talk a little more about that, but specificity is another piece of the puzzle. It's not always a rational or completely conscious process.

16:26 There are a lot of forces. Both the context of change kind of affects how we kind of make decisions about change, but also internally and things that are happening in our environment. And some of the things that we know deep down, implicit cognitions that will impact that. So stage tasks involve values, emotional reactions, implicit cognitions, and salient experiences. So when we look at, you know, it's hard to create all of the processes actually in an actual treatment session. But life gives us some opportunity to experience these. So events, motivating contextual influences, personal experiences that affect the engagement and completion of the stage tasks. So what do these stages represent? If you think about any theory of behavior change, there's multi-dimensional. It's not just one thing. We talk about vulnerability, intention, decision making, implementation intentions, commitment, self-efficacy.

17:33 So there's a lot of different aspects of that. And what the stages do is kind of help organize some of those different aspects of the change process. They're not boxes. You don't put people in them, and it's important that you don't label people, that you label them right. They represent critical tasks. So it's a changeable state, not a stable characteristic. So I tell people, I don't even call people precontemplators anymore. They're people in precontemplation. Because if you have seen a good MI video from the group in Albuquerque, you'll see, I mean, Theresa Moyers used one that I showed, Theresa Moyerss is doing something with [unclear]. You'll see that this person moves from precontemplation to contemplation within a 20-minute interview. of you. And so it's not like they're stuck there necessarily. You just need to realize that they're in precontemplation. All we're trying to do is get them to move forward.

18:35 And we need to kind of solve the problem of action-oriented treatments, but pre-action clients. So we need strategies for pre-action staged activities. So here's what I think is the takeaway from that first piece of the puzzle. When I first got into this field and worked a lot in alcohol as well. They were called addictions or diseases of denial. These people are all resistant. I won't treat you unless you can quit drinking. Confrontation was the only way to deal with people. And I think what the Stages model has done as we moved along is change the conversation from resistance to readiness, from confrontation to evoking motivation. from excluding to welcoming the unmotivated, from willpower to a process of change. And I think that's really the takeaways that I would like from kind of learning about the model is to move this way.

19:40 And the field has moved this way. So, you know, even AA, Hazelden kinds of places are teaching the stages of change and have moved to a kinder, gentler approach are dealing with people and their lack of readiness, rather than calling it resistance and die. So that's one piece that I think is really important. The second piece is really the specificity and patterns of change. What we also began to realize was there's a common path that characterizes this change process across all intentional behavior change. So change process behavior is behavior and goal specific. So if I have a goal of cutting down, that's different from a goal of quitting. And if my goal is about drinking or smoking or eating or using certain substances, it doesn't necessarily mean that all of the other stuff is gonna go with it.

20:40 So it's really specific. So how do you begin staging something? You define action and maintenance. Where is that person in terms of this particular behavior? And the difference, whether you're talking about diet, or drinking, or physical activity, medication adherence, coping activities, condom use, it's specific. And that's really why this model has really taken off. Because basically, if you think about all kinds of health, promotion, disease management, it requires behavior change. You either have got to start some new behavior, you've got to stop a problematic behavior that's destroying your health, or you've got to modify behavior. And those are three different patterns, but it's the same process. And that's because most of these areas have been studied with the model. And it makes sense, because basically we all want to be in that mid-range there, moderate itself, regulated behavior patterns.

21:42 A lot of times we go to access, we get feedback, and you realize, okay, that's not good, I can't keep doing that. And feedback can come from, you're overdoing exercise and getting pain, it can come from the hangover from the night before, it comes back and you have to move back into this moderated self-regulated behavior pattern by making some change. Sometimes there are things that are absent, like physical activity, and you wanna bring it up. But you don't wanna do what the anorexic does, right? which is moves from absence to beginning to kind of do it. And it's, oh, if two hours is good, maybe six hours of exercise would be really good. And so they move to excess. So we need to kind of keep that healthy lifestyle well-being zone is really what we're shooting for for all of us actually. And it's not new. I mean, the Romans talked about, in medio stat virtus, virtue is in the middle. And so that's really moderated and self-regulated behavior.

22:44 And we'll talk about that a little bit more. So if you specify the behavior or constellation of behaviors that find action. So if somebody says I'm gonna try and put cocaine use. Okay, all right, good, that's the behavior. So you're talking about abstinence and abstinence from any use of cocaine. All right, so that's the target behavior. Then you have to kind of do a bit of a task analysis to indicate what's the frequency, intensity, difficulty, and skills needed to perform this behavior. I've learned over time that we need to be aware of what I call the change burden. And when I'm talking to docs, it's really interesting. Because if you know that, well, is there a difference between giving something BID or TID? And they go, yeah, well, it's just one time a day. No, it's not. It's a big deal to kind of change from BID to TID. Originally, if you'd booked at the HIV treatments, you had to dedicate your life to that treatment because you had to do some drugs in the morning, some in the afternoon, some in the evening, some with food, some without food.

