Changing for Good

by James O Prochaska

  Self-changers often don’t give themselves credit because they don’t know just what they did to change. Many people we have interviewed first tell us, “I just woke up one morning and quit.” When we ask more detailed questions, they begin to remember. They remember the weeks prior to that fateful morning, when perhaps they switched brands and became increasingly disgusted with smoking. They remember earlier attempts to quit smoking. They remember when they avoided people and the places that were filled with smoke during the two weeks after quitting. They remember enlisting the aid of several friends at work by announcing their attempts to quit smoking. Remembering your own efforts to change will reinforce your commitment.

  Change is often associated with a new way of life. A diet is successful when it is combined with more exercise, healthier foods, and revised eating patterns. In maintaining weight loss, overeating may not be the first danger sign. Instead, the early warning signs may involve a lessening of commitment to the new lifestyle. Maybe you and your family return to sitting in front of the TV, and suddenly it becomes “too late” or “too hard” to exercise. The loss of these valuable new supports undermines your commitment and makes it almost inevitable that you will gain weight again. Once you abandon exercise in favor of watching TV, how far are you from grabbing a bag of chips?

  How, then, can you maintain your commitment? First, jot down the difficulties you encountered in your early change efforts. Review the list you made from months ago of the negative aspects of your problem behavior. Keep both lists in a safe place, look at them periodically, and refer to them at the first sign of slipping. During the maintenance stage, they can act as psychic booster shots.

  Second, take credit for your accomplishment. Maintenance is not the time for criticizing yourself for having had problems, but for taking both credit and responsibility for change. Use the new year, your birthday, or the anniversary of your change (it need not be a year—celebrate a month!) to reflect on the success you have had and to renew your commitment.

  Renewing your commitment is especially important when you are trying to modify regularly occurring behaviors. Maintaining weight loss is a constant issue for people with weight problems, and requires frequent boosts of commitment. Similarly, timidity and passivity in interpersonal relationships require that you make special efforts with a variety of people. With these problems and many others, redoubling commitment is a critical part of maintaining change.

  Keep a healthy distance

  In maintenance as in action, commitment is not enough; environment control remains a necessary ingredient for success. As you progress through the months of maintenance, you will find your self-confidence increasing and temptation decreasing. Gradually, you will be comfortable in the presence of certain temptations or situations. But you may not become completely immune to them. Too many times, situations arise that can trigger a relapse.

  Especially during the early months of maintenance, it’s best to continue to avoid people, places, or things that could seriously compromise your change. Hanging out at a bar in order to be close to a group of friends may maintain friendships but endangers your sobriety. Staying “friends” with your former spouse may feel familiar, but it can threaten your independence. And stopping at the bakery because your kids are coming over for dinner is a generous but ultimately self-defeating gesture. Controlling your environment never signifies weakness but, rather, intelligence, health, and foresight.

  Create a new lifestyle

  In maintenance as in action, countering is an important partner to environment control. Since stress often triggers problems, from weight gain to marital discord, it is invaluable to develop ways to cope with stress. Chief among stress-reduction techniques, as always, are exercise and relaxation.

  Working to create alternative behaviors is one of the most important and rewarding challenges of maintenance. Individuals with drinking problems, for example, are frequently amazed at the number of activities open to them that do not revolve around alcohol. Make time for something that you’ve always wanted to do, and you will find you like yourself more and more.

  Check your thinking

  What you think and say to yourself has profound effects on your behavior; negative thinking can pose serious problems. Your attitudes toward a problem remain as important in the maintenance stage as your ability to deal with that problem, the quality of your life without it, and the consequences of possible relapse.

  When you moved from precontemplation and contemplation to preparation and action, the positive aspects of changing became more prominent, and the negative aspects began to dwindle. If you are in the midst of a major change, no doubt you remember how your pros and cons charts changed as you drew closer and closer to action. Health matters, family pressures, and personal concerns all contribute to a decision to take action. Eventually the positives clearly outweigh the negatives.

  Problems may now seem far away and less threatening as you move into the maintenance stage. Being at this distance now may lead you to minimize the dangers and risks of your unwanted behavior, and maximize its appeal. Again, the process of forgetting is involved. You may tell yourself that your drinking wasn’t that bad; that smoking is better than gaining weight; that the difficulties your shyness created were never major. Denial, distortion, and rationalization are the enemies of maintenance.

  To prevent these negative thoughts from gaining a solid foothold, check your thinking periodically to see if you are being consistent and honest with yourself. Review your reasons for changing. Ask one of your helpers to remind you just how serious your problem was. Go back to the pros and cons exercise in Chapter 6. Be honest with yourself. When it comes to your problem, you are as capable of distorting the truth as anyone. The smarter you are, the better you are at rationalizing.

