Changing for Good

by James O Prochaska

  Do you come home later than expected because of drinking?

  Do you argue with your spouse when you drink?

  Do you argue about drinking?

  Has your work suffered, or have you been late or absent frequently?

  Be honest when answering these questions. A hangover is the consequence of drinking; calling in sick after a night out is an indication that drinking is affecting your work.

  Being stopped by the police and charged with DUI (driving under the influence) or DWI (driving while intoxicated) is a sure sign that you have an alcohol problem. Many people drink and drive without being apprehended, so they continue to believe that their drinking practices are safe, and that they have committed no crime. Answer these questions:

  Do you drive after a party where you drank heavily?

  Do you have a few drinks before going out on a date or to a party?

  Do you use a designated driver when you go out drinking with friends?

  Examine your own view of alcohol’s impact on our society. Do you tend to downplay its role in family violence and abuse, in sexually transmitted diseases and lost productivity, in auto and household accidents? Finally, take a look at the role alcohol plays in your life. Can you imagine your life without it? Could you go to a party or a bar and order juice? Does the image of a can of beer or a mixed drink appear whenever you imagine yourself relaxing or having fun? If so, drinking may be an integral part of your self-image.

  Even when confronted with strong evidence, many problem drinkers remain evasive. If you are not sure if you are a problem drinker, but suspect that you may be, you may choose to consult a professional for objective feedback. Many employee assistance programs offer a confidential two-or three-session evaluation; the evaluator may refer you to a different program if you have a problem that requires extensive treatment.

  Shorter evaluations exist as well. At the University of Houston’s psychology clinic, for example, a program called Drinker Checkup offers a two-hour assessment. Quick checks such as these, which offer written and verbal feedback about drinking levels, patterns, benefits, and problems, are becoming increasingly available.

  You must be careful when you seek professional help. Some programs offer feedback simply as a way to drum up business. And certain addiction specialists believe that your concern about your drinking is prima facie evidence. The fact that you have showed up is enough for them to diagnose a drinking problem. Investigate the evaluator before making an appointment.

  If you candidly and honestly answered the questions on the previous pages, or if you have seen a professional evaluator, you know if you have a problem with alcohol and that awareness is not enough. The challenge is in making the decision to change.

  Contemplation

  The decision to change drinking behavior is difficult. In addition to the formidable physical challenge of quitting, there are countless emotional difficulties that make this decision a frightening one. When you decide to tackle your problem drinking, there will be no choice except to go public, since everyone who knows you will become aware of it. If you used alcohol as a social stimulant, you will have trouble socializing; if drinking was your way of letting off steam, you will be uptight. Many people never change their drinking patterns because they believe they will have to give up too much.

  Even your spouse may not encourage you. One woman, who was genuinely upset about her husband’s drinking binges, declared that she really hoped he was not an alcoholic who had to quit drinking. The effect on their social life, she felt, would be chilling.

  Many problem drinkers decide that their problem is not so bad, and can be solved with minor behavioral adjustments or a little self-control. In some cases, this is possible. Perhaps a minor change in your drinking habits is all you need. Or perhaps that would be the equivalent of trying to change you car tires with a pair of needle-nose pliers.

  Fierce debates rage throughout the professional community over the appropriate goal for people with drinking problems. In general, therapists view abstinence as the best and safest goal for individuals considered to be “alcoholic” or “alcohol dependent.” Restraint and self-control are looked upon as responsible goals for “alcohol abusers” or “problem drinkers.” The problem, of course, is in how you define who is “alcohol dependent” and who is an “alcohol abuser.”

  We believe the argument is moot. No one is diagnosed as alcohol dependent until they have tried to use restraint to solve their drinking problem. This is a key dimension of the definition of dependence: The individual drinks more than intended or has tried, unsuccessfully, to stop. Once restraint has been eliminated as a possibility, abstinence is the logical goal. In many ways, it is easier to achieve success at abstinence than restraint. Once you have started drinking, it begins to affect the evaluation and judgment centers of the brain, and it becomes more difficult to maintain your commitment to moderation.

  Preparation

  Whether your goal is restraint or abstinence, you must first develop a realistic plan and make a firm commitment to follow through on it. The secret is not simply to work harder but to work smarter to implement the plan. Seize upon an opportunity—a particularly embarrassing or inspirational event—to gain extra motivation. Listen to the frequent, forceful verbal commitments you are making, and gird them with a continuing commitment and a solid time frame for action.

  Action means stopping some behaviors and beginning others; in the beginning, for days and even weeks, not drinking is the central focus. This may seem obvious, but to succeed in this abstinence (or restraint, if you choose that path), you must develop “behavioral refusal skills” the skill to refuse offers and pressures to drink, the skill to order nonalcoholic beverages, the skill to know when the urge to drink nearly overwhelms you, and the skill to avoid or walk away from tempting situations.