23:55 That burden was just great. So now it's wonderful that we have medications that you can take one shot for every couple of months or some of that kind of stuff. So reducing the change burden is also important, but we need to kind of understand the change burden to understand the level of difficulty. How high is the bar for our patients in terms of doing this? And it's different. It's different for somebody who's coming off the streets and homeless than it is from somebody who's got resources. So you have to define the partial goals and behaviors also that indicate positive activity, but don't actually make the target. So some people reduce and they're happy. And I've had a heroin addict tell me, I'm doing good. I said, well, you're still using heroin. He goes, yeah, but I'm not shooting up. So he's in action for not shooting up, but in precontemplation for using heroin. So we need to kind of understand that and whether our target is starting in something, modifying something or stopping something, a behavior.

25:05 In addictions, you actually have all of those are in this process because basically what I did in my book, Addiction and Change, is really think about the process of initiation also as going through the stages of change. So in precontemplation, there's little interest in using substances. And as you move forward, people begin thinking about it, mostly adolescents, and adolescents start. drug use starts in adolescence, they get some social influence and they get prepared to kind of how to use it. They learn how to use it. They start using it regularly and then they create a problematic use which means that it's maintained a dependence or substance use disorder. Now lots of people move through these stages for different substances. I mean almost everyone in the United States almost has moved through these stages to to begin gambling. But they move and they used it in a controlled, well-defined, self-regulated manner.

26:08 And so for them, it's not a problem. For the people that we're working with, they become a problem because not only do they get, the biology starts kicking in, and the neurotransmitters start kicking in, and the problematic use starts expanding, and the loss of self-regulation starts happening and you start getting a substance use. Once you're there, you have to think about the stages of recovery. And when we see people in precontemplation, often they are in the end stages. So what addictions really are, are well-maintained changes for an individual. And then you've got to go through the recovery process. The interesting thing is you can be in different places with regard to these different substances or different behaviors. So this is an adolescent who's regularly smoking nicotine and marijuana, is beginning to use alcohol problematically, but is in precontemplation for heroin and cocaine and LSD and eating disorders, is start doing a little bit of gambling, sports gambling now.

27:20 It's becoming interesting. So he's starting to do that. He has thought about taking amphetamines and tried them once or twice. He's not sure he likes them or not. What's interesting is the same belief system that helps these people be over here in maintenance and keeps them over here in precontemplation, there can be one belief system that works for both. These are soft drugs. These are hard drugs. I'm virtuous. I don't use any of the hard drugs. But it's marijuana and tobacco, come on. We're not going to have any problem with that. So you have people in different places with regard to the stages of initiation. You also have people in different places in terms of stages of initiation, in terms of the treatments that we're providing them. So this is an individual who's willing to take this medication, but just is beginning using that, is willing to come to therapy.

28:29 So they've been coming to treatment, but they're only very beginning and maybe getting ready to do some more relaxation stuff. They want nothing to do with mutual help. Don't touch my smoking and don't touch my marijuana use. And they are in action for learning about how to be more assertive. So you see that what you have then is you have a matrix that you need to kind of look at when you're working with an individual to kind of understand where are they and where are they with regard to the specific behavior that we're looking at because of the specificity. And then we also have this a lot of times we overwhelm patients with the number of changes that they need to make. So this is the best way to take care of yourself, your lifestyle's destroying you, change your eating habits, stop smoking or drinking, start an exercise program, get plenty of rest, learn how to handle stress. And of course, patients are accommodating. Then they go, I gotta find another doctor. Because free advice and unrealistic advice hinders change and we need to be careful about doing that.

29:38 So the takeaway from this second puzzle piece is really this, it's important to be aligned with client goals and target behaviors. Multiple behavior changes increase the complexity and difficulty of change. So you need to be kind of moving back and forth across these different target behaviors. And be sure you understand what the changer means when they're talking about their goals. So yeah, I'm willing to take this medication, which medication? My goal is to smoke marijuana occasionally. What does that mean? I want to eat a low fat diet. I don't know what that means. You can do that multiple different ways. What's low risk drinking? Challenging depressogenic thoughts. All of these, you need to kind of get some concrete and be more specific for them, for you to understand where they are in the process of change. And the final part of this initial part is really about intentional change.

30:41 So this process that we're talking about now is really about intentional behavior change. It's multi-dimensional with interactive dimensions. And it involves the stages of change in these activities or coping activities and client processes. There are other types of change. There's imposed change, which really is largely in response to or driven by external forces. So people put in prison. I always say, I can stop people from using drugs. I just got to get a good prison, not one where you have drones coming in and dropping stuff into the yard and doing that kind of stuff. Some divorces are really imposed change. One partner wants it, the other partner is resistant and doesn't want it. So they're in precontemplation, the other person's in action and that creates a lot of tension. And the person who makes the most out of that is the lawyer. And then I've got, I'm gonna talk a little bit about practicing smoking cessation because we discovered this in a study that we did there.

31:45 So there are imposed changes, there are developmental changes, aging, child development. I know you're gonna be three hours behind me in aging, but I'm gonna be three hours ahead of you, but we're all, by the end of the day, we're all gonna be one day older. And there's nothing you have to do to do it, I mean, just to stay breathing and living. So developmental changes happen a lot of times, we don't have to do much about that. And then there's biological and neurological changes that are separate from but often related to behavioral changes. So we know, I mean, using a lot of a certain substance changes the brain. And you've got to accommodate that when you're dealing with that part of it. So it's not a model for all types of change. And the first thing to realize is absence of a behavior does not signify intentional change of a behavior. The imposed change effect can be similar to punishment. It suppresses versus changes behavior.

