Changing for Good

by James O Prochaska

  Making the least of it: Denial and minimization

  Probably the most common defensive reaction, denial allows us to protect ourselves by refusing to acknowledge unpleasant occurrences. From time to time, we all pretend that disagreeable realities, such as pain or danger, simply do not exist.

  I had one client, Harold, who went through so much money he was nearly bankrupt. To make matters worse, he was on the verge of losing his job for the third time in four years. His violent temper terrified his children, who no longer wanted to be around him. His wife was considering leaving him. Yet, convinced that life was fine, he continued to pour all of his energy into his skiing club and none into his work or his family. As far Harold was concerned, “I’m coping perfectly well with all the stresses in my life. It’s my wife who can’t cope.” He felt she was trying to take away his freedom and his fun.

  Precontemplators love denial. Despite all evidence to the contrary, they can’t admit to their problems. Alcoholics are especially well known for denial. I have encountered people faced with physical evidence of their intoxication, who still swear that they have not touched a drop. Problem drinkers also minimize, a form of denial: “Maybe I do drink a little too much, but I can handle it,” they say, despite the fact that the incidence of job loss, liver disease, and divorce among alcoholics proves the opposite.

  Denial filters out information that might help these people change. As a result, they are often surprisingly uninformed about the behaviors that others consider problematic. A thirty-seven-year-old nurse named Carol, who had smoked for twenty years, refused to believe that cigarettes could kill her. Even though she was in the health field, Carol truly did not know that smoking is the most preventable cause of death in the United States, one that claims 400,000 lives a year. “I just always insisted,” she says, five years after quitting, “that the medical experts were still debating the effects of smoking.”

  “Good excuses”: Rationalization

  When we rationalize, we offer plausible explanations for our behavior. Even if that behavior is immature or irrational, we justify it in rational, adult terms. Our rationalizations may appear sound to us, but they are full of holes.

  Every evening, Maureen spent more than an hour getting her eight-year-old daughter ready for bed; in the middle of the night, she allowed the child to crawl into bed between her and her husband. She drove her daughter to and from school every day instead of letting her take the bus with the other children. When friends and family members expressed their concern about Maureen’s doting, she coolly told them to mind their own business.

  Maureen’s rationale for giving in to her daughter’s every demand was, “My mother was much too severe, and never indulged any of my needs when I was a child.” An overly restrictive mother does not provide a good reason for erring in the opposite direction with one’s own child.

  Nonetheless, rationalization is extremely common. The phenomenon is best expressed by this amusing conversation from the movie The Big Chill:

  “Don’t knock rationalization. Where would we be without it? I don’t know anyone who’d get through the day without two or three juicy rationalizations. It’s more important than sex.”

  “Oh, come on. Nothing is more important than sex.”

  “Oh yeah? Have you ever gone a week without rationalization?”

  Rationalization’s cousin, intellectualization, refers to the use of abstract analysis to rob events of personal significance. The intellectualizer is able to avoid emotional reactions to and painful awareness of his or her problem. Most of the reasons people give for remaining addicted to nicotine and alcohol are intellectualizations: “I need one vice, so it’s cigarettes,” say some smokers, although, of course, no one “needs” a life-threatening behavior. “My uncle drank a pint of whiskey a day and lived to be ninety!” say some heavy drinkers, although, in general, alcoholics shorten their average life span by twelve years. “That cancer stuff has only been proven in rats smoking the equivalent of eighty packs a day”—such ideas are disseminated by the tobacco industry, which interprets quite convincing studies in a shamelessly misleading style.

  Turning outward: Projection and displacement

  When we are unable or afraid to display our feelings toward the true source of our problems, we may redirect them against someone or something else. This defense involves transferring the source or object of pain to anything other than the self. “The best defense is a good offense” is the slogan of people who turn outward.

  Carl had been abusing alcohol and drugs for a dozen years. His third wife, Beth, confronted him early in their marriage about his problems, but he didn’t want to hear about them. So he began to criticize Beth. She had grown up with a hypercritical mother, and had always striven to be perfect; she couldn’t stand the criticism. Carl tied Beth up in knots, making her face one imaginary problem after another while losing sight of his own problem. Meanwhile, Carl continued to drink and use drugs, free from interference.

  Carl’s systematic attack on Beth is an example of displacement. Also known as scapegoating, displacement is a form of turning outward, in which we take out our anger, depression, or frustration on a substitute object or person, one that is available and safe to attack. Another form of displacement, known as projection, occurs when we diagnose in someone else those problems that we carry ourselves.

  Turning inward: Internalization

  We can also turn feelings inward, believing not that others caused us pain, but that we ourselves created the problem. By turning inward consistently and failing to express negative feelings appropriately, we begin to internalize, or “swallow,” these feelings. The result is habitual self-accusation, self-blame, low self-esteem, and sometimes depression.

