Human Up Season 1 Ep 8: The Stages of Change Model

This is a transcript of Human Up Podcast Season 1, Episode 8 with Dr. Carlo DiClemente, which you can watch and listen to here:

Dave Marlon: Hi, and welcome to the Human Up Podcast! I'm Dave Marlon and I am amazingly honored today to spend some time with Dr. Carlo DiClemente. Welcome doctor. Glad to be here. Davis Carlo DiClemente, PhD, ABPP is a professor Emeritas of psychology at the University of Maryland, Baltimore County and the director of the MD Quit Tobacco Resource Center. He is a co-developer of the Transtheoretical Model of Behavior Change and the author of numerous scientific publications on motivation and behavior change with a variety of health and addictive behaviors. His books include addiction and change, substance Abuse Treatment, and the Stages of Change, group Treatment for substance abuse and the Self-Help Resource for Changing for Good. Dr. DiClemente is the recipient of awards including the Lifetime Achievement Award from the Addictive Behavioral Special Interest Group of the Association for Behavioral and Cognitive Therapies, the John p McGovern Award from the American Society of Addiction Medicine, the Innovators Combating Substance Use Award from the Robert Wood Johnson Foundation and a presidential citation from the American Psychological Association.

Again, welcome Carlo!

Dr. Carlo DiClemente: Thank you, David. It's a pleasure to be here and glad to be part of this.

Dave: That's awesome. Just reading through your credentials. One, it warms my heart because I've spent about 38 years in the medical field and I value, I think my greatest achievement was getting the Nadac advocacy award, so being able to advocate for people. I love the fact that I've helped about 10,000 people get clean and sober and that's amazing. But I respect your accolades so much, and like I said, it's a super honor to have you here. Could you start us off by telling us a little bit about your story and what got you interested in addiction and behavior change?

Dr. Carlo: Sure, David. So actually psychology wasn't my first career. I was actually ordained a Roman Catholic priest and worked in the diocese for about four years before deciding that I really, the pastoral counseling part of my work was the part that really kind of engaged me. And so I left and went to kind of do a master's degree. I had really no background in psychology and did a master's degree in New York at the new school for social research and then was lucky enough to get in an invite to be part of the graduate program at the University of Rhode Island. And so that's really how I got started working on that. So I'm working on my PhD. They liked people who had, they would call it life experience. So I had a Wall Street banker and army soldier who was also part of my class that we were all part of that.

So I was really kind of very interested in doing clinical work. And then I took a class from Jim Ska and he was working at that time on trying to look for common processes of change and looking across different kinds of therapies. So even in the class what we did was reviewed all kinds of treatments and tried to look for what were the active ingredients that made people change or helped people to change. And so after I took that class, I decided to ask him to be my mentor for my dissertation because I foolishly thought that basically I will. I said, Jim, I really like those processes of change. I would like to study those processes of change. He goes, okay, well, we have to pick a behavior. So he went back and forth for a while and I was smoking cigarettes at the time and he said, I think we should be doing smoking.

No, no, no, we don't want to do smoking. I'm wrong smoking. I don't want to do smoking. What about anxiety or depression? No, you can't count anxiety. You can't count depression. You can't need to do something that's countable, so you could really look at what success looks like. So I said, okay, I'll do smoking. And so I kind of looked at all the literature, pulled a bunch of stuff together and decided to do a research project on smoking. And that's really where we got started working together. The research project actually identified each of those processes. We built questionnaires that focused on the processes, and I recruited people from two programs. So I don't know if you go way back also. So SH had a smoking cessation program.

Dave: Shado?

Dr. Carlo: Yes. It was version therapy. Version therapy, exactly. And then there was another cognitive behavioral treatment that was there. Then I made the argument to Jim that if we're going to look at processes of change and these are things that people need to do, then the processes need to work for self change as well as therapy change. So we recruited a bunch of people who had quit on their own. So I got people who quit the two weeks after they quit. They had to be successful for that two weeks and asked them these series of questions and then followed them five months later for looking at outcomes in terms of who was smokers and who was smoking. But I was really interested in comparing, did they say that they were doing different things if you're in therapy, if you're in this therapy? There was a little bit of that, but it wasn't very different.

