Obviously, this does not happen overnight. We believe that it takes smokers an average of thirty-six to forty-eight months of maintenance before they feel little or no temptation to smoke. Some never pass the maintenance stage, reporting significant longings for cigarettes in certain situations even after fifteen years of abstinence. Some former smokers appear to use no conscious change processes to control their behavior because they experience no temptations that need to be controlled. They experience themselves in the same way as individuals who never smoked.
Solid self-efficacy Terminators transfer their “center of gravity” from their problems to themselves. They look, think, feel, and act not with false bravado but with genuine confidence. They are convinced that they can function well without ever again engaging in their former problem behaviors.
It takes an average of twelve months before many people who ultimately terminate smoking become fully confident that they can cope with tempting situations without lapsing. Confidence peaks one year after action begins, but temptation does not bottom out until two or three years later.
Solid self-efficacy is never guaranteed. Again, certain people who have not smoked for ten years still lack the confidence to say they will never smoke again. Such “lifers” must continue to counter the temptation to smoke; some stave it off by promising themselves that if they ever develop a fatal disease, they will begin smoking again.
Using the criteria of 100 percent self-efficacy and zero temptation across all high-risk situations, we have found that 16 percent of former smokers and 17 percent of former alcoholics have reached the termination stage. These people are not in recovery; they have recovered. This does not only mean that these former alcoholics will never have a drink again. It also means that they will have no temptation to drink and are fully confident that no matter what situations they encounter—whether they are angry, anxious, bored, depressed, celebrating, or socializing—they will never again rely on alcohol as a way of coping.
Many others still have to use some change processes in certain situations to keep from relapsing. Those who still experience some temptation and lack of confidence in certain situations continue in the maintenance stage. This doesn’t mean that they will necessarily relapse. It just means that they still have to make some efforts to control tempting situations.
A healthier lifestyle Life changes are essential for maintenance; a new lifestyle is essential for termination. The difference is in the permanence of the change. In maintenance, you modify parts of your life—social contacts, daily schedules, behavior patterns—to overcome your problem. In termination, you institute a healthier lifestyle as a means of preserving your gains and promoting new growth.
Two approaches to abstinence from alcohol illustrate the difference. Robert has alternated between action and maintenance for twenty years, staying sober 90 percent of the time. When he lapses or relapses, he puts his action plan back into gear; he cuts out parties, goes back to A.A., works out three times a week, and rewards himself for each week and month of sobriety. After months of success, he quits going to A.A. and to his health club. He puts himself back in tempting situations and he expresses resentment over always having to control his temptation to drink.
Shawna, on the other hand, learned early that staying sober was much easier when it was part of a healthier lifestyle. After quitting drinking, she quit smoking for good measure. She sees herself as a health advocate—one who has integrated exercise, not smoking, and a low-fat diet into her life. She loves to socialize, but in healthy settings, not in smoke-filled bars and clubs.
Shawna does not spend her energies on struggling to stay sober or free from smoking. She spends her time on activities that are healthy and enlivening.
The real solution
Creating a healthier lifestyle involves altering more than your problem. Recent studies of people who successfully overcame troubled drinking on their own showed that half of those individuals also quit smoking on their own. Smokers in relationships with other smokers have little chance of successful termination unless they develop new relationships that support their changing selves. It is simply naïve to believe that you can go on living the way you did before and have the consequences be different.
Although you can never be problem free, you can live in ways that reduce the recurrence of self-defeating behaviors. Just as being in top physical shape is the best way to prevent injury and disease, being in top psychological shape makes it less likely that you will engage in self-destructive behaviors.
If you believe that life is passing you by, you will find it easy to give up on yourself. Spend your time and energies on self-enhancing activities instead. You will be less tempted to indulge in self-defeating behaviors. Pursue your dreams of being a student or a teacher, a parent or a lover, an adventurer or a traveler, and in this way commit to live life to its fullest while preventing behaviors that short-circuit your endeavors. As long as you act on your potential to change, you will discover that even the darkest days will end and the most tempting situations will pass.
As you progress through the stages of change, you will appreciate the major accomplishment you have achieved in moving from precontemplation to termination. By acting on your potential for change you not only resolve a problem, but create a happier and healthier self.
APPENDIX A
Foolish Freedom
IT REMAINS DIFFICULT to believe that many otherwise intelligent human beings actively resist becoming aware of the ways in which they are endangering, damaging, or even destroying their lives. You have no doubt heard the slogans of people who maintain their right to just such a foolish freedom. They go something like this: “No one can tell me how to live my life.” “I’ll pull my own strings even if they hang me.” “They’re my children—I’ll spoil them [or beat them] if I want to.” “No one is going to tell me how to manage my money—even if I am going broke.”