  A good action plan starts with environment and stimulus control. Limit availability of alcohol, avoid places where drinking is encouraged, shun contact with other drinkers. If alleviating frustration and controlling anger have been important reasons for drinking, relaxation is an important countering method. Physical exercise and assertiveness training are also beneficial, as are anger management techniques. Seek solutions to depression and anxiety problems, and work to create healthier personal relationships and a positive lifestyle. All of these techniques are needed to avoid becoming what A.A. members call a “dry drunk,” someone who is not drinking but who has not changed his or her lifestyle.

  Maintenance

  As you move from action into maintenance, remember that a lapse is not a relapse. You can eat one potato chip without finishing the bag; you can have one drink without reneging on your total commitment. Don’t assume that taking a single drink means that you have lost control—unless you give up and give in. A relapse means a full-fledged return to your old pattern of drinking, not one evening’s slip-up.

  Rather than undermining your self-confidence with multiple slips and self-defeating statements, reward yourself regularly. Give yourself credit each time you encounter a situation in which you used to drink but avoid it now. Your family and friends will take your abstinence for granted quite rapidly, and their praise will die down long before the struggle is over. For this reason, it becomes even more important to keep giving yourself positive reinforcement, both in words and deeds.

  A big challenge is in the long haul. Many individuals find that they must recycle through the stages several times before they are successful in controlling their drinking. You must employ active change strategies over months and years in order to achieve long-term sobriety or nonproblematic drinking.

  Remain active and vigilant during maintenance, and continue to use your refusal skills. Do not become overconfident. A big danger sometimes lies in the belief that you are free to return to risky situations. Keep reviewing the reasons you have for not drinking, and stay alert for signs of trouble—increasingly frequent urges or temptations to drink, returning to the old haunts, and generally p
utting yourself in harm’s way.

  You may be acutely aware of the difficulties and sacrifices you have made by giving up drinking; now make an effort to focus on the long-term benefits. Your liver, central nervous system, and overall well-being will improve dramatically; your family’s lives will improve as well.

  The road from precontemplation to maintenance is filled with problems and possibilities. Alcohol is an addictive substance, and giving it up requires courage, patience, and persistence. To be successful, take each stage a step at a time; work hard to overcome urges; have the courage to make a commitment and follow through on your decision; show persistence in taking action; and learn to navigate the cycle of change. Many others affected with alcohol problems have been able to gain safe passage.

  DISTRESS—THE FEVER OF MENTAL HEALTH

  If you suffer from psychological or emotional distress, rest assured that you are not alone. Distress is the country’s most prevalent and recognizable psychological problem. According to the 1978 President’s Commission on Mental Health, distress affects as much as one quarter of the adult population at any given time. A national household survey found that a third of all women and nearly a fifth of all men admitted to being troubled by distress in the previous year.* Because it is so common but does not localize the disorder, psychological distress is known as the fever of mental health.

  The vast majority of distressed people confront their problems without professional treatment. They overcome the problem by themselves or with the help of friends, family, clergy, or others. Although most individuals eventually overcome their distress, they do not do so as quickly or efficiently as they would have had they followed a systematic guide for behavior change. A large number of self-changers mistreat themselves by using alcohol or food to alleviate the blues. Drinking and overeating often exacerbates distress. This makes it doubly important that you relieve emotional distress by the careful application of change processes, and not by overindulgence.

  Psychological distress self-assessment

  The self-assessment shown here measures the severity of your present level of distress. What it does not do is establish a specific diagnosis or explain the reasons for your distress. Please indicate how much you have been bothered by these problems during the past month, putting the appropriate number (0, 1, or 2) in the space provided beside each sentence.

  0 = not bothered at all, 1 = not bothered much,

  2 = bothered a lot

  Not having much interest in things (D) ____

  Feeling too tired to do things (L) _____

  Feeling afraid or scared without good reason (A) ____

  Having trouble remembering things (I) ____

  Feeling hopeless about the future (D) ____

  Having trouble getting up in the morning and facing the day, even when I’ve had enough sleep (L) ____

  Worrying too much (A) ____

  Having trouble making up my mind (I) ____

  Feeling sad or crying without good reason (D) _____

  Having trouble getting myself going (L) _____

  Feeling nervous, fidgety, tense (A) _____

  Being so restless I can’t sit still (A) ____

  Being bothered by some unimportant thought that keeps running through my mind (I) ____

  Feeling blue or down in the dumps or depressed (D) ____

  Losing my appetite or losing weight without trying (L) ____

  Feeling keyed-up or overexcited (A) ____

  Avoiding certain places, people, or things because they frighten me (A) ____

  Add the numbers in each column separately and record the total score in the box at the bottom of the column. The result will be four scores; double-check your arithmetic. If your score on D—for Depression—is 3 or higher, then write “high” next to the box labeled D. If it is 2 or less, write “average.” If your score on L—for Lowered Energy—is 3 or higher, then write “high” next to that box. If it is 2 or less, write “average.” If your score on A—for Anxiety—is 5 or higher, then write “high” next to the box. If it is 4 or less, write “average.” And if your score on I—for Inefficient Cognitive Functioning—is 2 or higher, write “high” next to it. If it is 1 or 0, write “average.”