The processes were very similar. I mean, the aversive conditioning one endorsed emotional arousal a little bit more than the other two. Some of the cognitive behavioral endorsed a little more of the cognitive processes, but in essence, they all endorsed a bunch of different processes. But the key thing that was happened was the people were asking me when I said, well, how important was this process to you in your quitting smoking? And they said, when do you mean? You mean before I came into the treatment program or before I tried to quit? You mean when I was trying to quit? You mean now when I'm actually already quit? And so we realized that if you're going to ask about processes and what people do, you have to incorporate not only the processes, but where are in the process of change. They are in order to figure out how the processes are going to work.

So that's really how we got started working together. And we put those together and people were doing a lot of things in decision-making at that time. Janis Mann were kind of focused on that. Pandora was talking about self-efficacy. Marla was doing something on maintenance. Somebody else was doing something on contemplation. And so we kind of just put our heads together and kind of figured out, well, wait a minute. Let's look at this process because I know there's a, people have to make a decision. So there's a contemplation phase, and then there's some other phase that we call determination. They have to kind of earlier, it's now preparation,

And then where was action and maintenance, but we also tried to do it according to the research. So as luck would have it, NCI was very interested in how people quit on their own and they put out a RFP for that, and we had data on how people quit on their own, and we had a model that we were creating to kind of look at that. So we went in and did that, and we went in, I was in Texas then I was in my internship and I stayed in Texas in Houston for quite a while, and he was in Rhode Island. And so we built a project that we could do both. We could get four or 500 people from Rhode Island and four or 500 people from Texas and have a little bit of cross-cultural kinds of verification as well.

And luckily, we got the money and that was the start the thing. And we did, that project was not an intervention, it just followed smokers for two years, asking them every six months kind of where they were, what they were doing, how tempted they were, how confident they were, what their decision-making process was, how much they valued different pros and cons, and we just followed them for two years. And that's the data that really drove us to kind of think about the interaction of the stages and the processes, and that was really the beginning of the model. That's

Dave: Beautiful. Let me ask, because some of our viewers or listeners may not know the Transtheoretical model now of the five stages, it sounds like when Jim approached you to include smoking that you were pre-contemplative?

Dr. Carlo: Yes. I was in pre-contemplation and did not want to quit. And as I started the research project, I still was smoking until about cognitive dissonance gets to you after a while and you kind of go, okay, no, I can't keep doing this and interview people about smoking cessation. So I finally quit. I actually switched to a pipe trying to be a psychologist with a pipe or something, and then decided that's it. The whole thing is over. We don't need nicotine. Yes, I was precontemplation

Dave: During the study. Then while you were doing the work, you began to contemplate it and then I guess you were preparing to act. Yes. At what point,

Dr. Carlo: Go ahead.

Dave: Where you switched to the pipe, did you use Nicorette gum or a patch or any other pharmacological tools to help you when it became time from the action stage?

Dr. Carlo: No, actually nicotine replacement actually came a little after quit smoking. This is pre Chantix. This is pre Chantix, pre NRT. Yeah. So yeah, so I kind of then had to make a decision, and so I decided I'm going to do this. I had a plan. So what I did was I did some of the aversive kinds of stuff. So I bought really low tar nicotine cigarettes and smoked a lot of them the day before I was going to quit as they're kind of noxious and they weren't really pleasurable. And so I kind of did that and then I quit and then went on from there to not use. I think after that I may have had one or two puffs of a cigarette a couple of times, and that was

Dave: Well, bravo. Good job on that personal journey.

Dr. Carlo: Yes.

Dave: What did you do for the maintenance part to

Dr. Carlo: So in action, I used some of the strategies, cognitive behavioral strategies. I mean, I chewed on swivel sticks and

Had candy and did all of that kind of stuff that you use. And so there were tools that you used there. And then after a while I wasn't really thinking much about cigarettes, and so I kind of start exercising and doing other kinds of things. So I was running down there on the bayou and doing some of that kind of stuff. And that really helped me. And the research also convinced me that I just needed this was really studying this and trying to look at how people did. It was really a motivator to continue and to sustain the change, which is what happens in the maintenance

Dave: Stage. Just over 10,000 patients get separated from a substance and mostly substance use disorder treatment. However, of my 10,000 clients, I'm going to say almost every one we identify, there's stages of change within the treatment plans that myself or my CS made. So to me, being able to talk to you is such an honor because you help frame the work that we do. To me, this is a calling. This is more than just my job. This is what I'm supposed to do here on the planet. Which maybe you want to go back one sec. I find a ton of spirituality connection to the work that we do, and it almost doesn't surprise me that you came from a pastoral perspective into psychological, both sincerely wanting to help, but do you find some benefits in your dual training?