Often those who have grown up with an overcontrolling parent are especially vulnerable to this all-consuming need for control. These people seem to have vowed to themselves, “Never again will I let anyone control me. If anyone is going to be in control, it will be me.”
Maria had a tyrannical father who insisted on knowing and controlling every detail of her life. He chose her clothes, her friends, and her college. When she went out on a date, he waited up for her and pumped her with questions as soon as she walked in the door. Maria seethed inside, but never dared stand up to her father. At the age of thirty-three she found that she had total control over her husband. She determined what they did, when they did it, what they bought, and whom they socialized with. She was in such control during sex that she was unable to let go and enjoy herself.
Even people who do not have an overwhelming need to control their lives can be vehement about continuing their self-destructive behaviors unimpeded. A partial explanation can be found in the laboratory research of a zoologist named Calhoun. Unlike most researchers, Calhoun studied wild mice (instead of domesticated white mice and rats) to learn how they strive to control their own behavior.
Calhoun provided his wild mice with an electric switch with which they could choose bright light, dim light, or no light in their cages. The mice consistently threw the switch that turned on the dim lights, avoiding bright lights and darkness. But when the experimenter turned on the dim light, the mice ran over to turn it off, substituting bright light or no light. In another experiment, Calhoun gave the mice control of a switch that turned a revolving wheel on and off. Running in the wheel was their only source of exercise. To stay healthy, caged mice need to run about eight hours a day, so, as you might expect, the mice periodically turned on the switch and ran. But every time the experimenter turned on the wheel, the mice immediately switched it off, even though they needed and wanted to run.
This is foolish freedom. The mice preferred mastering the switch to running. They demanded control over their behavior, even if it meant sacrificing their own health. White mice, bred to be easily
handled and manipulated, are too tame to exhibit this kind of behavior. Many of the research psychologists, like B. F. Skinner, who studied domesticated animals, concluded that human beings can be easily controlled by external conditioning. Sigmund Freud, on the other hand, believed that human beings are more like wild animals, controlled by internal biological drives.
In the industrial age in which Freud lived, much of life consisted of boring routines, and an individual’s defenses served to control internal impulses that threatened to master the psyche. In those days, inhibitions were strong because internal impulses were correspondingly powerful. Today inhibitions are weaker. In our information age, it is the external not the internal messages that threaten to overwhelm us. Humanity’s very same psychological defenses now seek to control the demands society and the media make on us—to just do it, to choose the real thing, because what you want is what you get. Too many people cannot control their media-fueled desires. We smoke, drink, overeat, and overspend. We seek fulfillment in external objects.
Internal impulses can keep us from attending to the tasks at hand. Similarly, external messages can captivate our minds and keep us from concentrating on what is most important to us. Unfortunately, we have trouble distinguishing helpful messages from harmful ones. It seems the only freedom we can achieve is negative—freedom from the demands of others. It is certainly true that many of us have such a strong desire to be in control that we resist beneficial changes.
People who, like the wild mice, insist on being in control at all costs are out of balance. They are rebellious precontemplators, equating freedom with control and resisting the most well-intentioned external influences that could free them from self-destructive behavior. Such people maintain closed lives, filtering out all information that might help them change, regardless of the source. As a result, they are often surprisingly uninformed about the very behaviors that others see as problematic.
Under what conditions are we likely to be open to the developmental processes within us or the environmental processes outside us as freeing influences that enable us to change our lives intentionally? Under what conditions do we experience these same processes as coercive forces imposing change on us that we must resist with our best defenses?
To respond to these issues adequately would require an adequate theory of personal freedom. Unfortunately, such a theory does not yet exist, mainly because psychologists and other social scientists have not taken personal freedom seriously. But the existentialist philosopher Bergmann does point the way to a model of personal determinism.
First, let us be clear that the assumption that people can be free is not a tender-minded position that contradicts the tenets of tough-minded scientists. Freedom is not incompatible with determinism. Freedom and determinism have all too long been paired as polar opposites. Personal freedom requires a deterministic world which is predictable and controllable. One of the most terrifying problems is to experience our lives as being unpredictable and uncontrollable.
By opposing determinism to freedom, we are left with the untenable notion that we can be free only when our behavior is entirely uninfluenced. According to this notion, only acts of sheer caprice, performed in total independence of advantage or reason, can be free. Freedom becomes limited to actions that are truly spontaneous and unpredictable, totally unbounded, and yielding to no authority—not even reason. Freedom thus must materialize out of nothing, like the irrational but apparently spontaneous acts of rock bands who end up smashing their instruments for the sheer sake of being free from encumbrances.
