Changing for Good

by James O Prochaska

  Although relapse is never desirable, our view is that change is often circular and difficult. The spiral cycle of change (Chapter 2) shows how contemplation, preparation, and action usually follow relapse. Relapsers most often take one step backward in order to take two steps forward.

  THE TEN LESSONS OF RELAPSE

  After relapse, before committing to another round of action, most people benefit from a period of self-reevaluation in which they learn from their recent mistakes. To strengthen subsequent self-change efforts, there are ten important lessons to be learned from relapse.

  Few changers terminate the first time around

  It’s rare to overcome a problem on your first attempt. Clinical research indicates that only about 20 percent of the population permanently conquers long-standing problems on the first try. This means that the vast majority of self-changers relapse.

  We do not fully understand why, but it is clear that few people have had any help or instruction in applying psychological methods to their problems. They are unaware of the relationship between processes and stages (and quite frequently, of the existence of either). Yet, despite this lack of experience or training, many people expect to get it right the first time. This is an unrealistic expectation.

  Without the help of a professional or a book such as this one, a change regimen is necessarily developed by trial and error.

  Trial and error is inefficient

  After discovering that many self-changers eventually succeed at overcoming problems of weight control and smoking, one leading psychologist observed: “That’s what self-changers do. They rely on trial-and-error learning—but with more errors than learning.”

  It’s tremendously frustrating to set out to change only to relapse in spite of your best efforts. What do you do the second time around? That is a major dilemma facing professionals, who say, “We gave our clients our best effort the first time. If we knew anything better to do, we would have tried it. So what do we do with the relapsers?”

  The answer is, help them learn from their relapse experiences but encourage them to rely on guided learning rather than on trial and error. It is inefficient, not to mention frustrating, painful, and unhealthy, for smokers to make four attempts at quitting over ten years before finally succeeding. Most people want to move to a smoke-free life much sooner than that.

  Using relapse as a guide to effective learning can help you benefit not only from your own experiences but from those of other people. For example, just by reading this book you can take advantage of the combined wisdom of thousands of self-changers, laypeople, and psychotherapists. You can learn to apply the appropriate change process to each stage of change, a lesson that would take years of trial and error to master.

  Change costs more than you budgeted.

  Few self-changers realize how much change costs, and consequently fail to budget enough time, energy, or money. You may recognize that it took years to establish your problem behavior, but believe unrealistically that you can reverse this deeply embedded pattern in a few weeks. In reality, it takes an average of about six months of concerted action before you may be ready to move into maintenance.

  Nor is time the only issue. Few self-changers are prepared to use five different change processes during action. Even those who are aware of the variety of processes at their disposal believe, at least the first time around, that willpower alone can overcome their problem. As a result, they have developed no substitutes for behaviors that have served an important function in their lives. How will they replace 30 cigarettes a day, 210 a week, or over 10,000 a year? How will they counter 8,000 temptations during six months of action? What reinforcements will they use to make up for all the instant gratification?

  Sheer willpower is not enough. What is needed is a commitment over time to an action plan that exploits all that the processes have to offer. The lack of such a commitment leads to insufficient effort, an attempt to move into maintenance too soon and eventually and predictably, relapse.

  Professional state-of-the-art weight-control programs have learned this from experience. These action-oriented programs, which once lasted for ten weeks at most, have in many cases been extended to twenty-two weeks or more. Because this reinforces clients during most or all of the action stage of a weight-control program, a higher percentage of participants successfully reach the maintenance stage.

  Using the wrong processes at the wrong time

  Many people blithely apply powerful psychological processes with little forethought. The result can be mistreatment. Here are three major ways in which the basic processes of change are often used incorrectly:

  Becoming misinformed When information on self-change is scarce or inaccurate, consciousness-raising techniques may backfire. Self-help information can be partisan or outdated. A generation ago, many men read marriage manuals to gather information about overcoming premature ejaculation. These manuals taught men that they were becoming too aroused during intercourse and needed to distract themselves (by thinking about work or by chewing on the inside of their cheeks). Later research has shown that overcoming premature ejaculation actually requires learning to tolerate more arousal, not less. Distraction prolongs the problem.

  You need accurate information to avoid misguided strategies.

  Misusing willpower When people attempt to change and fail, they frequently conclude that they have not used enough willpower. We have already discussed how excessive reliance on willpower at the expense of other change processes can lead to failure and frustration. Willpower can be misapplied in other ways. Many people try to will the unwillable—to change what happened in the past, for example. This is an excellent way to produce anger, anxiety, or depression, but is quite ineffective as a strategy for change.

