Changing for Good

by James O Prochaska

  Furthermore, any movement from one stage of change to the next represents considerable progress. If, after years of avoiding a problem, you consciously begin to acknowledge it exists, and think seriously about changing it, the transition from precontemplation to contemplation is no less significant than from preparation to action. As you will soon see, action, as important as it is, is neither the first nor the last stop in the cycle of change.

  Maintenance

  There are great challenges at every stage, and the maintenance stage is no exception. For it is during maintenance that you must work to consolidate the gains you attained during the action and other stages, and struggle to prevent lapses and relapse. Change never ends with action. Although traditional therapy sees maintenance as a static stage, in fact it is a critically important continuation that can last from as little as six months to as long as a lifetime.

  Without a strong commitment to maintenance, there will surely be relapse, usually to the precontemplation or contemplation stage. I know a thirty-nine-year-old single parent who, after years of abusing alcohol and marijuana, had remained sober for more than a year. However, she knew she was at continued risk of relapse, so she consciously provided herself with distractions to lower her temptation to drink when she felt distressed; she practiced an active and intelligent maintenance. Another recently reformed drinker I treated kept a bottle of booze in his desk drawer, to “remind” himself, he claimed, and to “test his willpower.” It wasn’t long, of course, before his willpower knuckled under to temptation.

  Programs that promise easy “change”—through crash diets, one-day smoking cessation sessions, or whatever—usually fail to acknowledge that maintenance is a long, ongoing process. Millions of people have lost many pounds through various trendy diets, but regain the original weight (and often more) over the next few months. We all know someone like our middle-aged friend, who enrolled in a weight-control program and summarized: “It’s easy to lose weight. I started out at 155 pounds, and have lost 160 pounds in the past four years!” Her failure to consolidate the benefits of the action stage is typical of participants in change programs that ignore the importance of maintenance.

  Termination

  The termination stage is the ultimate goal for all changers. Here, your former addiction or problem will no longer present any temptation or threat; your behavior will never return, and you will have complete confidence that you can cope without fear of relapse. In the termination stage, all of this holds true without any continuing effort on your part. You will have exited the cycle of change and won your struggle.

  There is a lively debate about termination. Some experts believe that certain problems cannot be terminated but only kept at bay through a life of decreasingly wary maintenance. Certainly one can terminate cigarette smoking. There are people who smoked heavily for much of their lives and stopped, eventually feeling absolutely no temptation. On the other hand, there are people who remain in maintenance, craving cigarettes fifteen years after they quit smoking. We shall explore which types of problems can be terminated and which types require a lifetime of maintenance.

  THE SPIRAL MODEL OF CHANGE

  When Carlo and I first identified the stages of change, we believed that self-changers moved consistently from one stage to the next. Our plan was straightforward and linear:

  Precontemplation → Contemplation → Preparation → Action → Maintenance → Termination

  But things did not turn out so simply.

  Linear progression is a possible but relatively rare phenomenon. In fact, people who initiate change begin by proceeding from contemplation to preparation to action to maintenance. Most, however, slip up at some point, returning to the contemplation, or sometimes even the precontemplation stage, before renewing their efforts. The average successful self-changer recycles several times. Most people who quit smoking, for example, report three or four serious attempts before they succeed; New Year’s resolutions are typically made for five consecutive years or more before resolute changers achieve the maintenance stage.

  Don’t be discouraged; read on and you will see how those who keep trying do finally succeed. Completing the challenging journey from contemplation through to termination requires ongoing work, the development of a relapse prevention plan, and continuing application of the appropriate processes of change.

  The plan outlined in this book represents what we believe to be the best method to bring about the desired changes in yourself. However, despite everyone’s best efforts, relapse remains the rule rather than the exception when it comes to solving most common problems. The feelings relapse evokes are not pleasant. You may feel as though you have failed completely; you are probably embarrassed, ashamed, and guilty. You may feel that all of your hard efforts at change have been wasted. Demoralization sets in, and you may want to give up on changing entirely; you may slide back all the way to precontemplation.

  Several such setbacks may make you feel as though you are going around in circles rather than solving your problem. And, to some extent, that is the case, but the good news is that the circles are spiraling upward. A successful self-change is like climbing the Leaning Tower of Pisa: First, you walk up, but as you approach the lower part of each floor, you begin to head down. A few steps later you resume your ascent.

  In Chapter 2 is a graphic representation of the pattern of change; most successful self-changers go through the stages three or four times before they make it to the top and finally exit the cycle.

  The vast majority of people struggle for years to find effective solutions to their problems. They try not to become demoralized by failure, although sometimes they feel they will never change. They are embarrassed or frustrated when someone comes along and tells them, “I quit smoking years ago. It was easy.” In our studies, we did locate some people who were able to change with no false starts, no failures, and no relapses. But they are rare. Of the contemplators we followed for two years, only 5 percent made it through the cycle of change without at least one setback.

