Knowing what to do
The question remains: How do you know when you need professional help? We have found five factors that distinguish people who rely on self-change alone from those who try psychotherapy after unsuccessful attempts at self-change.
Ineffective self-change Many people seek professional help when their self-change efforts are not effective. In studies of college students’ use of psychological services, for instance, it was discovered that most students decided to enter psychotherapy only after trying unsuccessfully to cope with the problem alone or with the help of a close friend or relative. Our own research has found that psychotherapists give the same reason for their entering therapy.
Although we encourage relapsers to learn from their setbacks and to prepare to recycle through the stages of change, there are times when self-change is insufficient or when people become stuck or frustrated. Few self-change efforts are “wasted.” At the least, most reduce the severity of the problem and assist therapists in understanding what has been accomplished and what remains to be tackled.
Long-term problems If your problem persists indefinitely despite your efforts, it might be time for professional help.
Recurring problems All changers require helping relationships. If your emotional distress has been prolonged or severe, you may profit from enlisting a professional helper. Many problems, such as weight management and emotional distress, are lifetime challenges rather than short-term difficulties. Some people find themselves recycling through the same problem month after month, year after year, never learning more about the process or improving their chances at success.
The key question then becomes: How many times should you recycle through a problem without improvement before seeking professional assistance? There is, of course, no single answer to this question. This self-assessment, however, can help you address it yourself. Answer yes or no to the following questions:
Do you feel you have given self-change your best effort?
Have you tried to learn from your previous self-change efforts?
Is your problem important enough for you to seek professional help?
If your honest answer to all these questions is yes, you should seriously consider professional assistance. If, like many people, you respond to the first two questions with a begrudging no, then you should consider a more serious, sophisticated self-change attempt, following the guidelines in this book.
Negative coping Strategies of negative coping—especially wishful thinking and self-blame—make it much more difficult to change, and our research has found that people who use these strategies excessively often seek psychotherapy. Wishing a problem would change by itself instead of actively taking charge of it leads to prolonged contemplation and inactivity. Intense self-denunciation may paralyze your adaptive resources and add distress to your original problem.
No helping relationships Professional assistance is especially valuable if there are few helping relationships in your life. Few of us have as many satisfying relationships as we would like, but most of us receive enough support to go on about our lives. Others do not have supportive friends and family, or are involved in relationships that when it comes to change are unsupportive or even downright hostile.
This is where psychotherapy can be extremely helpful. After all, it is basically an interpersonal, helping relationship. Many prospective clients enter treatment yearning for technical expertise—information, methods, and guidance. But the most highly rated curative factor in psychotherapy is the therapeutic relationship, a natural and effective remedy for a scarcity of supportive friends and family.
The “Three Unables”
There are inherent limitations in self-change books, including this one, about which you should be aware when considering professional help. We call these limitations the “Three Unables”:
Unable to understand No matter how clearly we present the stages and processes of change, and how they can be used by self-changers, some people will distort or misunderstand that information. In a minority of cases this is due to intellectual, visual, or memory limitations, but most usually, it results from selective perception. Most people understand what they want to understand and vice versa. Professionals can help remove these perceptual blinders, although unfortunately you might not be aware of having them.
Unable to apply The interpersonal nature of psychotherapy virtually guarantees an ongoing check on whether the message is being understood and applied. No self-change book can accomplish this. Although we have made every effort to make our guidelines broad enough to apply to all self-change situations, while making them specific to the most common problems, it is possible that you can come away with a conceptual understanding that is not the same as an ability to apply the information in a practical fashion. Your individual difficulties may require more detail and assistance than a book intended for thousands of people can provide. Under these circumstances, psychotherapy is a good option. Be honest with yourself, though. “This self-change stuff sounds great, but it’ll never work for me” is an all too frequent rationalization.
Unable to comply Perhaps you understand our self-change methods, and even begin to apply them tentatively. But then, as quickly as you began, you stop. You have achieved awareness but have problems with action. As you know, awareness is only the beginning of change, not the end point. If insight was all it took to change, there would be fewer cases of obesity, anxiety, and other maladaptive behaviors. It is not easy to translate awareness into sustained action. Psychotherapy has the advantage of repetitive and monitored practice. You are provided with a guide who can restate points, repeat methods, and personally shepherd you through action.
If you have decided to change, and none of the exceptions noted in Chapter 3 apply to you, consider first the sophisticated self-change methods described in this chapter. If, however, you honestly believe that self-change alone is insufficient, then it is would be wise to supplement it with professional treatment.