Dr. Carlo: Oh, yes. I think that that's true. I mean, I think especially in the contemplation phase, there's an importance of values and where people can find values that will actually drive the decision, but also support the decision. Because again, most of us need to do things for important reasons. And I think the spirituality writ large or small or however you want to kind do the R and at the SI think it's a very important component of that and especially in addictions because one of the things that I've been working on in that addiction and change book was trying to think about what are the mechanisms of addiction? And we have different terms that we call addiction, which is really interesting because it is a brain disease as some people call it, but that's based on the neurotransmitters part of it. It's a behavioral disease because it's a self-regulation, behavioral control kind of problem that a lot of people have in covid. So I've been called a behavioral disease, but it's also a spiritual disease because the substance takes over all the other pleasures and all the other values in these people's lives. And so basically they become, I think the substances suck the values out of them and make it not pleasurable. So I think as you know that all three of those things I think are important mechanisms that we need to address in treatment. A hundred percent agree.

Dave: I've learned to reframe the spirituality component to what I call it is your meaning making system, because too many of our clients come in and if they hear the word God, they just shut down. So trying to determine what you use to make meaning, and I like the fact that you said that we need to do things for important reasons. So that importance is emphasized when it's integrated with our meaning-making system. Now, the fact that once you remove a substance that you've been dependent on for quite a amount of time, that you have a much greater capacity for spirituality, for a meaning-making system for God, even it compounds the significance and the importance of that spiritual component. Well said. Yep. I agree. Thank you. And I like the way you categorize those three. I'm guessing that you have a knack for classification in stratifying pieces.

Dr. Carlo: Yeah, I mean, so the whole point of what we've been trying to do, what Jim and I tried to do in the beginning is the model is not a theory. The model is a heuristic framework. I liken it to the genetic kind of model that there is that showed you how the genes kind of work. That model was done before all this genetic kind of stuff was even figured out. But the model helped to see that, oh, okay, there are these different aspects that are important that we need to be looking at and we need to be studying. The other thing the model does, as I think you said already, it really does help you to understand what we call readiness.

That readiness and motivation is not a single thing. You need motivation all through the process, but that there's different tasks at different times in the process that are identified by the stages. And then there's the processes, which are the engines that kind of help people move. And these processes, I mean, they come from different theories of therapy. That's why it's called transtheoretical. So basically Jim was kind of doing stuff on, and he still has a book out there on the systems of psychotherapy that looks at the kind of processes from analytic perspectives and gestalt perspectives, some of these processes, cognitive therapy perspectives, because you think about reevaluation. So the names are kind of a little esoteric in terms of consciousness raising, self reevaluation, environmental reevaluation, the emotional arousal, and then the behavioral processes are reinforcement management and humanistic kind of process of taking responsibility and choice and stuff. So the processes are the way that we have kind of thought about the mechanisms that people have to use to kind of move through the stages, and that interaction between the stages of the processes, different ones are needed in the pre-action stages, then in the action stages. And that's where you think about cognitive behavioral being so important. It's true because there are cognitive aspects of the change process, and there are behavioral aspects of the change process, hence

Dave: Your trans theoretical model of change you for laying that out to me. Beautiful. Yeah. So yeah, that's how we got there. That's amazing. Now, you were a student for Professor Prochaska in a class, and then you asked him to be your faculty advisor on your dissertation. Exactly. Did you become friendly with them?