  Irene had this habit. After dating for five years without, as she put it, “a success” (getting married), she began to view herself as “a hopeless old spinster,” even though she had just turned twenty-five! Frustrated with the dating game, Irene was internalizing the blame, beginning to feel and act hopeless. Thus began a vicious cycle: Irene didn’t feel wanted, so she acted as though no one would want her, which decreased the chances of anyone expressing serious interest.

  Resigned, demoralized precontemplators, who are aware of a problem but have given up doing anything about it, frequently turn inward. They say, “I can’t do it.” Their feelings of inevitable failure protect them from trying to change, and as long as they cling to their belief that they can’t change, they probably won’t. The defense works like a charm, but an unlucky one indeed.

  HELPING PRECONTEMPLATORS

  Part of the problem of keeping a program of research moving in a field that lacks consensus is that there is no agreement as to what should be studied next. Sometimes our sponsors pressured us to implement programs before we felt ready. The National Cancer Institute was so intrigued by our early studies of self-changing smokers that they requested we develop applications as we went along with our research, rather than waiting for all our data to come in.

  Their request was sensible—500,000,000 people alive in the world today will die ten years before their time, on average, because of tobacco use. And other self-change programs have limited impact. We believed then (and have since demonstrated) that this is because such programs do not take into account the stages of change. For example, more than 70 percent of eligible smokers in a major West Coast health maintenance organization (HMO) claimed that they would participate in an upcoming home-based self-help program. However, when an excellent action-oriented program was developed and publicized, only 4 percent of the smokers signed up for it.

  Even if the program had been successful with a third of its participants (which is an overgenerous estimate) its impact on the population of smokers in the HMO was paltry.

  So we were asked to develop a program that would do better, that did take the stages of change into account. Because we did not yet have all the data we needed, there would be some kinks to iron out as we went along, but anyth
ing we could do to get a stage-matched program up and working would be valuable. How, we wondered, would we ever lure precontemplators, the people who by definition resist change? How could we reach people who were unaware of or defensive about their problems?

  We found that a newspaper advertisement worded to appeal to those in the contemplation stage drew two hundred calls for our self-help materials. Different ads generated responses from about the same number of people in the action and preparation stages. We had to experiment with the precontemplators. We ran an ad asking for participants in a self-help program for “smokers who do not wish to change.” Surprisingly, this advertisement—exactly the same size as the others—drew four hundred precontemplators.

  And compare our program’s success rate. In a stage-matched program at the largest HMO in New England, designed to meet the needs of all smokers—even those not yet ready to change or only just getting ready—we got a participation rate of approximately 85 percent. If this program had only a 20 percent success rate (the study is still in progress, but this estimate seems to be low), it means it had a 15 percent impact rate on the population, or one thousand to five thousand times greater than that achieved by traditional programs.

  No one wanted to look at impact rates before because participation rates were so low. This is not surprising, considering that the vast majority of programs are designed to help only that small minority of people who are ready to take action. According to data from representative samples, fewer than 20 percent of any problem population are prepared to take action at a given time.

  At one western HMO, when administrators discovered subscribers were avoiding the action-oriented program they had developed, they decided to go all out to persuade smokers to participate. Their doctors showed smokers a videotape detailing the horrors of smoking and the glories of quitting. The HMO nurses spent an unusually long time telling smokers what good medicine for them quitting would be. They followed up with telephone counseling calls pressuring smokers to sign up for the program. Thirty-five percent of their precontemplators did sign up, but 3 percent actually showed up, and only 2 percent finished.

  As Abraham Maslow once said, if the only tool you have is a hammer, then you have to treat everything as if it were a nail. Although we hadn’t expected to be developing treatment programs so quickly, we couldn’t help but be pleased at how successful they were. And our programs were successful precisely because we first took the trouble to ascertain what tools were needed. In one sense these tools (the processes of change) were already in the toolbox, but till now nobody had known when exactly to use them. Let’s take a look at some of the tools that precontemplators find most helpful.

  CONSCIOUSNESS-RAISING

  The first step in fostering intentional change is to become conscious of the self-defeating defenses that get in our way. Knowledge is power. Freud was the first to recognize that to overcome our compulsions we must begin by analyzing our resistance to change. We must acknowledge our defenses before we can defeat or circumvent them.

  Increased consciousness, whether it comes from within or without, is invaluable. Many precontemplators lack the information to perceive their problems clearly. Like a flashlight in a dark library, consciousness-raising makes that information available. As is the case with all the processes of change, there are many different techniques that can be used to increase consciousness. You can gather information by reading, or by watching an informative program on television. You can explore the interpretations of your behaviors that friends or therapists suggest.