  FIGURE 1. The Spiral of Change

  The vast majority of relapsers—85 percent of smokers, for example—do not go back all the way to precontemplation, but return instead to the contemplation stage. Very soon, they begin to make plans for the next action attempt, internalizing the lessons they have learned from their recent efforts. That is why we prefer the term recycle to relapse. The return to contemplation can be an auspicious, even an inspired time for continuing to change. Recycling gives us opportunities to learn. Action followed by relapse is far better than no action at all. People who take action and fail in the next month are twice as likely to succeed over the next six months than those who don’t take any action at all.

  As soon as we had good data on the stages of change, and the processes that bring it about, we were ready to ask the big question: Was every process equally useful at every stage, or were some processes more effective at one stage than at another? Although we weren’t sure what the answer to our question would be, we did know that the answer would be interesting and valuable to everyone in the field.

  CHAPTER 3

  Making Changes

  CARLO AND I solicited subjects for our first round of interviews by advertising in the local newspapers. As luck would have it, a psychology professor at Brown University, Rhode Island (a man not known to us), saw the ad. He called us to ask if we knew that the National Institutes of Health (NIH) was looking to fund exactly the kind of research we had already begun to do.

  Smoking is a costly national problem. Heavy smokers are at great risk of developing emphysema, lung cancer, and various cardiovascular diseases. The cost of the medical care these individuals must eventually receive is a national burden. The NIH wanted ultimately to discover why most professional smoking cessation programs do not work, so that they might institute programs that do work. It made sense for the NIH, therefore, to encourage researchers to find out how people were able to quit smoking on their own; it was hoped that the d
ata would lead to a useful model of change that others could emulate. And this is exactly what happened.

  We obtained from the NIH a copy of its announcement seeking to fund research on self-change approaches to smoking cessation. Their requirements were tailor-made for our project. Even though the necessary applications were due in two weeks, we managed to produce a proposal of 160 pages! The NIH scored us very highly, on the strength of a study we ran on two hundred people who had tried to quit smoking, and funded five of the several projects we suggested.

  By this time Carlo was practicing in Texas. John Norcross joined us (when still a doctoral student) in our efforts to follow, over a two-year period, one thousand people who were trying to stop smoking by themselves—five hundred in Texas, and five hundred in Rhode Island. Simultaneously, we collected data from eight hundred people who were attempting to lose weight, some by themselves, some by enrolling in weight-control programs.

  We had progressed from primitive interviews to sophisticated studies and complex data sets. When eventually we fed all the reports through our mainframe computer, the result was a chaotic table of numbers. The numbers told us clearly that there were highly significant differences in how frequently people use the various processes at particular stages of change. There was less than a one in ten thousand chance that these differences were random.

  The differences made no sense. I couldn’t detect any meaningful relationships among the ten processes we had measured, and the five different stages under consideration. Imagine a table with five stages times ten processes: fifty different scores with no predictable pattern. Processes I expected to be used in the contemplation stage were used just as much by relapsers, who also used processes. I thought were exclusive to the action stage, My data analyst announced that the study was a bust. He said that my belief that I could use the stages of change to integrate the powerful change processes from competing systems of psychotherapy was not supported by the numbers.

  For months I felt lost, like one of my clients facing the wilderness of change and having no idea how to proceed. Maybe change truly was a random affair. Maybe trying to find a predictable pattern to human behavior was like trying to play the stock market scientifically and systematically, when the evidence proves that throwing darts at the stock page is likely to be just as profitable.

  Night after night I studied the silent numbers, willing them to talk to me. I remembered how Freud had once complained about his brain not being big enough. I was reminded of my first research project in graduate school. Day after day I glared at my results, unable to interpret them, much less write them up.

  In grad school I knew my data were garbage, based on a study that was hopelessly confounded. But now I was not faced with a fouled-up semester assignment. I no longer had to satisfy a dreaded authority figure. There was only myself to face—and the feeling that my life’s work had been fundamentally unsound. Just when I was ready to despair I had an idea. About 1:00 one morning, I decided to remove the group of relapsers from the data. Relapse had not been part of our stage model. Maybe relapse was messing up our results the way it so often messes up people’s efforts to change.

  Once I removed the relapsers everything became clear. Just as I had hoped and believed, there were systematic relationships among the stages and the processes of change. Table 3 represents the integration occurring among the processes most often used by successful self-changers at different stages. I woke Jan up at 2:00 A.M. to share these exciting results with her. Her sleepy response was, “Jim, I’m happy for you. Now get to bed.”