  There are problems that do not respond to direct applications of willpower—impotence, for example. When Stan tried to command an erection—clenching his fists, tightening his muscles, and saying to himself, “Come on baby, get it up”—he had no success. As we tense up, blood is drawn back to the heart, where it can be pumped to the muscles involved in voluntary activity. The blood comes from the involuntary parasympathetic nervous system, which controls areas like the stomach and the genitals. By misplacing his willpower, Stan wound up with hard muscles and soft genitals. He was powerless to will an erection.

  You cannot will every change. You must turn to more effective change processes.

  Substituting one bad behavior for another By mistreating themselves, people frequently wind up substituting one problem for another. This occurs most often with people who counter anxiety by taking a drink, thus transforming an anxiety problem into a drinking problem. People who use eating as a countering technique for smoking often end up with a weight problem when they quit smoking. And many people would rather return to smoking than face extra weight.

  Although problem substitution does not occur automatically, it does occur frequently. Good countering and environment control techniques are essential during the action and maintenance stages in order to prevent it.

  Be prepared for complications

  It would be pleasant if change were so simple that you could work out each individual problem at your own pace. But change seldom involves only one problem at a time. Problems often coexist; changing one can exacerbate another.

  The encouraging news is that our research shows that common problems have common solutions; the techniques may vary but the processes remain the same. The processes used to solve smoking problems can be used simultaneously to solve eating problems. The processes for coping with external social pressures can be applied to internal emotional pressures. If you have learned to use relaxation, exercise, assertion, and countering thoughts techniques, you are prepared to counter not only the temptation to relapse but also the emotional distress and social pressures that often accompany major change.

  The path to change is rarely a straight one

  Self-motivated behavior change follows a cyclical pattern similar to that o
f developmental change. For example, many young people in the United States leave home “permanently”—and return—an average of three times before they are truly ready to live on their own. They go off for a time to practice independence, then come back to the security of home. With the support of their families, they further prepare themselves to meet the challenges of adulthood. When they return home, all that was gained from their forays into the world is not lost; normal development means that they are not going in circles but, rather, progressing up the spiral staircase of change.

  A lapse is not a relapse

  If one swallow does not make a summer, one slip does not make a fall. In changing your problem behavior, you are likely to slip at times and lapse into old ways. A lapse does not mean that you have failed, or that a complete relapse is inevitable; you may still win the battle the next time around.

  Many people do give up as soon as they lapse, because of how they view the event.* They have an almost religious belief that abstinence is an absolute state that can never be broken. If they lapse even once—by having a single cigarette, dessert, or drink—this means that they have fallen from grace. A corollary belief is that if abstinence is ever broken, willfully or not, the change attempt has been a total failure. Guilt and recrimination are then in order; any new change attempt must begin again at the start.

  Guilt and self-blame are actually very ineffective change processes. They tend to cripple change efforts, not stimulate them. We regularly encounter clients whose guilt turns a lapse into a relapse. Darla sought psychotherapy for assistance with her weight problem and her resultant social isolation. She had repeated the identical diet cycle six or seven times without learning from her failures. She would take effective action for one or two weeks, then suffer a relapse brought on by binge eating junk food while watching television. After the first few cheese puffs, she told herself, “I’ve failed. It’s hopeless. I’ll never be able to lose weight. I might as well pig out now.” Once Darla learned not to equate a lapse with a relapse, and to avoid “catasirophizing” her slip, she was able to resume dieting and exercising the next morning. Ultimately, she conquered her weight problem.

  Every relapse begins with a slip. But it is foolish to give up hope after relapsing. We can recover from our slips, learn from them, and continue toward our goal of permanent change. Take lapses as signs that you must redouble your self-change efforts.

  Mini-decisions lead to maxi-decisions

  Few relapses are conscious. The stated intent of all changers is to take action and maintain their gains until they are free from their problem. But change teaches you how easy it is to fool yourself. You may make any number of what we call “mini-decisions” that ultimately have negative consequences.* We mentioned some of these earlier: deciding to keep some beer in the house in case company drops by; buying some of your favorite cookies for the kids; easing up on your exercise program because you feel so good.

  Such mini-decisions can lead you to begin shifting direction away from maintenance and toward relapse. Before you know it, you may find you’ve gone back to your old ways, never having made a conscious maxi-decision to relapse.

  Distress precipitates relapse

  The most common cause of relapse is distress. Researchers consistently find that distress (including anger, anxiety, depression, loneliness, and other emotional problems) is involved in 60 to 70 percent of relapses in alcohol, drug, smoking, and eating problems.