Before I can experience this chaos as freedom, I must experience my reason as something other than myself. If I feel coerced when obeying my reason, then my reason is not an intimate part of myself. I experience my thoughts as alien and unfree when I am obsessing, when I cannot get that thought out of my mind. I don’t identify with the thought. The thought is intrusive, oppressive, and obsessive.
The primary prerequisite of freedom is a sense of self that is possessed by something that wants to be acted out. If I identify myself as essentially a reasonable person, for example, then I experience myself as most free when I act in harmony with reason. Reason is not alien to my sense of self but rather is an essential part of it. If the environment provides new evidence for quitting smoking, I can freely begin to contemplate quitting smoking if I identify the evidence as reasonable. From this perspective, I am not free when I am coerced into acting irrationally. As a reasonable person I might prefer not to smoke, but I may feel compelled to smoke by irrational forces within me. Thus, I experience my problems as due to coercion or compulsion, not to free choices.
If I identify myself with all my internal impulses, all actions that flow from within are free. From this perspective, I may continue to smoke unreasonably but feel guilty rather than coerced. This sense of self denies any psychological compulsion but at a cost of considerable guilt. The only true coercion occurs when forces literally external to me compel me to action. If my family pressures me into psychotherapy to work on my drinking, I may go, but out of a sense of coercion, not choice, because they were the prime movers of my action.
An act is free if I identify with the elements that generate it. An act is coerced if I feel dissociated from the elements. Thus, identification is logically prior to independence. Freedom is not a primary, but a derivative, experience. A sense of self is logically prior to self-control. Personal freedom is the acting out of our identity, our self.
Self-reevaluation is an important change process for preparing for liberating action. Through this process you come to think and feel differently about yourself (as a drinker, smoker, or whatever). You are preparing to give up and grieve for an important part of your identity—not just for now but forever.
Our research shows that increases in self-reevaluation lead to the greatest increases in the pros of changing. As you look to a future free from compulsions, addictions, or depressions, you can imagine a growing number of good reasons to shed your old sense of self.
Some of the reasons can be surprising. In a study with the Centers for Disease Control and Prevention, I was surprised by the number one reason our research participants gave for practicing safer sex. These were IV drug users, prostitutes, and street youth in five of the toughest cities in the United States. You might expect that the only reason to always use condoms would be to keep from contracting AIDS. This was the second most important pro. The first was to be a more responsible person.
Responsible freedom is when you choose to change for the best of reasons, regardless of what you were conditioned to do, what you feel compelled to do, or what is most immediately gratifying to do. Our fullest freedom emerges when we have the opportunity to choose that which would enhance our life, our sense of self, and our society.
Foolish freedom is reactive—reacting just to keep from being controlled or reacting to immediate consequences. Responsible freedom is interactive—interacting with feedback and information about how changing our behavior can be beneficial to ourselves and to others. You don’t have to resist if someone is trying to change you for good reasons. You can interact with the person and his or her reasons. If that person influences you to change for good, so much the better for both of you.
APPENDIX B
A New Paradigm
OUR WORK ON the stages of change represents a new paradigm of behavior change. Health officials will be especially interested in how this paradigm fares in health promotion programs. Some of the comprehensive data that support this paradigm are:
The stages of change approach has been cited as being perhaps the most important development in the past decade of research on smoking cessation specifically (JCCP, 1992) and health behavior change generally (Diabetes Spectrum, 1993).
The stages of change approach is being used for all of the HIV and AIDS prevention programs directed by the Centers for Disease Control in the United States. It is also implemented in all health promotion programs for dieting and for countering sm
oking and substance abuse in the National Health Service of Great Britain.
Our work is not just another action-oriented intervention. It is a new approach to understanding, studying, and optimizing how people change high-risk behaviors.
We have demonstrated with a dozen different problem behaviors that change involves progress through a series of stages, not just a progression from high risk to no risk.
Our work is producing principles of change that were hitherto unknown. It matches the most powerful processes of change to the needs of individuals at each stage of change.
Our approach is designed to match people’s self-change efforts at each and every stage of change. It is designed to work in harmony with how people change naturally.
Our approach is appropriate for individuals at every stage of change, and not just the 20 percent or fewer who are prepared to take action.
Action-oriented health promotion programs typically generate 1 to 5 percent participation rates. Programs based on the new paradigm typically generate 50 to 85 percent participation.
Action-oriented programs (aimed, for example, at smoking) typically reduce the rates of risk by 1 to 2 percent. Programs based on the new paradigm typically reduce the rates by 12 to 18 percent.
Action-oriented programs typically produce high initial success rates followed by dramatic declines in success over time. Programs based on the new paradigm typically produce lower initial success rates followed by dramatic increases in success over time.
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