  SELF-EFFICACY—A MEASURE OF SUCCESS

  Self-efficacy* refers to how you rate your ability to perform specific tasks related to your problem. Related to self-esteem and self-confidence, self-efficacy can be an aid to evaluating how you see yourself. As you change, your confidence will grow, and your self-efficacy level will rise.

  In order to assess your level of self-efficacy, first choose a behavior pattern that you want to follow. Then make a list of situations that tempt you to abandon the behavior For each situation, evaluate just how confident you are that you could still behave the way you want. For example, you may be completely sure that you will not drink at a church social, but your efficacy may wane when it comes to the annual company party. Use a scale from 1 (not at all confident) to 10 (extremely confident). Following is a sample self-efficacy chart, from the point of view of someone trying to stop drinking in social situations:

  When I am on vacation and want to relax: 9

  When I am under work-related stress: 6

  When I am lonely: 8

  When I see others drinking at a bar or party: 9

  When I am depressed: 7

  When I am craving a drink 8

  When I am hassled by others 5

  When I am offered a drink in a social situation: 10

  When I feel I need a drink to help cope with life: 6

  When I want to test my willpower over drinking: 8

  Total confidence: 76

  Total number of situations: 10

  Average level of confidence: 7.6

  Highest confidence Situation: #8

  Lowest confidence Situation: #7

  You must be brutally honest with yourself in filling out a self-efficacy form. In one of our studies, a male smoker who was attempting to quit gave himself a string of 10s after barely reading each situation. He did not want to confront situations that might shake his confidence. His efficacy evaluation was more fantasy than reality, and wishing didn’t do the trick for him. Another individual, who didn’t expect too much from herself, rated herself low in every situation; that did her no good. Bear in mind that the self-efficacy assessment is not a test, but a tool that can help you manage your maintenance.

&n
bsp; Once you have made a self-efficacy evaluation, examine your scores. In which situations are you least confident? Is there a pattern to them? Are certain situations especially challenging? You can use this newfound knowledge to develop your own relapse prevention plan. Rather than wishing you were supremely confident, develop a strategy to cope with difficult situations. Use environment control to avoid the most difficult ones, and countering to handle less threatening temptations.

  Guarding against slips

  The goal of maintenance is nothing short of a permanent change that becomes part of your personality. Permanent change is a high ideal, rarely attained without false starts or mistakes. Most people slip along the way—go off their diets, fail to be assertive with a boss or lover, or take a drink. How do you keep these momentary slips from turning into major relapses?

  Slips are usually the result of overwhelming stress or insufficient coping skills. Although slips are far from admirable, you can recover from them, learn from them, and continue toward your goal of permanent change. First, you must take responsibility for your slips and realize that they indicate vulnerability. Check high-risk situations—they should be on your self-efficacy evaluation—and develop a plan of attack against them. Then you must combat the absolutist thinking that equates a single lapse with total relapse.

  Life without problem behavior is undeniably different, especially when you have given up a substance or a way of life that was once your best friend. Quite often, the euphoria of an initial change gives way to a sense of loss and deprivation, which in turn may wear down your resolve.

  When we work with people who have given up drugs or alcohol, we encourage them to go through a mourning process. To maintain abstinence, it’s important that they say good-bye to their old friend and trusted companion. Yes, alcohol causes broken marriages, DWI arrests, lost jobs, but for many alcohol is a constant companion and sturdy crutch over the years.

  Regardless of your problem behavior, regardless of your level of disgust when you enter the action stage, don’t be surprised if you wake up one day missing your old habits. Don’t think, however, that this means you cannot live without your old behavior; you are in the process of making a new self that does not need your old problems.

  HELPING RELATIONSHIPS

  DURING MAINTENANCE

  People around you are often extremely supportive while you are in the action stage. Soon they take your change for granted. One person who recently kicked his habit complained to me: “I wish they would keep up the congratulations for as long as they kept giving me grief about my drug use. How soon they forget!”

  It’s not unusual for self-changers to complain about the difficulties of continuing with helping relationships during the maintenance stage. But it is more important than ever to have an understanding person nearby during maintenance, especially when you are experiencing a crisis that could lead to a relapse. One of the most valuable functions of organizations such as Alcoholics Anonymous is the support they provide their members during maintenance. Having someone to call on who has been where you are, who can understand, and who can help is invaluable.

  There are many ways in which you can help your helpers to be supportive during maintenance:

  Revise your contract Expand your initial contract with your helpers. Give them the permission and even the responsibility to confront you if you start reverting to old behavior or express overconfidence and expose yourself repeatedly to tempting situations.