Dr. Carlo: Oh, we became friends and colleagues. I've got to say. I mean, Jim died a couple of years ago, but the early stages of our working together was an intense existential experience of two minds, kind of thinking and doing things together. And so we were really kind of in sync. We would go to conferences and sit by the pool and spin these ideas like crazy and go, wait, so determination, but we can't find it. So the original part of the model only had pre-contemplation, contemplation, action and maintenance. We couldn't find decision making. We couldn't identify a way to get that. So determination was in there in the conceptual part came out when we talked about the model, and then it came back in when we realized that the contemplations phase was just too large. You needed to split that up a little bit. Originally we start contemplation and contemplation more ready for action. And so we then said, okay, well wait a minute then now we've got to, how about putting those in a preparation stage? Wow. So it's organic. It's not, again, the processes, we don't say those are the only processes ever used. And the processes really are things that everyone would recognize because they are common experiences and activities of individuals that advertising goes to tries to influence all the time

In order to get people to change their behavior,

Dave: Moving them from pre-contemplative to contemplative. Interesting. Well, I often, I'm a giant fan of group, and I find that there's things that can be accomplished in the group process that the best psychoanalyst in the world can't do. And it sounds like the synchronicity that you and Dr. Prochaska had showed the leveraging of having the two of you as opposed to just one of you.

Dr. Carlo: Yes, surely did. And we've remained friends through the whole time. I was actually at his memorial service and said a few words, so

Dave: Sorry for your loss. For our loss, yes,

Dr. Carlo: Yes. A few years ago now.

Dave: Thanks.

Dr. Carlo: Okay.

Dave: Now, I looked at some of the critiques of the model, and some folks say that it's too rigid. I liked, and as I thought about it, because I see lots of clients, particularly the more challenging ones that I see, and while the stages of change, it's just kind of running in the background for what I do. While I'm making that ascertain very quickly and then what we need to do to move them along, but I don't use it. And you mentioned this when we started, when you were doing your tobacco study, it wasn't an intervention. This was measuring the stage of change, which that's such a critical delineation, this tool to me, it's critical and helpful for, but I should ask, what are your thoughts on the critique of too rigid or too linear?

Dr. Carlo: So I think a lot of people, I mean, even Bandura in the beginning kind of criticized us because he goes, well, they're going back and forth, and once you move forward, you can't move backward. I'm going that because a butterfly, a moth turns into a butterfly, it never goes back. I'm going, well, we aren't talking about moths and butterflies. The problem is that people have taken that in a rigid way and kind of made, I even say to people, let's not talk about pre, it sounds too much like a quality of the individual as opposed to a state. They're in pre-contemplation. And if you see a good motivational interviewing interview, a lot of times you'll see, I mean, bill Miller, Terry Moyers and others move someone in an interview from pre-contemplation to contemplation in 20 minutes. So it's not boxes. They aren't boxes that you put people in.

They are tasked that need to be done, and some of them can be done more or less well as you go along. And so that's the difference that I think, and we've never had it as rigid in terms of you've got to always go forward. Linear is what are our fantasy moving. I not tap you on the shoulder. You go, oh yeah, gosh, that's great. I think I'm going to decide to do this. I plan to do it, I do it, and I never look back. And as you know, that's not the way. Hey, things happen. And so our model has never been one where you can't go into contemplation, think about things and decide not to do it, and move back to freak contemplation. So you can go, no, I don't want to do this. You get people coming into treatment or whatever and they say, I rethought this. No, I don't really want to do this. And so you have movement back and forth. You have slips and other kinds of things that happen during the action phase. And then you have relapse, which I'm working on a book on relapse and recycling now trying to think through the function of failure in behavior change.

Dave: Really,

Dr. Carlo: I think we

Dave: Call it recurrence more than relapse. Trying to reduce the stigma.

Dr. Carlo: Yes. Oh, I'm excited for your new book. Yeah. So yeah, I agree with you, and I make the argument to drop the relapse idea, but most people talk about relapse, but when we were thinking about it, it was relapsed to smoking, and that's how the circle came in. So the idea that people recycle through this process, and we found that out because some people, when we were looking at people who we classified as relapsers for smoking or recurrence for smoking, we found that they didn't look like a separate group of people. Some of them looked more like people who were doing were in pre-contemplation. Some of them would look more like people in contemplation. So basically what the idea was was the recycling means that as a relapse, if I give up on this change, then I go back to one of the earlier stages, the pre-action stages of change and make until my next attempt, because we know people make multiple attempts before they're successful. Often for a lot of times,

Dave: I remember being shocked when I ran the largest treatment center in the state for years, and I always was an absolutist that you're clean and sober or you're not. And then one of my outcomes measures are like, well, good news. Our clients are consuming 25% less when there's a recurrence. And me recognizing that, wait a minute, that's actually a success. That's a success. And it's not something to be diminished, discounted, or discarded. So the fact that it is a circle, it also, it makes sense because even in whether it's sobriety or recovery or abstinence, there's ebbing and flowing in that when they're considering a relapse, oh, new year's is coming up and I'm thinking about going out. So it is certainly an ebb and flow because we're dealing with humans.

