Changing for Good

by James O Prochaska

  “I’ll never get better!”

  “I’m a shit.”

  “I’m too afraid to do that.”

  “I can’t do it—I’m helpless and incompetent.”

  “That’s too hard—it makes me feel scared. I won’t do it.”

  A crucial step for distressed contemplators is to develop an awareness of the implicit, dysfunctional thoughts that reinforce their unhappiness. Cognitive therapists recommend making a daily log of these thoughts. Initially, the thoughts can be difficult to uncover. Start by logging instances of distressed behavior:

  DAILY LOG—SATURDAY

  Told Fred I can’t come to his party tonight.

  Spent evening sitting home, watching television, and feeling upset.

  Gave up on cleaning the house.

  Began to drink.

  Eventually, you will become adept at identifying the automatic thoughts underlying your behaviors. The client who began this log was able, on reflection, to remember the thoughts that triggered his behaviors:

  DAILY LOG—SATURDAY (with the thoughts underlying my behaviors)

  Told Fred I can’t come to his party tonight:

  “I won’t have a good time.” “Nobody likes me.”

  Spent evening sitting home, watching television, and feeling upset:

  “Nothing I do makes a difference.” “Maybe I’m going crazy.”

  Gave up on cleaning the house:

  “My mind just won’t cooperate.” “I don’t have the energy.”

  Began to drink:

  “Maybe this will make me feel better.” “Nothing else is working.”

  Even a simple daily log can provide you with lots of essential information. Your own list will reveal the number of times your distress is associated with negative consequences. If you record your log on a daily basis, factual incidents, not distorted recollections, will provide you with the reasons you need for changing. These jottings can form the basis for a pros and cons assessment (discussed in detail in Chapter 5).

  In addition, you will begin to see the pattern of your elusive thought processes. For example, the preceding log reveals indifference, helplessness, and low self-esteem. Information such as this will be essential when you try to alter your thought processes during the action stage.

  It is also useful at this stage to gather factual information about distress and its ramifications. Few distressed people realize just how universal their problem is. Do some reading about your type of distress. Ask your loved ones how they experience your distress. Does it influence your behavior toward them and your children, co-workers, and neighbors? The answers may make you uncomfortable, but self-awareness will lead to incisive self-reevaluation. How long are you willing to remain distressed?

  Action

  Chronic distress can operate in a vicious cycle. The causes of distress give rise to effects that can in turn cause further distress. A failure at work, for example, can cause distress. The effects of anxiety, depression, lowered self-esteem, and cognitive impairment can cause further failures at work, which leads to more distress, and the cycle continues.

  Yet you can disrupt your own cycle by understanding the circular and self-perpetuating relationship of all the parts, and by intervening at one or more points. You do this by using the three change processes that are most effective during the action stage—countering, environmental control, and reward—and applying them to at least two, and preferably more, points on the circle of distress.

  Countering techniques These can take the form of exercise, relaxation, assertion, countering thoughts, and active diversion. As long as you are physically able, you should exercise, for both the psychological and physiological benefits. Daily aerobic exercise is the simplest popular therapy for depression.

  You might also consider “pleasant event scheduling.” Create a list of pleasurable activities, and make sure that you partake in at least some of them every day. Many of these activities, such as gardening, dancing, playing a musical instrument, crocheting, or social engagements, combine relaxation and activity or recreation. The list is endless; the important thing is to tailor the activity to your own interests.

  Progressive muscle relaxation was originally developed to counteract anxiety. The relaxation state is incompatible with anxiety; you cannot be anxious as long as you are relaxed. Learn and practice the relaxation techniques described in Chapter 7.

  Clinicians recognize that passive, dependent personalities often repress their frustrations; over time, this can result in pent-up anger or depression. Assertiveness training is frequently used in treating psychological distress. Assertiveness affects many parts of the distress cycle, helping you to correct thoughts, alter relationships, improve interpersonal behavior, and feel more capable and vital.

  The most thoroughly researched professional treatment for distress is cognitive therapy, which combines the above methods, emphasizing the countering of dysfunctional thoughts. Regardless of the origin of distressing feelings, behaviors, and relationships—countering maladaptive beliefs can stop the vicious cycle cold. The objective of cognitive methods is deceptively simple: Identify dysfunctional thoughts, dispute them, and replace them with realistic, healthy ones. You have already learned to identify underlying thoughts by keeping a daily log. Here is a method to counter those thoughts, using a triple-column diary.

  In the first column of the diary, record your “Automatic Thought,” what you tell yourself when you are distressed. In the second column, indicate whether there is solid, scientific evidence in support of your thought. Ask yourself: Is this thought a realistic appraisal of the situation? Or have I fallen for the lies of distress?