32:48 You see that with some of your clients who are coming in who are on probation. Basically they're going, okay, I need to get this act together because I need to satisfy the probation and do that kind of stuff. I don't really want to change this stuff, but I'm going to stop doing it because I want to make sure I impress the judge. So there are differences between developmental and post biological and intentional changes. And when we talk about multi-health conditions that complicate addiction treatment a lot of times, there's a combo of biological, neurological, and intentional change. I mean, you know, people can bring on the [unclear] episodes, but usually the [unclear] episodes may be triggered by some biological thing. But then the reaction to that and some of the other kinds of things that they do brings in some of the intentional change process, medications, other kinds of things. So this study that we did with pregnant women was really interesting because many women stopped smoking during pregnancy and they quit for six, seven, eight months.

33:53 As soon as they find out they're pregnant, they quit. Sometimes before they're pregnant, they quit. And they appear to be in maintenance. I mean, I said action takes three to six months. So, well, these women should be in maintenance, right? However, postpartum, many of these women relapse at rates like they just quit yesterday. By six months, often 70% of the women who quit during pregnancy are back to smoking. You say, well, how is that? All of these women were in maintenance. That's not true. They stopped or suspended smoking, but they didn't quit it. And we compared them to women who were trying to quit, and they didn't look the same. So the women who quit during pregnancy were using few of these processes of change, were very confident that during pregnancy they will not smoke. So in another study we asked them, well, what about postpartum? And there you could see more of the thing, well, I hope this is really, I'm going to be able to quit for good and those kind of things.

34:56 But the reasons for stopping involve protection of the baby. And once you know you can protect the baby outside the womb, it's almost entirely extrinsic motivation. We asked them how much of this is for you, how much for the baby, 95, 99% for the baby. So there was not the intrinsic motivation that's needed to create intentional change. So extrinsic motivation is helpful. I mean, I've worked with drug courts and some other groups and whatever, and it's helpful. The judge is kind of helping and giving options to the person to go into treatment. It's extrinsically driven, but it's helpful to get them in front of the treatment provider. But it also can elicit resistance and rebellion. And it can also make the imposed change rather than intentional change. So intrinsic motivation and personal ownership of change is very important for initiating and sustaining intentional change. But it's not either or.

35:57 Both of those are important and can be used and helpful in getting people to move through the stages and complete the tasks of the stages. So that's the first three pieces. I wanted to stop for a minute and see if anybody has any questions or thoughts or comments about what we've presented so far. Pretty clear so far. Good. Yeah, I mean, you guys use this model anyway. And so basically, you're familiar with it. I just don't know whether all of these dimensions you've kind of thought about. And hopefully, I'm just helping you kind of go over it again and kind of think about it in maybe a little different way or not. We'll see. I think that's it. You're adding texture and context to all the texts that we've read. But these are great examples. Thank you. OK, moving on to finding different other pieces of this puzzle.

37:00 So the other puzzle piece that was really important to other processes of change, these are the change engine or mechanisms. And what we found in our research is there's a co-variation between the tasks and the processes, the stages and the processes. So doing the right thing at the right time is important. That different processes work better to produce change when they're activated in different stages of change. And mismatching can interfere with change. If you're really working with people and giving them a lot of action-oriented kind of process activity for them to engage in, but they're still back in contemplation thinking about it, that's a mismatch. And it's unlikely that that person is going to be successful in adopting all of the activities that you kind of say are important. So what are these processes? They're really human experiences, and people kind of think about them as kind of something esoteric, but they're really not.

38:00 Each process is a distinct mechanism, but it often operate in combination. And if you watch any TV, you see many of these particular processes being executed in the various ads that you watch. Because they're trying to get behavior change. They want you to buy this product. They want you to kind of change the way you think about this and use this medication. So they're engaging people in the processes of change. And we've, this understanding of the processes has been supported by factor analysis with different behaviors across different. Mammography, alcohol, treatment, tobacco, a variety of other kinds of problems and things. So what we found is there's essentially two, we're not exclusively saying this, but two sets of processes that represent two types of critical clinical activity that needs to be happened to enact behavior change.

39:11 There's a cognitive experiential set of processes and a behavioral set of processes. And if we think about the processes, this is the cognitive experiential set, so consciousness reasoning, making people more aware of certain aspects of the problem or certain aspects of the change that are really important. no arousal, experiencing some strong emotions about the problem. Self reevaluation, really changing how I see this behavior in relationship to my life and values and how it fits with me. Environmental reevaluation, how does this behavior and how would this change affect the people around me and positively and negatively impact others? And then social liberation, becoming aware of the norms and the societal sanctions and support systems that might be in there for people. And you'll see that these are actually all different parts of different theories of therapy. I mean, all theories, all therapies use consciousness-raising, gestalt therapy stresses emotional arousal, the cognitive therapy does self and environmental re-evaluation, and social liberation is really really kind of awareness of societal kind of norms that other groups have used in their targeting processes as well.