  Sometimes awareness of a problem comes quickly. Ellen, a fifty-year-old fashion designer, had been obese all her life, carrying some two hundred pounds over her ideal weight. She had made a few halfhearted attempts to lose weight, but never really saw her obesity as a problem. “My husband always made me feel attractive,” she reported. “And because I had my own business, other people did things for me, so I didn’t have to move around much.”

  A visit to her doctor made all the difference. “When my doctor said, ‘I don’t want to scare you, but…’ that was it.” His words confirmed her escalating fears: “I could see I was dying; my sugar level and blood pressure were sky high, and my ankles were enormous.” Within weeks, Ellen had decided to lose all of her weight, and two years later she had achieved her goal.

  Some consciousness-raising techniques can be used in everyday life. Once, when teaching a class of three hundred students, I developed a habit of ending sentences with the phrase “on it,” in much the same way some people say “you know.” I would say things like “Freud is the second most famous psychologist of all time, on it, and Skinner is now the most famous, on it.” I was unaware of the problem until a freshman had the nerve to confront me about it. I tried to interpret what “on it” meant to me, but could not discover any deeper meaning. Without increased awareness, however, I could do nothing about this irritating habit. Eventually, I asked my class to raise their hands whenever I said “on it.” With three hundred hands making me fully conscious of this habit, I changed in record time.

  Becoming aware of defenses

  Although consciousness-raising does not usually result so quickly in change, becoming aware of a problem behavior remains the first step in changing it. Accordingly, the first step in countering defenses is becoming conscious of what they are and how they operate. Below are a few examples that should help reveal which defenses you use most frequently. Try and pick out which responses represent which defenses commonly used by precontemplators.*

  Situation: You are waiting for a bus on a city corner. The streets are wet and muddy after the previous night’s rainstorm. Suddenly a taxicab sweeps through a puddle in front of you, splashing your clothes with mud. Possible responses:

  I wipe myself off with a smile as though it didn’t really happen.

  I just shrug it off. After all, things like that are unavoidable in the city.

  I yell curses at the taxi driver.

  I scold myself for not having worn a raincoat and protecting myself.

  I let the driver know that I don’t really mind, it was no big deal.

  I let the driver know that bystanders have their rights too.

  I begin to chase after the taxi, throwing whatever objects I can find.

  I mentally kick myself for standing too close to the edge of the street.

  Responses 1 (“it didn’t really happen”) and 5 (“no big deal”) illustrate denial and minimization. Responses 2 (“these things happen”) and 6 (“bystanders have rights too”) are examples of rationalization and intellectualization; these answers circumvent emotional hurt by intellectually justifying the situation. Responses 3 (yelling curses) and 7 (chasing and throwing objects) clearly show turning outward against the object. Responses 4 (“I’d scold myself”) and 8 (“I mentally kick myself”) exemplify turning inward.

  Checking our defenses

  Although no one relies on one personal defense forever, we tend to be consistent. John Norcross, for example, is a wonderful intellectualizer, always ready with explanations to justify problematic behaviors. Here is a typical conversation between himself and a friend:

  FRIEND: Hey, John, I notice you’re putting on weight.

  JOHN: Yeah, not enough exercise. I’ve been too busy writing.

  This response sounds plausible enough, but does not directly address the problem (putting on weight), instead shifting the blame to something else (writing). If we look a little more closely at John’s life, we see that he uses this defense in a variety of situations:

  NANCY (John’s wife): John, I notice that you’re spending an awful lot of time in the office and less with us.

  JOHN: Yeah, not enough time. I’ve been too busy writing and seeing patients.

  By examining his own defenses, John made an important step in moving toward contemplation in changing his problems with weight control and overwork. After all, we are not completely governed by our defenses, merely guided by them. Simple awareness of our “men
tal tricks” helps us to gain a measure of control over them.

  In fact, all maladaptive defenses can be transformed into positive behaviors with awareness and practice. Throughout the course of this book, you will learn techniques to transform defenses into coping mechanisms. Table 5 gives a few examples of these transformations.

  Consciousness-raising self-assessment

  For each process of change, we will provide you with a brief self-assessment. These checkpoints are powerful tools for information and self-correction. The information these assessments yield can dramatically increase your chances of moving into the next stage and thus successfully reaching termination. We emphatically recommend that you take these self-assessments, and take them seriously. Be honest and realistic. You must engage in these processes to move forward; if you mislead yourself, you will impede your progress.

  Fill in the number that most closely reflects how frequently you have used the method in the past week to combat your problem.

  1 = Never, 2 = Seldom, 3 = Occasionally, 4 = Often, 5 = Repeatedly

  FREQUENCY:

  ____ I look for information related to my problem behavior.

  ____ I think about information from articles and books on how to overcome my problem.