Dr. Carlo: And then I think that's the reality is you've got to always think about people moving back and forth and thinking and rethinking what their choices were in terms of making behavior changes and doing that. And again, even in our project match study, which was a large alcohol study, we started measuring instead of measuring just abstinence and abstinence throughout the whole 12 months, that was afterwards when you measure that it's 20%, maybe 30% if they get that. But we looked at percent days abstinence and drinks per drinking dinner. And so as two of the outcomes, which were easier to kind of use because it's not just dichotomous yes or no, but it also really showed that there was a lot of progress, even in the people who went back to drinking. There was a lot of progress in terms of percent days abstinence. They came in at 30% days abstinent, and they were at 70 and 80% days abstinence at the end of our treatment,

Dave: Which probably also reduced bias because when you're doing a pass fail and no, and you're reaching out to people, you're going to get, it's a lot harder to get a positive response as opposed to, well, how many drinks and how many days, or how much tobacco use in what amounts? So it probably increases your sample size, which to me is so much of a challenge. We do a lot of data tracking here at our clinic and getting six month, one year and two year follow-ups from our clients is a challenge despite everything we do on the front end and offering financial incentives, it's still surprisingly tricky in this

Dr. Carlo: Information age. And the stigma of relapse also contributes, I think, because I think there's that sense. I remember my first research project, that project I told you about, I would call these people back and say, how are you doing with your smoking? And are you still abstinent? But I would call, and I knew this was the person who I was in the study, and they would tell me, they're not home. I'm sorry, they aren't home, they're not available. I'm going, but you'd recognize them and it's you. I know it's you. Okay. But alright. But that's how they would do that. So it's interesting.

Dave: Yeah, it is. Now, I was going to ask you about the new as a M. It looks out the new as a M isn't going to include the stages of change as we now do. Do you have any thoughts about the fact that it's not in the new dimensions?

Dr. Carlo: Yeah, I mean, but they still have readiness in there, right?

Dave: Yes.

Dr. Carlo: Okay. So readiness is the whole point is how do you measure readiness? I mean, you can measure it with a one to 10 scale, you can measure it with a anyway. But I think understanding readiness for us means to kind of think about the pre-action stages. And David Lee used to always kind of talk about our stages when he presented the a m stuff. So I don't know what the thinking was behind that, but I think that stages in there, even before it was readiness, but they would always teach the stages as part of understanding the way you classify it, right? It's a way to understand readiness.

Dave: Right. Interesting. Well, I'm sure whatever a S version comes up next, the needing to measure and to classify readiness will continue as long as we're talking about behavioral change. So again, thank you. You're welcome. Now you mentioned you looked at my website and you saw that I work at Vegas Stronger. And

What I did is I ran the largest commercial rehab for about 13 years before I sold it to American Addiction Centers. And I watched them essentially take the soul out of it and ruin it. And then what I recognized was that it was we're able to deliver all the services of Hazelden or a Betty Forge or a solutions recovery to our most underserved on an outpatient basis. So that's really what we built. And I'll mention a stat right away is that I've now treated 2200 clients in Las Vegas who are unhoused. And guess what percentage of them end up having a substance use disorder?

Dr. Carlo: I going to say twenty one hundred and ninety nine.

Dave: Okay. Yeah, it was 95%. So I'm going to guess that some of them have fooled us, but it's certainly very high. And I guess I don't want to put words in your mouth. My sense is a lot of the current homelessness crisis is truly the addiction epidemic. Now, I'm not denying that there's an affordable housing crisis, but I believe that's mostly still the iceberg below the surface that we haven't seen yet, that most of our unhoused are really mental illness and substance use disorders. What's your sense from where you are?