40:39 So those are the cognitive experiential processes here in the behavioral processes. So choice and commitment. Clearly if you think about existentialism or you think about humanistic psychotherapy, that's what they focus on. This control and counter conditioning is really [unclear] behavior modification. And either creating cues or eliminating cues or substituting new behaviors or old responses. And then reinforcement management is really building skinner stuff, building that. And it's interesting that helping relationships came in under behavioral processes when we do factor analysis. And I think that's because helping relationship is really of the scaffolding that I'll talk about a little later that really mean that the clients need. And when we talk about processes, processes are also behavior specific. So just because you're doing something like stimulus control about drinking doesn't necessarily mean you're going to do stimulus control about your marijuana use. And so again, the stages and the processes are behavior specific and need to be thought about in terms of the behavior of those.

41:56 I worked in an inpatient unit once and it was very interesting to watch the staff. I was consulting, watch the staff work. They brought a guy in who had cocaine problems and wanted to stop his cocaine. They did an analysis and they said, okay, you have an alcohol problem as well. You're drinking too much. So he said, I don't have an alcohol problem. I've got a cocaine problem. And the staff fought with him for the whole 28 days. Those are the good old days of 28 days. They fought with him for 28 days about whether or not he had an alcohol problem or not, and lost the leverage about the cocaine issue, I think, because he was so rebellious about the alcohol thing. So it's really important that you do this specificity and that you work in each of those areas very specifically. This you aren't supposed to see. This is a slide that they say never to show anybody because it's just too confusing.

42:57 But however, this was one of the aha moments that we had in terms of developing the model. Because this is our two year, we followed people for two years. This is a group of people who started out at baseline in contemplation and ended up two years later in maintenance. And to be in maintenance, they had to be at least six months off, so probably for that last six month, four to five period, they were in maintenance. And what you see is that processes change over time. Also, temptation and confidence. Confidence goes from the lowest on the left hand side to the highest on the right as you get to maintenance. You see stimulus control being very high, being able to manage your environment and keep the stimulus out of there. You see, temptation levels come very low. You see, some of these go up, like some of the more cognitive experiential, and then come back down again.

43:58 Because consciousness raising starts up a little high, and then actually ends up lower. Because you don't need that when you're quitting smoking. You don't need consciousness raising at that point. You're really supporting it with behavioral processes. So this is what told us that the processes and the stages go together. So when you think about that, you try to promote a client engagement in these different activities as they're working on these different tasks of the stages. And it may be a little different when you're talking about initiation or modification or cessation. Much of this early work is done on cessation. But when you start doing things on initiation, you may need more cognitive experiential processes in maintenance so that you keep going. you may know as you do, if you think about exercise, for example, you get into exercise, and if you don't find something in exercise and don't keep re-evaluating it as something that's really important for you, you don't keep doing it.

45:01 It drops out of the thing because I'm too busy. So we can learn a lot about these processes and the stages by looking at ourselves and our own changes. So, how do I see the interaction of the stage task and the change model? So, we create interventions, right? And life creates interventions also. The life context and the social environmental influences also provide impetus for these processes. So, if I'm thinking about making a decision, how does this go? Does it go directly from intervention to decision? No. goes through the processes of change. So engaging these processes helps me kind of create this decisional balance that's tipped toward the decision to change. And that's the task completion and trying to do it well enough. Similarly, if I think about successful action, I do an intervention, but the intervention doesn't produce a successful action.

46:02 The intervention is supposed to activate many of these things that you're teaching coping processes that you're teaching your clients to do, and they're doing the coping processes is what makes the successful action. And again, life context and social influences provide additional mechanisms that can either promote or hinder this process. And you know as well as I, there's a lot of hindering that happens out in the community for substance users going back out in the community and getting in touch with some of their older friends or other former people that they've used their drugs with. So that's how I think we think about the processes in terms of how you go. And you know why I think this is integrated and eclectic, because are there specific intervention strategies that are better at different stages and with different change processes? MI seems to be, was really developed, thinking about precontemplation and contemplation tasks.

47:12 CBT and DBT and ACT have been developed, trying to activate both experiential and behavioral processes. So the challenge for us is always, what are the strat, they have to do the processes and the tasks, we have to provide the strategies to help initiate and empower them to do these processes. And then we thought about, can you do this in a group? And we have created this group therapy manual. The activities in it are plebeian. And nothing that you haven't done or couldn't think about doing. The difference here is we actually, for each activity, We focus on whether it's pre-action or action kinds of activities, and what processes of change we're targeting. So each of these activities has a target process or processes of change.

48:12 So this says, well, we're really gonna target target consciousness raising with this activity. Oh, we're gonna chart software evaluation with this activity. So when you're doing groups, you know, it's better to think about leading an orchestra than conducting a group. Because with all these people in different stages of change, you've got to be really moving back and forth and working with them, honoring their current stage, and trying to promote movement to the next stage. OK, again, I'll stop for a second. Are there other questions or thoughts from the crew? I liked your point going back a bit about the need for specificity, especially in a rehab situation where we lump it all together. But that brings a different way of looking at it because it can and does bring roadblocks. Right.

49:13 Because rehab is multiple things. It's multiple changes, not just one. I mean, obviously, the most important one is dealing with the target behavior of the substance use, but really trying to kind of look around at some of the other behaviors they need to change as well. Okay, let me keep moving on through here. So the other piece of the puzzle that we found was relapse and recycling. Relapse is not a stage of change. We originally thought about it as maybe a stage of change and then we decided it's It's not because when we started looking at people who we classified as relapses, they were very heterogeneous. Some of them looked like they were in precontemplation, some of them looked like they were in contemplation, some of them looked like they may be even in preparation. And so we realized, well, so relapse is an event, it's not a stage. And that basically what people do is recycle through the process in order to kind of make change happen.

