Changing for Good

by James O Prochaska

  TABLE 7. SAMPLE FUNCTIONAL ANALYSIS

  Antecedent →: Stress Fatigue Social discomfort

  Behavior →: Smoking

  Consequences: Satisfaction Relaxation Calm

  An ABC functional analysis helped a forty-four-year-old teacher get to the bottom of his nicotine addiction. His craving always occurred when he was exhausted or stressed during a hectic day at work, or when he was uncomfortable at a social function. Once he discovered the true antecedents and consequences of his need for cigarettes, he became aware that he didn’t smoke—as he had always claimed—because he “liked the taste.” Rather, smoking functioned for him as a kind of sedative.

  Try taking one of your problem behaviors and listing its typical antecedents and consequences. Table 7 presents a sample functional analysis for cigarette smoking. To be most helpful, your functional analysis should focus not only on the external events that precede and follow a behavior, but also the internal events that may be controlling it. Pay attention to what you tell yourself before engaging in an undesirable habit. Just before you ate that piece of cake, did you tell yourself, “This will make me feel better”? Before starting on a weekend binge, did you declare, “What else are weekends for?” Prior to getting depressed, did you ask yourself, “Am I some kind of idiot?” Are angry outbursts at your husband preceded by thoughts such as, “He’s just like my father”?

  These types of statements, which trigger problem behavior, may be so automatic or unconscious that you are not even aware of them. To increase your awareness, ask yourself, “What am I telling myself that leads to engaging in this problem behavior? Am I giving myself unconscious permission to indulge?”

  Many people can control their problems at work, but their controls go to hell when they return home in the evening. They eat sensibly all day long, for example, but pig out at night. What self-statements help them to justify this lack of control?

  I’m home and I can do whatever I want.

  There’s nothing I have to do for others now, so I can indulge myself.

  I just need to escape from reality.

  After all I’ve done today, I deserve this.

  Make a written list of the statements you make to justify your problem behavior. You may be surprised, and you will certainly move toward taking action.

  What is the payoff for indulgence? There is the pleasure of gratification, of course. Look at all the other reinforcements that can be gained from a single act of self-indulgence in a consumptive behavior. First, there is pleasure—mmm, mmm, good! Then, there is often a very real reduction of stress; letting go of ego controls can feel like a break from the hassles of everyday life. Also, indulging a vice can feel naughty but nice. And finally, there comes a feeling of freedom in doing what you want to do—and to hell with the consequences!

  How wonderful it would be if most problem behaviors did not exact a heavy toll. One barely delayed consequence of self-indulgence, however, is that often we end up saying, “I shouldn’t have eaten so much,” “I shouldn’t have wasted so much money,” “I shouldn’t have smoked that cigarette,” “I shouldn’t have been so anxious.” In short, “I shouldn’t let one part of me take over the whole of me. That part becomes like a demon I can’t control.”

  Functional analysis involves us in two long-standing psychological controversies: How deep should we search for the unconscious antecedents and consequences of our behavior? And how far back in time should we go in analyzing these triggers and payoffs? Psychoanalysts say we need to go to the core of our unconscious, a journey that often takes us to our earliest childhood experiences. Behaviorists, on the other hand, say we should examine events in the immediate environments that precede and follow our problem behavior.

  What should a self-changer do? Unburdened by ideologies, successful self-changers tend to go as deep into unconscious events as they can on their own, and as far back in time as they believe is relevant to their particular problem. Sometimes, these explorations are far-ranging.

  A forty-eight-year-old housewife was well aware that she often responded to her husband as if he were her father. He knew it too, and occasionally said, “I’m not your father. Quit treating me like him.” Over the years, she realized that she was projecting some deep-seated resentments she felt toward her father onto her husband. Gradually, she began to accept that she needed to face the unresolved conflicts with her father in order to improve her marriage. She went to her father’s grave and pounded her fists on the earth, expressing rage at his abandonment of her at a young age.

  Most self-changers, however, focus simply on the events preceding and following their problem, and on their internal reactions to these events. For that reason, we encourage a functional analysis that stays primarily in the present. However, if you find that less conscious thoughts and feelings are accessible to you, you should certainly consider them.

  Consciousness-raising, as you have seen, remains important throughout the contemplation stage. Your objectives should be to develop greater awareness of your problem behavior, to gain insight into how your thinking and feeling maintain the problem, and to begin to develop a personal conviction of the value of change. When you have completed these steps—more information, more awareness, more self-motivation—you will be ready for the preparation stage of change.

  GEORGE’S CHANGING SELF-IMAGE

  George took consciousness-raising so seriously that he began to joke that he knew more about alcohol than was good for him. Until he discovered that alcohol abuse was a factor in more than 50 percent of automobile accidents, George had always attributed his accidents to the people who got in his way. Until he read that the majority of violent encounters involved alcohol abuse, he had ascribed his violent behavior to others who got on his case. He learned, too, that drinking was often the root cause of divorce and job loss. All these insights, along with George’s weakened defenses and keen intelligence, meant that he could no longer deny that he had the profile of a problem drinker.