Dr. Carlo: No, that's my sense as will. I mean, I think in the sixties we kind of did the de-institutionalization process and whatever, and we put a lot of people on the streets and we didn't come back with a substantive treatment that would enable us to hold these people together and keep them kind of from harm and do that. So I believe our treatments, I mean, I think one of the issues is our treatments are not comprehensive and intensive enough, and it's not even intensity. It's an intensity. Yeah, I was going to say duration, duration, duration being the absolute key. Exactly. Because I mean a 28 day program, well, that was the magic when I started in Syria, it was 28 day, you get 28 days once a year from your insurance company if you're lucky, unless you're Canadian, then you could kind of get them to do multiple times and nevermind. So the interesting thing is that it takes a while. If you take those three mechanisms that I talked about, it takes a long while for people to the brain to readapt from being soaked in these substances.

And we know that. I've talked to people who said, I go into treatment the first couple of weeks. I'm in treatment. I'm in a fog. I'm just trying to figure out who I am, let alone doing any of the work for recovery. And actually one guy said, it took me two months. I was in a therapeutic long, long-term therapeutic community. The first two months, all he did was walk in the woods and try and kind of get in touch with myself because that's what he needed to do in order to do the work. And again, we say about spirituality, well, you got to find some of, you got to revalue some of these things and find those. So we have treatments that are too short and not allowing people to have the space to get into the recovery. And so basically they go through revolving doors and they go back out on the street. And then drug abuse is an expensive habit. And so for the individual and for the community and certainly for the family. Exactly. And so they lose their resources. And so they're out on the street and that's what they do and figure it out. Now, some of them actually kind of prefer to be out there because they can live the life they want to live without being bugged by a lot of other people. But that preference I think is a negative preference. It's not a positive preference.

Dave: I question their agency because to me, I do homeless outreach all the time. And what I'll talk to someone saying, no, I want to be here. I get the feeling if I do a motivational interview session with them for a period of time that that's not true, that that's a defense mechanism that they're using. Especially I'm in Las Vegas, we had a hundred days where it was north of a hundred degrees. It is too hot to be laying in the rocks or in the bus terminals in our city. So when somebody tells me that they want to be there, I call bs. Yeah, I think

Dr. Carlo: I call it latent motivation more.

Dave: It's a little different.

It's interesting. Also, I ran the largest managed care company in the state before I got into the treatment side. So I was the president of the HMO and insurance company. And my penance for doing that is that I have to arm wrestle with them on a regular basis now, and many of them, they'll allow a three week stay in an outpatient setting. And I, on a regular basis will explain, I have somebody who's been using fentanyl for eight years, they've been homeless on the streets for eight years. We're not going to develop new neural pathways. I'm barely going to have them functioning three weeks in and that I'm trying to show them that the math works. If you allow me to treat 'em for four months, for five months, for six months, the math works. You're going to have way less hospitalizations. You're going to have way less just cost to the community that it's an investment That makes sense.

But something that I rarely pass up an opportunity to get on my soapbox is that our clients are never going to advocate for this. This falls on us as clinicians. As educators. We are the ones who have to carry this albatross to the managed care companies that advocate for them to do longer treatments, longer treatment episodes, because you had said 30 days than two months. And then longer, in my experience, I was two years of engaging every day and going through processes before when my wife said something mean to me or I stubbed my toe that my first thought wasn't drink. Jack Daniels, that I had had 20 years of ingrained neural pathways and behaviors that it absolutely changes. And I'm so grateful that change exists. But it takes, and I don't know if I was a hard or nut than most, but it certainly took more time for me

Dr. Carlo: Than three weeks. I mean, it depends some on the resources that you have and the social capital that you have and all that kind of stuff that might help you a little more or less. Many of these folks that are homeless don't have a lot of that social capital. And so that's not there. But it's really important to kind of, so the neuroadaptation part is one piece, the behavioral self-regulation piece is the other. And we think of action as taking three to six months

So you don't move into maintenance until after three to six months of really having made the change because it takes three to six months to create the new pattern. And we found that, I mean, we interpreted that from the relapse curves. If you look at the relapse curves, the first three to six months are tremendous. People drop off like crazy and then they level off at about six months. And there's still relapse after that, but it's much less. And so I think you have to look at the shape of the change and duration of the change. And like you said, I mean in the early phases of action, you meet a lot of all the regular things that happen to you, but you haven't been through New Year's, you haven't been through a 4th of July, you haven't gone through a football game and done sat outside and did the pre-gaming and all of that. So you do have intensity and frequency kinds of cues that I think you have to kind of learn how to manage over the long haul in order to make the change and be significantly into recovery and be able to sustain that over time.