50:17 And there's a difference between successful recycling and just a redo. Some people do the same thing over and over again expecting a different outcome. You know, and that's Einstein's definition of insanity, right? But if you don't change what you're doing, you're not successfully recycling. So you really need a learning perspective here. What have I learned from where I have been and what I have done, and how can I make this next stop, this next step, or next attempt better. So a lot of people would love to, we'd love to have success this way, right? I mean, I know that's true for all of the people who go through your program. But most of the time, it looks like this. It's really messy. And you get regression, people moving backwards. Sometimes you have slips and falls that people take while they're on the action phase here. And usually that indicates there's some problems in the process or the plan that they're working on.

51:22 Relapse, I have changed the way I just, you know, relapse isn't just using. Relapse is when the person gives up when making the change and says, no, I'm not going to do this anymore. And I learned that from clients who kind of said, you know, no, I didn't, I didn't rela- yeah, I did drink and I had a binge episode and I did all that kind of stuff, but I didn't relapse. I'm still working on this. I'm still trying to make change. So as long as the person is continuing to try and stay in action and make some changes, even despite the falls and the foibles and all the other kinds of stuff that go on, they're still in action. It's when you say, okay, I can't do this. They move back to what you're doing before, whether it's as much or not as much, but still you're going back to just regular use of substance or back to the old way of doing things. That's relapse.

52:26 But even there, basically they move back into recycle. So when they're relapsed, they actually go back and say, okay, I can't do this. they're in precontemplation. So what the important thing is not to just focus on the relapse in terms of where they've been, but also where are they now in terms of where they are in their process of change. And this is the relapse curve. So this is everybody up here is totally abstinent. Total abstinence by the time you get to 12 months is 20%, 30%. Not impressive. you say, OK, well, I don't know about that. Because relapse is probable with any health behavior change. And if you think about diabetes, diet, medication, exercise, all of those experience high levels of relapse. Often, the same rates as addictive behaviors are even more. So relapse is a problem of instigating and sustaining behavior change.

53:29 And that's why we need this successive approximation learning as opposed to one trial learning. It's a problem of adequately completing the critical tasks of the stages. And so Tom McLellan did a study in the 2000s that was in JAMA. These are relapse rates for asthma and hypertension and diabetes and drug addiction. And you see that they're very similar. So drug addiction has gotten a bad rap. that oh, it's responsible for all this addiction. These are addiction. These are relapsing disorders. These are, no, relapse happens all the time in all kinds of behavior changes. So I think it's really important for us to kind of do that and to teach our clients that as well, so that we begin to kind of reduce some of the stigma. And recycling, so I talked about relapse.

54:31 It's not a [unclear] failure, but it's a learning opportunity. And again, if people see it as a failure, they just kind of sit back there and sit in precontemplation for a while and get more disordered and more problems and more things happening to them. This is the individuals, like I just said, who knew that. I already talked about that. Recycling is how you learn to adequately accomplish the tasks of the stages and get it done well. So the model gives us a way of kind of thinking about the change process that gives us a picture, a GPS view of the larger context of change and how things happen. And yet, we need to go into the individual where the individual is and follow them and try and work with them where they are in that particular piece of change. And then the relapse piece triggers the recycle.

55:33 So that's the model and why we've always had it as a cycle and helping people to understand that this is also a cycle of change, not just a linear model of change. And I don't know how many of you are in recovery, but many of us who have put addictive behaviors have needed multiple attempts. And what I say to people is even if this is the first time somebody comes into treatment, they're not change virgins. They've tried on their own. They don't come with you without trying on their own first. And they failed trying on their own and now they're coming in. So even they have a history, a relapse history that could be used to try and help them understand what works and what doesn't work for them and how to complete these tasks of the stages. better. So I'm working on a new book that's just almost finished with. It's back to Guilford. We'll be publishing it. It's called the Function of Failure in Successful Behavior Change. And it's important to, so that's another piece that I found as I was kind of going through and working with different people and working with consulting in different places. Failure is important for successful approximation learning. Figuring out what went wrong and fixing it is really important. What our model does is it offers a blueprint on how change happens and some of the key ingredients. So getting these tasks done adequately may take multiple attempts. Recycling is not just doing the same thing over and over and expecting a different result, it's what can I change now, what can I learn from how I, the last attempt that I made and move forward in terms of what I'm doing.

57:36 And this is just a template that kind of helps me kind of conceptualize, you know, you can move forward in this process of change with a little interesting concern, moderate amount of interesting concern or a lot of interesting concern. And it's the same with decision making. You can make a weak decision, a stronger decision, or a really strong decision based on values and other kinds of things. You can have a weak commitment even after you've decided your commitment may not be strong enough to take, or your planning might be problematic, and prioritizing may be problematic. Once you get into action, you can implement a plan, but you can implement it, as my dad would say sometimes, half-assed. You know, do it right. you're doing it, you're just kind of in there, you're going through the motions, but you're not doing it. Or the plan's problematic, and you need to kind of change the plan midstream. And then you need to build it into your lifestyle and avoid relapse.