WHERE TO SEEK HELP
After having decided to consult a professional, how do you find the one that is best for you? The advice you receive from friends will probably be vocal and conflicting: “See Dr. X, he’s the best!” “Anyone but Dr. X; I’ve heard bad things about him.” “I think you need an experienced female counselor.” “I’d only go to a psychologist [or psychiatrist or social worker]” And so on.
In order to rank the importance of sixteen factors in choosing a therapist, we asked more than five hundred psychologists, psychiatrists, and social workers what criteria they followed when they chose a therapist. We found that among the most important factors were:
Competence
Clinical experience
Professional reputation
Warmth and caring
Openness
The five least important were:
Specific profession
Being outside of the client’s social network
Success with similar patients
Cost per session
Research productivity
For us, a therapist’s clinical expertise and interpersonal skills are the two most important factors. Keep these two characteristics foremost in your mind when searching for a psychotherapist. Although cost per session was not judged to be a decisive factor by psychotherapists entering therapy, this was probably due in part to their relatively high incomes. Your budget may be much tighter. However, health insurance covers at least half the cost of therapy for many people, and a majority of therapists use a sliding scale to benefit less affluent clients.
We agree that the specific profession of the psychotherapist should not be a major influence in deciding where to seek treatment. Be careful of people who claim to be a “counselor” or “psychotherapist” in most states, anyone can call himself or herself counselor or psychotherapist (neither is a legally protected title). In contrast, clinical psychologists, psychiatrists, clinical social workers, and psychiatric nurses are all licensed practitioners. Yet, t
here are considerable differences among them.
Psychologists generally have had the most formal psychotherapy training, have doctoral degrees in clinical or counseling psychology, and have spent one or two years as interns. They alone provide psychological assessment and testing. Look for a psychologist who has a doctorate in psychology, not in a “related” field.
Psychiatrists are physicians with residencies in psychiatry. They alone may prescribe medication and, compared with other mental health professionals, specialize in organic and biological treatments. Look for a psychiatrist who has completed a psychiatric residency and is board certified; approximately half of those listing themselves as psychiatrists do not have this certification.
Clinical social workers typically have a master’s degree in social work or social sciences, followed by two years of full-time, supervised experience leading to inclusion in the Academy of Certified Social Workers (ACSW). Clinical social workers offer psychotherapy and, compared with other mental health professionals, are specialists in community work. Look for a social worker who was extensively trained in psychotherapy, not in social services or administration.
Psychiatric nurses are registered nurses (R.N.s) who have obtained a master’s of science degree in nursing (M.S.N.). Psychiatric nurses practice psychotherapy and have the advantage of offering an integrated medical-psychological model of practice. Look for a psychiatric nurse who specializes in psychotherapy, rather than one who operates as an administrative aide.
What about theoretical orientation—the conceptual approach that the clinician uses to formulate cases and prioritize therapeutic methods—which those we surveyed believed to be of moderate importance? Today, the most popular theory is eclectic, or integrative, combining a number of diverse approaches to fit the needs of the particular client. Integrative theories are followed in popularity by psychodynamic, cognitive, behavioral, humanistic, and systems/family approaches. We recommend two routes to get through this psychotherapeutic maze.
Since different therapies emphasize different processes of change, your first option is to find a psychotherapist with an orientation that matches your stage of change. Self-reevaluation and consciousness-raising, instrumental during contemplation, are most frequently used by psychodynamic, psychoanalytic, and humanistic-existential therapists. Once into the action stage, where countering, control, and reward are very important, you might be most comfortable with a cognitive, behavioral, or systems therapist.
The second option is to select an integrative psychotherapist who can guide you through all of the stages of change, helping you choose the right processes for each one.
Take the case of Arthur, who consulted John Norcross, complaining of depression. Arthur’s wife was responsible for the appointment; Arthur, quite reluctantly, “came along for the ride”—a typical precontemplator. However, with the supportive urging of his wife, children, and psychologist, Arthur began to recognize the existence of his depression and the negative impact it had on himself and his family. During this early contemplation stage, John joined with Arthur’s family in repeatedly stressing his choices as well as the benefits of elevating his mood. After five or six sessions, Arthur began to initiate antidepressive behaviors.
Eight or nine weeks into treatment, Arthur made the decision to enter the action stage. He started exercising, socializing on a regular basis, and countering his self-defeating thoughts. At three months, Arthur’s mood was improved and his marital relationship was revitalized. He and his wife began to wonder how these gains could be consolidated and maintained over time, a sure tip-off that Arthur was about to enter the maintenance stage. Eager and motivated to institute long-term changes in their lifestyles, Arthur and his family have maintained improvement for several years now.