  He still resisted the label of “alcoholic.” Alcoholics drank before noon—George could wait until lunch. Alcoholics drank until they blacked out—George never lost consciousness. Alcoholics drank hard liquor—George preferred beer. Alcoholics were addicted—George could go a day without drinking, and even thought he could last a week. Alcoholics had no control over their drinking—George accepted that he had a drinking problem, but he was convinced he could control it.

  George’s increased awareness about the consequences of alcohol abuse, however, was continually changing his attitudes toward drinking. Until this awareness, the pros of drinking had always outweighed the cons. Drinking was his favorite social activity, an important part of his Irish heritage, an instant stress reliever, a frequent family event, a way of doing business and sharing with friends, a part of his tough reputation, and a source of outrageous stories. Drinking was so natural to George, it was like air; but now he realized that his air was polluted.

  Because of his love for his friendly pub he had lost his wife, his job, and his automobile insurance. His drinking had cost him brain and liver cells. His short-term stress relief was won at the price of his long-term stability. He had gone from a happy drunk to a bitter beer drinker, always ready for a fight. He knew from his readings that alcohol abuse leads to increased anxiety and depression. He mocked himself for treating his depression by drinking a depressant.

  Through consciousness-raising and emotional arousal, George was changing his mind about drinking. It was not easy. “Damn this awareness,” he cursed, more than once. He drowned the facts, the ambivalence, and the conflict with drink, but still had to face himself when sober. Worse still, he had to face his children. They were not proud of him, and who could blame them? He was wrecking his future and jeopardizing theirs. And George no longer had his wife, who had left him, or his boss, who had fired him, to blame.

  George had clearly reached the point of being disgusted by his habit; he was growing sick and tired of being sick and tired. He was
sick of himself as a substance abuser. He was tired of telling his children lies, and of having constantly to make excuses for his shortcomings as a father and a friend. George was getting ready to make a change. All he had still to do was a positive reappraisal, envisioning a new self after the change.

  THE FIFTH PROCESS:

  SELF-REEVALUATION

  There is another critical change process that you have to use to move through the contemplation into the preparation stage. This is self-reevaluation, or taking stock, an emotional and cognitive appraisal of your problem and your self. Self-reevaluation will reveal to you, once and for all, that your essential values are in fact in conflict with your problem behaviors. Successful self-reevaluation leaves you feeling, thinking, and believing that life would be substantially improved if you didn’t have those behaviors.

  Self-reevaluation follows naturally from consciousness-raising. Once you are well-informed about your behaviors and their consequences, you will begin to question seriously whether you can feel good about yourself while continuing with those behaviors. Self-reevaluators ask questions like “Can I consider myself to be rational if I continue to smoke?” “Can I feel responsible if I continue to drink too much?” “Will my self-esteem go up if my weight goes down?” “Can I feel like a family man if I work seventy hours a week?” “Can I become successful if I cannot cope with stress?”

  These questions are some of the easier aspects of self-reevaluation; we all would like to be more rational, responsible, successful, and healthy. There are tougher questions: What will you lose by abandoning your problem behavior? What time, energy, pleasures, or fantasies must you sacrifice in order to change?

  If change brought only positive gains, few of us would hesitate to make changes. After all, we can all engage in the kind of wishful thinking described a few pages back: “I wish I could change spontaneously, instantly, and effortlessly.” There are still people out there to feed those fantasies and tell you that an hour of hypnosis—rather than weeks or months of effort—will get you to stop smoking; that strapping a gizmo around your thigh or belly will cause you to lose weight; that listening to “miracle” tapes while you sleep will help beat depression. Although buying devices is easier than making an effort, it cannot help you make real behavior changes. Any change that is worth anything will cost something dearer than money.

  Self-reevaluation, then, requires not only that you abandon all hope of finding an effortless route to change, but that you confront some difficult questions: What are you willing to sacrifice for the sake of your self? Giving up drinking may mean you will spend less time with your buddies. Becoming assertive will be a shock to friends who are accustomed to your submissiveness. Less emotional distress may mean that those friends who helped you when you were down will be less focused on you.

  Change may also threaten your self-image. I knew a three-hundred-pound musician who looked like Shakespeare’s Falstaff onstage; when he moved through a crowd, people made way. After he lost 130 pounds, however, he was depressed to discover that his self-image had shrunk. He had not adequately reevaluated his problems before taking action.

  The techniques of self-reevaluation

  From both self-changers and our psychotherapy clients, we have learned that there are two complementary forms of self-reevaluation. One is an evaluation of the present, a negative view of how depressed and controlled we are by a problem behavior, and how we fail ourselves by not changing. This sentiment is frequently expressed by how “disgusted” we are by our habit. On the flip side of the coin is positive reappraisal, a forward-looking assessment of our healthier, happier, freer changed selves.