58:41 And in maintenance, you get lots more things that are happening that are infrequent, but could be even stronger kinds of urges to kind of go and back to where you were. So, what does recycling do? Recycling helps us to get through here and hopefully we learn from these where we were the last time and what we missed the last time. And if you ask somebody why were you successful this time and not the last time, they will normally tell you, well, I did it this way. I realized I couldn't just depend on my family. I had to kind of do this for me or I had to do this, I mean, I had to get, you know, this finally meant something to me. I got my spiritual values involved and that really worked. Or, you know, so they will tell you that they've learned from what happened in the past and that's how they're going in the future. So my goal with the book is actually helping people to kind of, when you're debriefing or relapse, don't just focus on the event.

59:48 What happened? Who was around? What were the triggers? What did you do? That's important. But look at the whole process. It may be had nothing to do with the triggers. It may be that the interest was, they had all extrinsic interest. And so basically they came through and when they got to the action part, it fell apart because it was all for somebody else and not for themselves. So, look at the whole picture of the process. Look at the decision and how did they do that decision. Look at the plan. How good was it? Was it feasible? Was it accessible? Was it acceptable? Was it effective? Did you revise parts that weren't working or did you just give up? You know, Alan Marlatt's abstinence violation effect. Oh, I had one potato chip. What the hell, I'm going to eat the whole bag. So you need to kind of think about what's going on there. the commitment? Were your commitments sufficient to match the withdrawal? All change is uncomfortable.

1:00:53 And if you don't have the commitment to face the discomfort and the withdrawal, especially from the substances, you can't really kind of do it. And did you find some valuable alternatives, reinforcements or support systems? Again, so look, when you're debriefing a relapse focus on the whole process of change and not just the triggers and it's important to understand that relapse is not the opposite of recovery this is actually from some of the clients not trying is and I think that's an important message because there's never a failure it's always a lesson so I'm arguing to kind of almost retire the term relapse because it's got so much stigma associated with it, we can talk about a setback and sustaining change. We can talk about a mistake that can be corrected, an opportunity to learn, a reoccurrence with lessons learned. You need a long-term multi-dimensional perspective. So the focus is always on getting well and getting better and not necessarily on, oh, you relapsed, so that's bad. And The problem a lot of times has been programs as well because the program is embarrassed about relapse as much as the client is.

1:02:19 The program doesn't want to hear about relapse. There is a needing of focusing on why didn't it work with this client and was it something that we did, not something that the client did in not helping them go through this process. I kind of push a lot of times to groups to kind of use CQI to kind of find out what's wrong in the process, continuous quality improvement. How do you kind of do this and work and how can we get better at doing what we do so the clients can get better at doing what they do? And that's the key. The final two things that I want to touch base on is first of all the role of self-regulation and self-control. We've talked about the processes of change. The processes are change generating activities. They're what I need to do to move through the stages of change. But all of these activities require adequate self-regulation and self-control strength.

1:03:26 So change regulating mechanisms are often underestimated. I mean, we know that a lot of people who come into your treatment program had problems with self-control before they even became addicted. Many of them were hyperactive. many of them had some self-control issues growing up, and that those get compounded when you start using a substance. So how do we kind of think about these change regulating mechanisms? So if you think about any of these personal process of change, all of our self-regulation models include self-observation, decision-making, self-evaluation, and real willingness to consider change planning. The self-regulation components, executive cognitive functioning and affect regulation. Can I get the person to kind of get that cognitive functioning planning and executing different kinds of activities?

1:04:27 Can I get them to manage their emotions effectively so that the emotions won't screw up the executive functioning? So self-control and self-regulation are essential in both initiation and modification of health behavior. They're also critical to beginning and completing the tasks of the stages. So when I've been working in this area and looking around, I found Baumeister's work. He's a social psychologist who kind of looks at self-control strength. And he's kind of looked at strength as a limited resource. That's the self-control strength that the limited resource that's like a muscle It can become fatigued and depleted, but replenished with regular exercise, followed by periods of rest. So self-control is not just a skill or a capacity. If you think about it as a muscle, it's something that we can do, but it's also something that we can get and be problematic. It's not limitless. Some people try to kind of change sometimes and they go, okay, well, I'm gonna quit drinking, but I'm gonna keep going to bars because that's where all my friends are.

1:05:35 You go, okay, you know, do you think you've got the self-control stress muscle to do that? Because that's not an easy thing to do. And it's not a limited resource. And so when you're kind of got a lot of stuff going on and then you go to the bar and then everybody's drinking, you, your self-control strength is tested. So you can build it, you can strengthen it, but it needs time to consolidate gage. It's like weight work. If you do lift weights and do that kind of stuff, you don't do that every day. You lift weights and then you lay off a day so that you kind of consolidate the gain. And it's involved in all the efforts. It actually becomes less involved, self-control strength, when they become automatic. So in maintenance, you don't need to use as much self-control strength a lot of times. What depletes this self-control strength? This is a litany of things that our clients experience on a daily basis.