Arthur’s progress was swift and sure, in part at least because of John’s willingness to follow his client’s stage of change. If Arthur had chosen a therapist who was determined to explore interminably the impact of his client’s childhood upon his current depression, Arthur’s self-described “action program” would have been stalled. If the therapist had pushed Arthur into specific behavioral tasks at the beginning of treatment, the client, by his own admission, would not have returned for his next session. By using the processes drawn from multiple theories at the right time, John successfully led Arthur through the stages of change.
How can you avoid therapists who will take you in unsuitable directions? How can you find one who will suit the treatment to you and not try to fit you into a predetermined mold? By assertively asking friends, workmates, physicians, clergy, school personnel, and mental health professionals. Ask as many people as you can so as to receive a balance of opinions. Once you have narrowed the field to two or three choices, arrange for a single appointment with each therapist. It is our conviction—and clinical experience bears this out—that most psychotherapists welcome assertive and well-informed consumers.
CHAPTER 10
A Changer’s Manual
BECAUSE OUR MODEL of the stages of change applies to a wide range of problematic behaviors, we have provided examples of a variety of self-change experiences. Individuals and health professionals alike should understand that our model has proven to be effective with every behavior we have studied thus far, not simply with one or two specific problems. Still, there is a virtue in examining in detail how to change a few of the more common problems.
In this chapter, we track what you need to do to overcome three specific problems—smoking, drinking, and psychological distress. Even if you do not have any of these problems, read on. This chapter describes in some depth the methods for applying many of the theoretical principles we have discussed earlier. While some approaches are specific to a given problem, many of them can be generalized to your own behaviors. And although this chapter is designed as supplemental guides for those who wish to overcome one or another of these three problems, we recommend that you read the rest of the book to help you prepare for successful termination.
SMOKING—THE NUMBER ONE HEALTH PROBLEM
If you want to quit smoking, you are not alone. Smoking is the world’s most prevalent and recognizable health risk and modifiable behavior problem. Thirty million Americans have quit smoking since the first Surgeon General’s report appeared in 1969, but fifty million are still smoking today. If you are among them, you have undoubtedly thought about quitting and probably tried to. You bought this book out of frustration, out of desire, and out of a willingness to change—and you want to know what to do.
We will hit you with the hard facts in a moment. These provide the most useful information available to move you through the stages of change and quit smoking once and for all. If you can resist running from the facts, and can effectively implement our recommendations, your chances of defeating humankind’s deadliest habit will be greatly increased.
Until recently, smoking was so acceptable that, with the exception of adolescents, everyone knew who smoked and who didn’t. In contrast, many smokers now hide their addiction—from their loved ones and even themselves—just as troubled drinkers do. Increasingly, we see spouses who don’t know that their partners smoke; young and adult children who don’t know that their parents smoke; and friends and co-workers who don’t know about their colleagues’ smoking habits.
Many smokers deny their habit to themselves. Many minimize not only the threats that smoking poses to their health, but the actual amount they smoke; some even deny that they are smokers. But you are a smoker if you have smoked at least one hundred times in your lifetime and if you smoke regularly, even monthly, now. If you typically smoke your first cigarette within thirty minutes of awakening, or if you smoke twenty or more cigarettes a day, you are addicted to nicotine.
Stage of change self-assessment
This self-assessment establishes your stage of change in the struggle to quit smoking. The more work you have already accomplished, the better your chances for success in the near future. Success will also depend on how co
nscientiously you apply the processes of change as you move through the stages. Give honest answers to the following questions:
Do you seriously intend to quit smoking in the next six months?
Do you plan to quit in the next thirty days?
You can determine your stage by the combination of answers you gave to these two questions (see chart).
Question 1: No
Question 2: No
Your Stage: Precontemplation
Question 1: Yes
Question 2: No
Your Stage: Contemplation
Question 1: Yes
Question 2: Yes
Your Stage: Preparation
If you quit smoking within the past six months, you are in the action stage. If you quit smoking more than six months ago and are still tempted to smoke, even occasionally, you are in the maintenance stage. If you quit, and are free of the temptation to smoke, congratulations.
The remainder of this section concerns the change processes, described earlier, that can help you quit smoking.
Precontemplation
Precontemplators rely heavily upon minimization and rationalization, both of which must be countered by consciousness-raising. Rationalization provides smokers with various and spurious “good” reasons for continuing their habit. Minimization similarly allows smokers to discount the overwhelming evidence that smoking is a destructive habit.
Changing for Good Page 21