  If you scored high on two or more of the four scales, with at least one of the high scores being depression or anxiety, then you may well be suffering from high distress. If the self-assessment reveals this, it probably indicates the presence of psychological pressure and the need for change, whether on your own or with professional assistance.* A high score on any one scale is still cause for concern, but you might be able to address the problem within the context of helping relationships. Average scores on all four scales, assuming that you responded honestly, indicates that there is currently no need for you to be concerned about emotional distress.

  There are widespread misunderstandings about the meanings of depression, lowered energy, anxiety, and inefficient cognitive functioning. The term “depression” may conjure up a picture of a tiny, elderly woman shuffling around a hospital ward in paper shoes. You may imagine someone in the throes of a panic attack when thinking of “anxiety.” These stereotypes are widespread but unfortunate; each represents an extreme case. Much more typical are milder and less disruptive forms of distress.

  Although we all experience distress differently, most of the following elements are usually present:

  Depression Unlike everyday hassles and occasional disappointments, depression is a pervasive state. You may feel sad, discouraged, and hopeless, have a diminished interest in life, and derive little pleasure from anything.

  Lowered energy The technical term for this condition is anergia, which literally means “lack of energy.” You may have trouble initiating projects, or experience decreased appetite and weight loss, general fatigue, or difficulty in getting started in the morning.

  Anxiety More than occasional nervousness, anxiety is a frequent feeling of nervousness and tension, excessive worrying, unrealistic fears of specific places or situations, general fears, and restlessness.

  Inefficient cognitive functioning Your cognitive abilities—memory, decision making, and concentration—are lower than usual. You may find yourself distracted, in a haze, or with a shortened attention span.

  Stage of change self-assessment

  The first step in any cycle of self-change is to recognize what stage of change you are in. This brief self-assessment will pinpoint your stage for psychological distress; complete it only if you had one or more high scores on the chart in Chapter 10.

  Are you seriously considering overcoming your distress within the next six months?

  Are you planning to overcome distress in the next thirty days (and perhaps taking small steps to do so)?

  Are you now actively overcoming your distress?

  You can determine your particular stage through the combination of answers you give to these three questions.

  Question 1: No

  Question 2: No

  Question 3: No

  Your Stage: Precontemplation

  Question 1: Yes

  Question 2: No

  Question 3: No

  Your Stage: Contemplation

  Question 1: Yes

  Question 2: Yes

  Question 3: No

  Your Stage: Preparation

  Question 1: Yes

  Question 2: Yes

  Question 3: Yes

  Your Stage: Action

  The remainder of this section will help you apply the change processes to psychological distress. We will cover each stage and recommend techniques to invoke each process in breaking the fever of mental health.

  Precontemplation

  Although distress is both common and recognizable, many people do not view it as a problem, thanks either to apathy, overt defenses, or ignorance. There are people who have been chronically distressed for years, and don’t realize that alternative states of being exist. They accept their psychological condition as normal, or “just how I’
ve always been.”

  Distress may go unnoticed because it is masked by other behavioral problems that receive all the attention—physical aggression, for example, abusive drinking, or loneliness. Understandably, people respond most quickly to visible problems like getting into fights, being fired from work, coming home drunk, or not leaving the house for days, while neglecting the underlying but less obvious distress.

  More women than men acknowledge distress. Because of sex-role socialization and cultural expectations, women are generally both more aware and more expressive of their internal turmoil. In private moments or public surveys, they admit distress and label it as such; they are disinclined to mask it. Men are less receptive to this so-called wimpish problem, and rarely express distress verbally. They may become verbally abusive, develop hypertension, or increase their substance abuse. One recent study found that fully half of drug users have a depressive disorder. Whether you are male or female, substance abuse may reduce your distress, but only temporarily. Distress returns with a vengeance along with the increased substance use.

  Sooner or later, distress becomes so unbearable that recognition and change are necessary. The good news is that most distressed people do overcome the problem successfully.

  Contemplation

  Psychological distress is an outrageous liar. It makes us think, feel, and behave in self-defeating and self-perpetuating ways. If you suffer from distress, chances are at least one of these statements is only too familiar:

  “It’s all my fault.”