1:06:36 Coping with stress in life, trying to stop thoughts, trying to stop urges, affect regulation, managing negative emotions of depression, anxiety, and anger, modifying or stopping addictive and excessive behaviors. Inhibiting thoughts, and actually here's one study where inhibiting, stopping a thinking is more, requires more self-control strength than performing a behavior. So, what do we do about the self-control strength? In developmental psychology, there's a concept called scaffolding. It's what you do with your little kids. When you put your two fingers out, and you help them walk along, and they are stumbling along a little bit. But those two fingers are scaffolding, just like we scaffold a building. And we try to put up stuff so that we hold it together until we finish fixing it and doing that kind of stuff. So scaffolding is a way to manage self-control strength. And the more challenge the self-control strength is, the more scaffolding that you need.

1:07:43 So recognize that this impaired self-regulation disrupts the work of the client and the process of change. Provide some external support systems that can support the change process. I got to say, AA gets a bad rap sometimes. But that 90 meetings in 90 days was scaffolding. It was getting people to kind of do something. If you could do something for 90 days and go to see these people and get these people to support you, that's a big deal. And that could help you with your self-regulation. Provide a way the client can build and rebuild that self-control muscle. You know, a lot of this, you know, most of you are, have decent self-control muscles because you're sitting here listening to me for an hour and a half and doing all that stuff. But basically, it's all the things your mom told you to do. You say, oh, why do I have to do that? That doesn't make any sense. She goes, do it, you'll be a better person for it.

1:08:47 They were actually supporting self-regulation by giving you some structure and some things that you had to do and some tasks that you've got to be accomplished. That builds the self-control muscle. And here, you know, make sure, a lot of times our treatments aren't long enough, make sure the building is well built before you take down the scaffolding. So you don't want to take down the scaffolding in the middle of it. You know, we talked about aftercare. It's not aftercare. It's got to be continued care. And actually, the process of change is much larger than any treatment program is possible. Because people are always in this process of change. in what SAMHSA talks about recovery as a process of change, where people become self-directed. So initial recovery requires adequate time and significant scaffolding.

1:09:49 So finally, let me talk about this. We got a few minutes. So how does intervention fit into treatment and self-change? Treatment behavior change is really a version of self-change. You guys, I know, all help think of what we do is really important, and it is. But we don't make people change. We don't change people. The people change themselves. We help them change. So self-change and treatment behavior change are not different phenomena. Interventions can enhance or hinder the personal process of change. I mean, I've seen some people who have worked with clients actually hinder their change process. So, you know, you have to be careful. Treatment strategies have to engage the mechanisms and have to have a chance of influencing change, to have any chance of influencing change.

1:10:50 And there's a significant difference between a treatment plan and a change plan. And I think this kind of has our way of thinking. People sometimes think, okay, if you follow this treatment plan, you will change. The change plan is always more important than the treatment plan. And the treatment plan should always be in service of the change plan. And I know I read parts of Richard's book. And you know, that's, you have a, you guys use a personal, personally kind of tailored way of kind of focusing on clients. And that's really what we need to be doing in terms of looking at their change plan. And how can my treatment plan help them accomplish their change plan? So we've really made many advances in understanding recovery. And really kind of focusing now on not Why do people recover, but how do people recover?

1:11:57 And I think that's been part of this model's contribution to this. But it shifts our understanding of the role of treatment once we understand the personal process of change. Because a lot of times, most of our research on therapy has focused on treatments, has focused on therapists, has focused on the environment, and has kind of said that, but there are like three blind men kind of walking around. The most important piece of this is the client in the middle. The elephant in the room is the client in our research. And it's important because I think what we see now is it's client process, treatment is a mediator of client process, more client process towards outcome. And that support systems, family, mutual help and treatment are all there to kind of help and support the client's process of change. Instead of thinking about going from treatment to outcome, you go from treatment through client process to outcome.

1:13:03 And I'll show you just a quick, a little bit of evidence for this personal process of change. Project MATCH was a large multi-site study, 950 outpatients, 774 aftercare patients, all with alcohol dependence. And so we looked to, you know, there's a lot of evidence for personal process of change. There's commitment language. Amrhein and Miller and Dunn have done, the more commitment language you hear in session, the greater the process of change, or greater the probability that person's going to make a change attempt. Patient to therapist talk ratio. The more the patient talks, the better the outcome. setting a date for change, doing an implementation intention kind of thing. Other things that have predicted outcomes are patient evaluations of their own strengths and vulnerabilities. We found self-efficacy and temptation to be a very important measure of outcome for patients.

1:14:09 And in one study with one of my grad students did temptation minus confidence. So the level of temptation across a bunch of situations minus their level of confidence, predicted time to first drink, time to first drink, number of drinks during the first week. And so these are powerful but personal kinds of markers that I think are really important for us to kind of keep focused on. So this project match study we did, we used three treatments. We used 12-step facilitation, cognitive behavioral therapy, and motivational-enhanced therapy. Both of the first two were 12 sessions, MET was four sessions over 12 weeks. And Bill Miller and myself and several of us created the MET one, Kathy Carroll and some other folks worked on CBT and TSF was done in collaboration with Hazelden and has now come out as a separate treatment.