  The third column is reserved for balanced, realistic thought. When your first, automatic thought is realistic—a minority of cases—there will be nothing to enter in this column. Most times, however, your distressed thoughts are not grounded in evidence or reality. In these instances, you will actively dispute the original thought and replace it with a realistic and healthier self-statement. Table 12 is a sample diary, filled out by the client who decided against going to a party.

  TABLE 12. SAMPLE DIARY

  Automatic Thought: I won’t have a good time.

  Evidence for It: None. Always had a good time before.

  Substitute Thought: When I’m distressed I tend to withdraw from others. But I’ll probably have a good time and it would help me to go.

  Automatic Thought: Nobody likes me.

  Evidence for It: None.

  Substitute Thought: Another lie told by distress. I could have more friends of course, but Louise, Joyce, and Fred are my friends when I allow them to be.

  Automatic Thought: Nothing I do makes a difference.

  Evidence for It: None.

  Substitute Thought: I can’t control everything, but I do run most things in my own life.

  Automatic Thought: I don’t have the energy.

  Evidence for It: Some. It’s true that I have less energy when I’m distressed.

  Substitute Thought: I can decide to go whether or not I have energy. I don’t really need a lot of energy just to be at a party.

  In the face of active, rational thinking, most automatic thoughts turn out to be falsehoods. Dispassionate examination allows you to see that there is very little evidence to support these thoughts. Your task then becomes to replace them with balanced and logical thoughts. As you practice countering many times, day in and day out, dysfunctional thoughts begin to fade and realistic replacements take their place. Your distress will fade, too.

  Environment control While restructuring thought processes, you can also restructure your environment so that it works for you rather than against you. The most important action you can take is to avoid those relationships, places, and situations that prompt your distress and replace them with supportive and healing contexts.

  Take the example of Lisa, a thirty-four-year-old chef, who went days without distress despite work conflicts, single-parent pressures, and omnipresent
financial woes. Her commitment to change and countering techniques were exemplary—until she visited her parents. Lisa’s religiously intolerant mother and father belittled her and were unaccepting of her as a person, a mother, and a worker. A weekend of parental rejection overwhelmed weeks of self-change; Lisa quickly reverted to self-depreciation. It took her some time and effort to resolve the initial guilt involved in temporarily avoiding this degrading interpersonal contact, since it essentially meant staying away from her parents. But once she did. Lisa was able to consolidate her change and build her assertion skills. This accomplished, she was able to gradually reintroduce herself to her parents’ home without prompting a relapse.

  Reward Reinforce even small steps in your progress. Treat yourself to a movie for completing a triple-column diary, or give yourself an hour of rest for exercising; solicit a kiss from someone for confronting fear or congratulations for assertiveness. Use whatever reward works for you. Contract with another person for pleasant-event scheduling, exercise, or relaxation. And contract with yourself to avoid the guilt and recrimination that accompanies psychological distress. Reward, not punishment, is the most effective catalyst for change.

  Used simultaneously, countering, environment control, and reward can disrupt the vicious cycle of psychological distress. These change processes are complementary rather than contradictory. If you substitute healthy responses for distress by using countering techniques, rearrange distress-inducing situations by employing environmental control, and reinforce recovery by rewarding yourself appropriately, then you can deal with all potential sources of distress—behaviors, cognitions, feelings, relationships, and family interactions.

  Maintenance

  Pulling out of individual distress episodes is indeed a major accomplishment. The goal, however, is maintaining a distress-free life. Having said that, it is worth pointing out that no one’s life is actually “distress free” as food will always be necessary to the overeater, so anxiety and depression are, in the words of one self-changer, “part of the cost of being alive.” But when you reach the maintenance stage, your life can be free from clinically significant distress. You should be able to prevent inevitable losses and disappointments from leading to a full-blown disorder.

  Begin the maintenance stage by honestly recognizing the possibility of relapse. Although it may seem paradoxical, the acknowledgment of this possibility will help you to firm up your commitment, maintain a healthy distance from distressing situations, and impress upon you the necessity of creating a new lifestyle. All of these ingredients are essential to successful, long-term maintenance, and to the recognition that a lapse is not a relapse, a slip is not a fall.

  People who are distressed can change, but distressful situations can always arise. Life simply cannot be free of psychological distress, as the triple-column-diary entry on the next page demonstrates.

  Automatic Thought: Once I have recovered from distress, I should never experience it again.

  Evidence for It: None. This is a wish, not a fact.

  Substitute Thought: Difficult as it is to accept, my distress will probably return. However, I am now better equipped to recognize it, alleviate it, and prevent it from getting too severe or going on for too long.

  Maintenance strategies prevent ordinary distress from becoming neurotic misery. All of the processes used during the action stage should be used in maintenance, and there are some further strategies to employ. One of the major allies of psychological distress is unstructured time. Empty hours, goalless days, and languid weeks conspire to elevate anxiety and compound depression. Exercise, activity, and diversion can fill the void in the short run, and relaxation training can help you tolerate unstructured time, and even to learn to use it for regeneration. But in the long run, these strategies may not suffice. You need to develop an assertive lifestyle, personal commitments, and a goal-directed life plan.