  The most effective self-reevaluation methods judiciously combine both approaches, and allow us to be pushed by our present, negative view of ourselves just as we are being pulled toward our future, positive selves. Leaning too much to either extreme can be self-defeating, and it is especially dangerous for those changers who picture themselves as disgusting, loathsome creatures. Such intense self-deprecation can easily slide into psychological distress or self-blame, either of which inhibits rather than stimulates change.

  As with the other change processes, there are a number of techniques useful in self-evaluation. Here are three frequently used by contemplators who are making the transition to the preparation stage:

  Think before you act Especially effective in dealing with consumptive behaviors such as overeating, drinking, or smoking, this technique can also be adapted to other problems. The fact is that over time, almost any habitual behavior can become so unconscious that it is reflexive. You can drink, smoke, eat, spend, or become angry, scared, or depressed without ever reflecting on what you are doing or why you are doing it.

  Stopping to think allows you to pause before the reflex, to begin to reevaluate just what your behavior means to you. Before eating something, for example, ask yourself, “Why do I want to eat this? Am I really hungry?” After you recognize the reason, go ahead and eat it if you feel like it. But after just a week of stopping to reflect, rather than responding reflexively, you will gain a measure of control over your habit.

  Although the questions you ask yourself vary from one problem to another, the intention remains the same. These are “why” questions: “Why do I want this cigarette?” “Why am I responding this way?” “Why do I think I need food?” The questions help you determine the reason for your immediate behavior or if you are acting out of sheer habit. You may find, for example, that you are acting for immediate gratification or trying to project an image of being cool, in control, or sociable. Even if you believe that the reason is physical—you crave a cigarette, a drink, or food—upon reflection, you will find that boredom, anxiety, or your current social situation account for your cravings far more often than you would think.

  Create a new self-image Manufacturers spend billions of dollars on advertising in order to create marvelous images for their products. Consumers spend even more billions to buy into these images. Images sell and persuade because they blend thoughts and feelings at varying degrees of consciousness, appealing directly to fantasies without considering reality. If you fantasize that you are a rugged male, free to roam the range, you know just what cigarette is the right one for you. If you want to be a sophisticated drinker, there is a scotch with your name on it. If you fancy yourself a sportsman, you’ll work extra months, even years, to pay for the car that reflects your sporting image.

  Advertisements project various images of drinkers as individuals—from those who work hard, play hard, and drink hard, to those who drink for relaxation. Similarly, advertisers create images of smokers as having fun, being cool, and acting sexily.

  What advertisers ignore, not surprisingly, are the harsh realities of drinkers who crack up their cars, wreck their careers, mess up their marriages, and screw up their children. They also ignore the health effects of smoking. A few years ago, a nonprofit group created a realistic film of a smoking cowboy. It began with an idyllic western setting, from a familiar advertising campaign, through which rides a lean cowboy, a cigarette dangling from his mouth. As the cowboy comes into focus, it becomes apparent that he is not a rugged model of health. He has the cough and wheeze of a heavy smoker, and appears to be dying. Predictably, lawsuits have kept this film from being widely viewed.

  You can create images for yourself just as easily as the mavens of Madison Avenue do. Try a scenario in which you don’t change: Your health and other aspects of your life, depending on your problem behavior, deteriorate further. Then imagine how you would think and feel about yourself if you did change. Would you feel relieved? Freer? Healthier? Would you be a better role model for your children? Would you be pleased about the change? Would others feel pleased for you? Would you actually feel that you have grown? The answers to these questions are self-evident.

  Make a decision Decision making is at the heart of moving from contemplation to preparing for action. But the decision to take action sooner rather than later is usually preced
ed by an evaluation of the pros and cons of a problem behavior. An evaluation or decisional balance is best made using the following four basic categories:*

  Consequences of change to self

  Consequences of change to others

  Reactions of self as a result of change

  Reactions of others as a result of change

  TABLE 8. SAMPLE DECISIONAL BALANCE SCALE

  1. Consequences to self

  Pros: Improved health

  Increased happiness

  More money

  More marital success

  Cons: Loss of some friends

  Less time with extended family

  Loss of “mood medication”

  Have to find other things to do

  2. Consequences to others

  Pros: Children can trust me

  Husband will be happier

  Boss can count on me

  Cons: Some friends, some family members will be threatened

  Family is not used to dealing with my moods, and will have to learn to do this

  3. Reactions of self

  Pros: See self as determined

  See self as more responsible

  See self as not needing a crutch

  Cons: See self as less fun

  See self as moodier

  See self as a stranger

  See self as getting older

  4, Reactions of others

  Pros: Children will be proud of me

  Husband will be pleased too

  Others will see me as being trustworthy again

  Cons: What will most friends say?