1:15:10 So there were no important treatment differences When we looked at a lot of the process variables, so stage, working alliance, temptation to drink, self-efficacy, and the behavioral and experiential processes. However, when we look at process dimensions, they did discriminate between the outcomes of the drinkers. So what happens to process dimensions during treatment? Well, here's the end of treatment process profile. So we looked at, we divided people up. And this is the outcomes for the aftercare and the outcomes for the outpatients. But we divided people up into people who were totally abstinent for the 12 months after treatment, people who had moderate drinking and no binge day during the treatment, during the 12 months and people who were the heavier drinkers, even if they weren't drinking as heavy as they were when they started to come in, okay? And we then said, OK, let's look at what did their baseline and end-to-treatment profiles look like on the stages of change subscales that we have for our URICA, the temptation to drink, abstinence self-efficacy, and the experiential and behavioral processes.

1:16:26 And we came up with what I think is a success profile. So this is a post-treatment. These are the yellow are the people who were abstinent. The red are the people who are the heavier drinkers, the moderate drinkers were in the middle. And that's where they were. These five things discriminated what we call a success profile. They have higher action or taking responsibility and decision-making. They had lower struggling to maintain. They had higher confidence, they had lower temptation, and they were using the processes, behavioral processes and experiential more than the reds. The reds were exactly the opposite, the heaviest drinkers. So at the end of treatment, this group of red people should not have been let out of treatment. They weren't ready yet. Because without any future treatments, this group, even after they left our program, didn't get much treatment after that and did fine all the way through until 12 months.

1:17:33 And the middle group was in the middle. And if you look at aftercare patients, you think I made a mistake and these are the same scales? No. This is actually where they were on these three groups were on the process of change, confidence, temptation, and experiential behavioral process. You'll see it's the same. High, taking responsibility, low struggling, high confidence, low temptation, and using the behavioral processes of change, and even the experiential processes of change a little more than the people who are the carriers. We did this also with Project COMBINE, which use medications and psychotherapy, and basically found very similar profiles. So it's really what the patient is doing at the end of treatment that drives success, long-term success. So getting and staying into recovery and both mental health and addictions requires completion of these critical stage tasks, use processes of change, build confidence, avoid overconfidence, be realistic about risks, build a healthy and rewarding self-directed life, as SAMHSA says.

1:18:52 So we need to be helping patients to work smarter, not just harder. So why is recovery a marathon? It's not simply abstinence or absence of the use disorder or the mental health symptoms. These disorders have disrupted a lot of the individual's life, as you know. I'm preaching to the prior here. Sustaining change involves a lot of changes in the entire context and functioning of the individual's life. So you need a very short-term and a long-term perspective. So where are we with this puzzle? Change is a process, not a product. I think we found important pieces. Motivation is multi-dimensional. There are personal change processes. Sustaining change often involves success of approximations, so relapse and recycling. Natural, I need a change, and treatment-assisted change involves a similar process. So where do we need to go? We need to add more neuroscience and behavior change, and integrate it with our treatments.

1:19:56 We need to measure the quality of completing stage tasks. So how can I measure a good decision, and a very strong decision? And how can I measure a really good plan? We have some dimensions, but we need to be able to measure that. And then how do I understand extrinsic and extrinsic motivation and influences? How to manage the function of failure in successful behavior change, how to get people to kind of see it as an opportunity, and then exploring the role of self-regulation. And then making sure that we are cognizant of the change burden and the impact that life context has on change and treatment. So I'm going to stop there. Thank everybody who helped me, thank all these organizations who funded a lot of our work. That's some of our teams that we've worked on. Some of these are teams that, some of our projects and some of these are, are my graduate students who are all now PhDs doing good work around the country.

1:21:05 So we have two minutes or so, or five minutes or whatever you have left. Any questions or comments or thoughts about this? Anybody else want to throw in any comments? I really appreciated the emphasis on not aftercare, it's continued care. And just the reminder of the terminology of what we're doing, whatever tools we're using, is where the goal is a self-directed life. And how many ways we can paraphrase and communicate that to the client, so important. Yep. So if we continue this, because Richard has said maybe we need to try and kind of meet quarterly or whatever, what I would hope to do would be to kind of get you to think about your clients in terms of some of these dimensions. If there's some of these dimensions that you'd like to go deeper into, we could kind of do that a little bit and talk a little more about processes of change and what do they look like and how do we see them.

1:22:10 in our clients. Or we could talk a little bit more about self-regulation or self-efficacy because I think that's a really important piece and understanding how people become efficacious and some of the influences of that. So Patricia, whatever you think, I mean, I think, you know, figuring out what you want and how we want to kind of structure this is would be up to you guys. And what I'd like the staff to do is to think about clients and bring in some of the client perspectives and kind of, you know, how does this work with this type of client? And we've encountered this kind of thing. Here's what I've done. Do you have any I've done, do you have any, what are your thoughts about that and light up a model or something like that? That might be very helpful. So we'll do a group huddle with the other clinicians and come up with a plan for that to be a little bit more point specific.

1:23:10 Yep. But this was an overview, so hopefully it helped give you a picture of the larger context that I'm working in anyway where I kind of see us. Okay, well, Dr. DiClemente, thank you so much for your time. It's a beautiful presentation. Thank you. Thank you, guys. I appreciate your being there. Good luck in your work. I think what's more important is when the rubber hits the road is where you guys are working. So I have tremendous respect for all the stuff that you're doing. So keep up the good work. Thank you so much. All right. Have a good, take care. Bye-bye. Thank you. Bye.