Dave: Neurological, behavioral, spiritual.

Dr. Carlo: Yep.

Dave: Yeah.

Dr. Carlo: Well foot. So for the behavioral part, I think I have a concept that I've been using that when I'm doing talks and stuff is scaffolding. So if you think about scaffolding is a developmental kind of thing where with little kids, you scaffold them, you help them, you put your fingers out while they're walking and trying to take a step here or two and you kind of help them. But that's called scaffolding. It's helping them move to the next developmental level by supporting them through that. And I use it in terms of scaffolding, the self-regulation skills. So some of the people like you're seeing, basically we need to build supports around them in order to help them relearn how to self-regulate and deal with that. So I mean, AA is scaffolding.

If you go to those meetings and you attend those, whatever, you have a group around you that continues to support you, and you may have wanted to go out and have a drink that day, but you went to the meeting instead and you heard somebody talk and you kind of go and that scaffolded your self-regulation so that you're now doing okay, you didn't go back, right? Have a drink. So we need to also think about how do we do that? And I think that's the housing issue that I think you were talking as well. I mean, how do you scaffold people into places to live? I mean, I did see there are several projects that I saw in various states that are actually trying to build really one room places that they could live in, one room, apartments and those kind of things that people can live in and be independent but not have to pay lots of money and do all stuff to get a place to live.

Dave: I often support congregate, sober or supported living then independent living as a progression. Sadly, with some of the housing first initiatives, I'll have clients who come in, they're doing great for two weeks, and then all of a sudden the case manager will say, your name came up on the housing list. They'll hand them keys to their own apartment and most of the time we just never see 'em again. So what we do is we remove any of their motivation to change and the work isn't done yet. That's why I like congregate, transitional, sober and then moving them to permanent independent.

Dr. Carlo: And even in independent David, I work with a group that does a lot of dual diagnosis and basically, I mean, they have an ACT team that even when they're independent, the ACT team goes to the apartment, talks to the person, make sure they're making food, helping them to figure out how to do grocery shopping and doing some of the things that are really important to really be able to live independently.

Dave: Well, that makes sense

Dr. Carlo: And

Dave: Makes sense. So on independent living, you could still have a degree of scaffolding, the most minimalistic, invasive of the various stages. Oh, that makes sense. Wow. I like you. I doing too, David. Oh, thank you. The title of our podcast, I call it human up, and I'd like to know what does that mean to you? What you think about when you hear that?

Dr. Carlo: Well, I thought about uplifting people and that would be what kind of uplifting humans. The other thing that strikes me is bringing back up the humanity of people who we are treating, because I do think that's a real important piece that again, with all the language that we're trying to clean up and everything else, I mean the humanity of the people who are struggling with these substance use and mental health disorders sometimes gets lost and we get frightened of them or we get upset about them or we kind ignore them. And so human up may kind of have a important kind of way to think about focusing on the humanity of these folks.

Dave: Thank you. I love that. And I appreciate that you recognized how often our social safety net doesn't operate with a level of dignity and the humanness. I talk about the fact that within the homeless in camps, they have a sense of community and they can often use drugs with impunity and expecting them to leave a camp to come to a shelter. When they get to the shelter they're sneered at, they're told to get in line, they're not talked to in a human way. We're trying to have the off ramp from these camps be a much higher hurdle to get into the social safety net. And that a leveling, particularly why like a recovery oriented system of care with many peers who are able to connect with people and treat people with respect as well as services. So we could get 'em closed, we help 'em get to a bed. And doing all of those things in a human way. It's so important for us as a country, as we're looking for system systemic approaches to address our homelessness crisis. Yeah, I called it human up because I was raised in the sixties and seventies, and if I was drinking too much, I was told I should man up the approach, which didn't work at all. And that we all need to human up. Yeah, interesting.

Dr. Carlo: That's a

Dave: Nice phrase. Yeah. Thank you. I value your time so much. This has been 50 minutes on the button. Thank you so much for spending almost an hour with me. Anything else?

Dr. Carlo: Good luck on your work, and I really appreciate that. This is where the rubber hits the road, and I think it's really important that we have people like you out there doing some of this and carrying so much for these folks. Thank you.

Dave: Alright, thank you. If you're ever in Vegas, you’ve got a friend. 

Dr. Carlo: Okay!