  Put your helper on call Make a “crisis card” to put in your wallet or pocketbook. On this card write a list of the negative aspects of your problem, as well as a set of instructions to follow when you are seriously tempted to slip. The instructions could read like this:

  Review the problem list.

  Substitute positive thinking for negative statements.

  Remember the benefits of changing.

  Engage in vigorous distraction or exercise.

  Call [support person’s name and number].

  Practice new behavior Strongly supportive friends can help you practice confronting temptations before they actually occur. This can be accomplished through role playing, which serves to generate realistic situations while you try out new, adaptive responses to them.

  Helpers should remember that they are not drama critics, but supportive resources; they can help the self-changer to say no clearly, both verbally and nonverbally. Therapists who teach “drink refusal skills” like to suggest alternative behaviors. A helper can encourage the self-changer to ask for a club soda, a second helping of salad, or a piece of gum. Helpers can assist you in practicing assertion skills by having you insist that they stop tempting you. Above all, they can discourage you from making temporary excuses—“Not tonight,” “I have a cold,” “I’m on medication.” These devices may work for a night or two, but delay the inevitable and firm no. These excuses also imply that the self-changer may be willing to accept an offer to go drinking in the future—another night, when he or she is healthier or off medication.

  Help someone else The last step of the Alcoholics Anonymous program, called the Twelfth Step, involves helping others with similar problems. This has become an integral part of many alcohol and drug programs. Although it may seem contrary to getting support for yourself, many people report that helping others is a key to helping themselves maintain change. The psychiatrist Karl Menninger liked to say, “Love cures people—both the ones who give it and the ones who receive it.” It is a refreshing, esteem-boosting experience to discover that you can not only help yourself but others too.

  Patience and persistence

  Many behaviors that we wish to change become problems because of our tendency to take a short-term perspective. We have become accustomed to the instant fix: fast food, instant coffee, quick pleasures. We can no longer wait for gratification. But short-term ecstasies—eating, drinking, or taking drugs—create long-term agonies. And a short-term perspective is counterproductive during the maintenance stage, where there is no such thing as a quick fix. Difficult as it may be, a shift in perspective can help you transform your life.

  Patience and persistence are the hallmarks of maintenance. Time can be an ally as you progress across the stages of change. One comforting thought, as you struggle with maintenance, is that the process is a lengthy one. You don’t have to get everything right all at once. Recalling how long you spent in the precontemplation and contemplation stages can provide an important reality check. However long it takes to change, consider how many years you may be adding to your life, and how improved the quality of that life will be in the years to come.

  CHAPTER 9

  Recycling—Learning from Relapse

  GINNY WAS IN the depths of depression for the fourth time. Although she thought she had overcome her fears of failure, her new job was not going well and her emotions were out of control. She was drinking and eating too much, but her top priority was coping with her depression, and compulsive consumption seemed to help. In past depressive episodes, Ginny had felt that she was not herself and would never be again. This time, as painful as the depression was, she felt confident that it would pass. Meanwhile, she was trying to keep it from disrupting her life any more than necessary.

  Molly was disappointed and surprised when she went back to drinking. She had done without alcohol for nearly five years. Despite an occasional temptation, she honestly believed that she would never again turn to drink. She was sure that she had dealt with every tough situation, but when her youngest son left home she found herself alone with a bottle. She knew she had to take action soon; she just wasn’t sure she was ready.

  Ginny and Molly have both experienced relapses. They both made excellent progress on their problems and maintained their changes for years. Eventually, however, they fell back to earlier stages of change. Ginny is contemplating her problem, trying to understand how she became so distressed by the prospect of temporary failure. Molly is feeling down but not out. She is preparing to get back into action,
to resume her battle with the bottle.

  Fortunately, the vast majority of relapsers do not give up on themselves and their ability to change. Like Ginny and Molly, most return to the contemplation or preparation stage and get ready to take action again. And our research shows that they have reason to be hopeful. Experience with change strengthens people, and relapses most often take them not to precontemplation, but to contemplation or preparation, relatively close to making commitments to renewed action.

  There are exceptions. For example, after losing many pounds, Steve, found to his dismay that he was gaining it back again. He had developed control over his once constant trips to the kitchen, and he was able to go out to eat without overindulging. But he was having a difficult time dealing with his anxiety, anger, and depression. Although Steve had learned how to cope with his environment, he hadn’t yet learned how to cope effectively with his emotions. And when he became angry and distressed, he began to overeat.

  Steve became so demoralized by his relapse that he lost all energy for change. He showed all the signs of a precontemplator on the verge of giving up. Some self-changers look on themselves as total failures after relapsing. Guilt, shame, or embarrassment makes them feel that the struggle is not worth continuing. They become defensive and try to avoid or ignore the problem.