  What makes emotional distress such a high-risk factor in relapse? For one thing, you cannot avoid your emotions the way you can avoid bars, restaurants, and in-laws. Also, emotional distress weakens you psychologically, in much the same way a fever weakens you physically. During times of high distress, you are likely to regress to less mature and rational ways of thinking and behaving. Distressing emotions speak in an absolute language until you tell yourself that you must do whatever it takes to overcome them.

  Few people have learned healthy ways of coping with intense feelings. As youngsters, many of us are taught to suppress our emotions in order to be considered “good” kids; we haven’t had adequate opportunities at home, school, or work to learn to talk about our distressing feelings. The outcome is that, as adults, we cope with distress by having affairs, smoking, spending, eating, drinking, avoiding close relationships, or in other frequently unhealthy behaviors.

  Social pressure is the other major cause of relapse. If your social network contains mainly people who share your problem, you are likely to experience intense pressures against changing. Self-changers threaten precontemplators who are not ready to confront their problematic behaviors. Change also threatens people who contemplate changing but have put it off.

  During periods of active change, you may feel that you not only have to change yourself, but you must change your social network as well. And if your social network values the status quo, it may reject you for violating its rules. Conversely, if your friends, colleagues, and family value individual differences and personal growth, you are less likely to feel pressure to stay the same; in fact, you may count these people among your helping relationships.

  Since distress and social pressure trigger the vast majority of relapses, it is important for you to include coping with these formidable forces when you create your action plan. This is especially true if you are in a cycle of change where you have already suffered a lapse due to distress or social pressure. Your plan should include a judicious mixture of relaxation, exercise, assertion, and countering techniques. You may find some old friends are stubbornly unsupportive; if so, your plan might include steering clear of certain social groups, and making new friends.

  Learning translates into action

  It won’t do you much good to have excellent ideas if you don’t put them to work. As someone once said, “Good ideas eventually deteriorate into hard work.” If you think about what you have been learning without acting on it, you are in danger of becoming a chronic contemplator. One of the crucial lessons we have learned is that far too many people get stuck in the contemplation stage. The strength of relapsers is that they usually are willing to risk taking action again in the near future; their initial action gives them strength and courage.

  Have you learned from relapse, and used your experience to prepare you for later success? Are you ready to base your next action attempt on informed change principles? You can find out the answers to these questions by responding to the following simple self-assessment:

  Have you identified the major causes of your previous relapse(s)?

  Do you have specific, action-oriented processes to counter the situations and emotions that induced your relapse?

  Are you more informed about the cycle of change and how it relates specifically to your problem?

  Can you tolerate a slip (lapse) without a total fall (relapse)?

  Are you planning to make change one of your highest priorities for the next three to six months?

  Have you prepared yourself for the possibility of complications and for more than one change at a time?

  Can you put your newfound learning into action?

  If you can honestly answer yes to all of the above, you are well prepared to recycle through the action and maintenance stages. However, if one or more of your responses is no, you may not be ready for renewed action quite yet. Instead of despairing or becoming apathetic, recognize that you have more to learn. Draw energy from the knowledge that you have not yet given the problem your best effort. A more active and informed change attempt awaits you.

  SEEKING PROFESSIONAL HELP

  After a number of relapses, or a particularly distressing one, you may decide that self-change is not working for you and consider turning to professional help. This section will help you determine what sort of help to seek.

  Increasingly, Americans are availing themselves of mental health services at a rate that has more than doubled over the past generation. In 1957, approximately 14 percent of American adults had sought professional help for men
tal health problems sometime during their lives.* By 1976, this number had risen to 26 percent,† and current estimates place it higher still. But even with this dramatic increase in mental health treatment, the fact remains that the vast majority of people still grapple with their problems on their own. We have begun to treat our emotional well-being with respect, and to recognize the transformational power of psychotherapy in our lives. Yet, there is a stigma attached to psychotherapy, based on some persistent myths:

  “You have to be crazy to see a shrink.” The majority of psychotherapy clients suffer from depression, anxiety, and interpersonal problems. Sound familiar? Marital problems and work conflicts are two primary reasons for seeking help, and surely these do not make a person “crazy.” A good argument can be made for the reverse. If you suffer from a pressing and continuing problem even after you have made sincere attempts to change, then perhaps you have to be crazy not to seek help.

  “All psychiatric patients are hospitalized.” This was the case up until the 1950s. Nowadays, however, fewer than 20 percent of people with mental disorders ever require hospitalization.

  “If not hospitalized, I’ll be in psychotherapy for years.” This is possible but not probable. The average number of visits to a psychotherapist ranges from three (public clinics) to fourteen (private offices). Most psychotherapy treatment tends to be brief, pragmatic, and problem-oriented. Intensive, long-term psychotherapy is the exception rather than the rule.