  A very important strategy in strengthening your commitment involves interpersonal relationships, which bring meaning and context to all our behavior. Most satisfying lives include satisfying relationships, and many people see family and friends as a primary source of gratification in life. Emerging research shows that helping relationships can serve as a buffer against future distress episodes by diminishing the severity of the harsh realities of the world and their negative impact. This buffer is one hypothesis for the repeated finding that married people live longer and more happily than single people.

  The hard facts of life—sadness, disappointment, even tragedy—cannot be avoided. But your reaction to them needn’t be distress; if you successfully navigate the cycle of change, you can learn to react to even the severest blows with appropriate, healthy behavior.

  CHAPTER 11

  Termination—Exiting the Cycle of Change

  IDEALLY, YOU WILL proceed systematically through the cycle of change, moving out of the resistance of precontemplation and into the acknowledgment of contemplation, then entering the anticipation of preparation, the flurry of action, and, last, the consolidation of maintenance. Few changers actually follow the path so directly; most become sidetracked at one stage or another. However, with persistence, knowledge, and experience, you may arrive at the point where you consider that you are now free from a long-standing problem. This is called “termination,” the exit from the spiraling cycle of change.

  There are professionals who believe that termination is impossible, that the most anyone can hope for is a lifetime of maintenance. In his 1937 paper Analysis Terminable and Interminable, Sigmund Freud asked, “Is there such a thing as a natural end to analysis?” His conclusion was that meaningful change was a lifelong pursuit, and that even psychoanalysis—the most intensive and extensive treatment then available—could not provide a complete resolution of all conflicts.

  This is a realistic approach. Personal growth is an openended enterprise. In the course of our work, we have met people who have maintained behavior change for five or even ten years before returning to an old maladaptive habit. Usually the return is triggered by a personal disaster, such as the death of a spouse. No program of behavior change can possibly anticipate and prepare you for tragedies that are decades away.

  Do not, however, overlook the benefits of overcoming a problem. With experience, you can identify its early warning signs: lethargy, overconfidence, and renewed temptations. Even if a problem is never terminated, it becomes less of a threat as the years go by. Vigilance can safely decrease over time.

  As for true termination, there is little consensus among the experts. We believe that it can occur, depending on the nature of the problem. While you may hope to terminate certain problems, others appear to be interminable. Experts often disagree as to which problems belong in which camp.

  Alcoholism, for example, is usually seen as a lifelong disease; Alcoholics Anonymous refers to abstinent drinkers as “recovering” alcoholics, never “recovered.” An increasing number of behavioral scientists, however, view alcohol abuse as a disorder that is subject to the same controls and contingencies as any other dysfunctional behavior. They chart the progression from abuse to dependence to addiction along a continuum, and resist the oversimplified classification of “alcoholic.” Our goal, whenever possible, is to help people be recovered rather than spend a lifetime in recovery.

  Age factors into the question of termination. With problems like smoking and substance abuse, the older you get, the more likely you are to lose your taste for the habit and quit. People have a greater potential to bring to termination those problems that tend to disappear with age. With other problems, like being inactive or obese, age works against you. People tend to become more sedentary and heavier with age. Problems that naturally worsen with age are more likely to require a lifetime of maintenance.

  DEFINING TERMINATION FOR YOUR PROBLEM

  How far and how long must you go before you consider your problem to be terminated? How do you determine when you have been vigilant long enough? How can you distinguish the real signs of t
ermination from the rationalizations that will cause your problem behavior to return?

  Our research and clinical experiences indicate that there are at least four defining criteria. These approximate standards divide terminators from lifetime maintainers:

  A new self-image Short-term change may be transitory, or it may result from temporary but unsustained action, developmental events, or just plain luck. However, if a significant revision in your attitude and self-image takes place during the maintenance stage, there is a good chance you will approach termination.

  Clients in maintenance frequently tell their psychotherapists that, while they have mastered their problem, they do not yet feel that the change is “theirs.” Their old self-image is inconsistent with their new behavior, but they have not yet developed a new one. As the new behavior takes hold, a new self-image, one that feels consistent with the healthier behavior, gradually develops. This development is a promising sign of termination.

  No temptation in any situation To terminate for good, you must experience no temptation to return to your old behavior, regardless of the situation. If you no longer feel any desire to smoke, abuse food or alcohol, spend money, or engage in any other type of problem behavior, no matter where you are or how you are feeling, you may have terminated the change process for that particular problem. The ability to enter restaurants, stores, bars, or parties without being tempted to lapse is a clear sign of termination. When you can feel sad, angry, depressed, or anxious without being tempted to counter these feelings with problematic behaviors, you should be encouraged. When you no longer dream or daydream about eating, smoking, or drinking, those problem desires are becoming extinct.