  I’m not sure what happened that night. Empiricists would insist that I had discovered relationships that were inherent in the results. Constructivists would argue that I had created the patterns myself and superimposed them on the results. From this perspective, other patterns could just as readily have been constructed. After ten years I still don’t know whether I discovered these relationships or constructed them. I also don’t know if it makes any difference. If the pattern holds, as this one has, across a wide range of data on self-changers, then who cares where the pattern comes from? It has provided a model of change that thousands of individuals have found useful. That’s enough for me.

  LEARNING FROM SELF-CHANGERS

  Self-changers, never having been limited by strict theoretical or philosophical arguments, have always sought the change processes that work, and have been remarkably effective in discovering and using all of them.

  Once we had evidence that the processes were at their most useful during specific stages of change, we went on to test this new linkage. The results clearly confirmed that the successful completion of certain stages was linked to the use of certain processes. Consciousness-raising, for example, is heavily relied upon by contemplators, as is emotional arousal. Self-reevaluation begins in the contemplation stage and becomes critically important in bridging movement from contemplation to action during the preparation stage. Each stage is best served by certain processes. Figure 2 shows the importance of several processes as measured during one group’s progress through the different stages.

  This discovery has enormous implications. The wisdom of successful self-changers has finally been understood, and can now serve as a field guide for anyone who wants to change, with or without professional help. For once an individual knows the stage he or she is in, this is the time to apply the necessary processes to progress to the next stage. Some understanding of the cycle of change exists; some control can finally be had over moving through it.

  The matching of process and stage is one key strategy this book gives to the dedicated self-changer. You do not need to learn a new series of techniques every time you want to change a behavior. You do not need three self-help books, three therapists, or three programs to solve three problems. In fact, there is some evidence that it may be more efficient to apply the processes to more than one problem at a time, rather than to try to change problem behaviors one by one. We are in the process of gathering more data on whether simultaneous or sequential change is more beneficial.

  Figure 2. A group of smokers’ use of three different change processes as they progressed from the contemplation stage to the maintenance stage, Notice how consciousness-raising is used most at the onset of change, whereas social liberation is more prevalent in the middle, and reward at the end of change.

  Undesirable behaviors, it seems, travel in packs and nourish each other. The single most frequent reason cited for relapse to alcohol, food, or tobacco abuse is emotional distress; former smokers who drink double their chances of renewing their habit; and weight gain is one of the most frequently cited results of quitting smoking (and one of the primary reasons women give for returning to smoking). Many successful change efforts focus on a group of behaviors rather than isolating one at a time—which bodes well for anyone who wants to stop smoking but fears gaining weight, for those who want to stop drinking but do not want to increase their dependence on tobacco, and so forth.

  At first, the simplicity of our model was seen as a weakness. In truth, even we were surprised to find that the integration of stages and processes described all kinds of change, not just one or two. Experts continue to tell us, “It’s a very nice model, but it will never work for my special problem.” (This comment is also frequently made by skeptical self-changers. You may, in fact, be feeling that way right now. Please read on.)

  Our response has been to test our model of change—and to allow others to test it—in all types of situations. It has always held up. More than one thousand people suffering from emotional distress (a combination of anxiety, depression, and lowered self-esteem) reported to us on their attempts to change with and without therapy. Our studies of one thousand psychotherapists investigated how these well-trained experts tried to solve their own problems with psychological distress, alcohol abuse, and cigarette smoking. An equal number of therapists told us how they attempt to help their clients overcome similar problems. All told, our studies on change have involved mo
re than thirty thousand people. (The Bibliography provides full references for most of these studies.)

  At this writing, our model is being used by the National Institutes for Alcoholism and Alcohol Abuse; the National Cancer Institute (in a telephone hotline set up for smokers attempting to quit); the Centers for Disease Control (in several projects aimed at HIV/AIDS prevention); Johnson & Johnson worldwide; the American Lung Association; and the American Cancer Society. In Great Britain, the National Health Service is training its employees to use the model to help smokers, drinkers, and drug abusers to quit, and to help people to improve poor eating habits. The World Health Organization is also considering adopting the model. It is part of ongoing projects in Finland, Sweden, Australia, Poland, and Spain. It is also being applied to encourage exercise, and to reduce drug, tobacco, and alcohol abuse, emotional distress, overeating, and more. (Appendix B outlines other applications and advantages of this “new paradigm” of behavior change. In all of these projects, the model holds up so well that its simplicity is now seen as its strength.

  Our model also addresses a disturbing and little-known fact that therapists have come to regard as natural and unavoidable. Fully 45 percent of people who make an appointment with a professional therapist drop out of therapy after only a few sessions. They often don’t show up in the data sets of success and failure rates of different therapeutic approaches. The thinking has been that since these people never really tried the therapy, they should not be counted—and this isn’t a wholly indefensible idea. What is indefensible is that therapists often vilify the dropouts, labeling them “unmotivated,” “resistant,” or “not ready for psychotherapy,” and give up trying to understand them.