Changing for Good Read online

  Changing for Good

  James O. Prochaska, Ph.D.

  John C. Norcross, Ph.D.

  Carlo C. DiClemente, Ph.D.

  To Our Children,

  who have changed our lives

  in so many good ways

  Jason and Jodi

  Rebecca and Jonathon

  Cara and Anna

  Contents

  Introduction: A Scientific Revolution

  Part One: The Science

  1. How You Change

  The Transtheoretical Approach

  The Processes of Change

  2. When You Change

  The Stages of Change

  The Spiral Model of Change

  3. Making Changes

  Learning from Self-Changers

  Integrative Conclusions

  Knowing Your Stage

  Part Two: The Applications

  4. Precontemplation—Resisting Change

  The Attitudes of Precontemplators

  The Defenses of Precontemplators

  Helping Precontemplators

  Consciousness-Raising

  Helping Relationships During Precontemplation

  Social Liberation

  George’s Increased Consciousness

  5. Contemplation—Change on the Horizon

  The Fourth Process: Emotional Arousal

  The Return to Consciousness

  George’s Changing Self-Image

  The Fifth Process: Self-Reevaluation

  Gail, the Diet Expert

  Helping Relationships During Contemplation

  6. Preparation—Getting Ready

  Continuing Self-Reevaluation

  The Sixth Process: Commitment

  Gail Prepares

  Helping Relationships During Preparation

  The Principles of Progress

  7. Action—Time to Move

  The Seventh Process: Countering

  The Eighth Process: Environment Control

  The Ninth Process: Reward

  Helping Relationships During Action

  Gail Takes Action

  8. Maintenance—Staying There

  A Strategy for Success

  Processes for Maintaining Change

  Self-Efficacy—A Measure of Success

  Helping Relationships During Maintenance

  9. Recycling—Learning from Relapse

  The Ten Lessons of Relapse

  Seeking Professional Help

  Where to Seek Help

  10. A Changer’s Manual

  Smoking—The Number One Health Problem

  Alcohol—Precontemplative Hell

  Distress—The Fever of Mental Health

  11. Termination——Exiting the Cycle of Change

  Defining Termination for Your Problem

  Appendix A Foolish Freedom

  Appendix B A New Paradigm

  Bibliography

  Searchable Terms

  Acknowledgments

  About the Authors

  Copyright

  About the Publisher

  INTRODUCTION

  A Scientific Revolution

  WELCOME OR NOT, change is unavoidable. Life itself is change, as the Greek philosopher Heraclitus observed over 2,500 years ago. Each moment is different from every other. Nothing remains static for an instant, from a planetary to a molecular level. Few of the changes we experience are under our control: When we watch the often tragic history of the world unfold, just as when we face our personal tragedies, we may feel helpless, or at least limited as to what we can do. Even the unexpected rain on a summer vacation is frustratingly out of our control. And, of course, we have no say over the passage of time.

  Although we cannot intentionally change many aspects of ourselves or our world, we can exert some power over the courses of our own lives. We can work to improve our economic situations, our family ties, and the condition of our homes. There are other kinds of changes we can make by ourselves—of our behaviors, thoughts, and feelings—and these are the kinds of changes that concern us here.

  For over twelve years now, my colleagues and I have dedicated our efforts to discovering how people intentionally change. We have been searching for an underlying structure of change, one that might be common to both self-administered and therapeutic courses of treatment for addictive behaviors. People do successfully reverse complex problems and addictions, with and without psychotherapy. We wanted to know if there were some basic principles that reveal the structure of change.

  We now have compelling evidence to suggest that there are. The three of us, John Norcross, Carlo DiClemente, and I, are practicing clinical psychologists, university professors, research collaborators, and self-change enthusiasts. We have conducted more than fifty different studies on thousands of individuals to discover how people overcome problems of smoking and alcohol abuse, emotional distress, weight control, as well as others. Our model—which draws on the essential tenets of many diverse theories of psychotherapy—has been tested, revised, and improved through scores of empirical studies, and is currently in use by professionals around the world. We never expected to produce a revolution in the science of behavior change—but that is just what our esteemed colleagues are claiming we have done.

  Dr. Barbara Rimer, director of the Cancer Prevention Research Unit at Duke University, was one of the first to suggest that our work was precipitating a paradigm shift in how health professionals understand and change high-risk behaviors. Dr. Howard Schaefer, director of Harvard’s Addictions Treatment Center, believes that we have provided an intellectual framework for a modern reformation in the approach to changing addictive behaviors. And Dr. William Saunders of Criton University in Australia reports that it is hard to remember how health professionals used to understand behavior change before our model emerged. Health establishments that use our model include the Centers for Disease Control and the National Cancer Institute, in the United States, the National Health Service of Great Britain, and Johnson & Johnson, worldwide.

  Our novel approach to change belies the old action paradigm, wherein change was assumed to occur dramatically and discretely. This action paradigm has dominated behavior change programs for the past three or four decades. Following this model, clients are enrolled in relatively brief programs designed to conquer smoking, weight, alcohol, or other problems; within weeks they are expected to take action and adopt healthier lifestyles. If they fail to take or maintain action, the clients themselves are blamed for a lack of willpower or motivation.

  We were the first to consider that it is this model of behavior change that is inadequate, and not those who wish to change. Successful self-changing individuals follow a powerful and, perhaps most important, controllable and predictable course. Along this course are various stages, each calling for particular and different approaches to change. The action stage is simply one of six stages—following precontemplation, contemplation, and preparation, and preceding maintenance and termination. No one stage is any more or less important than another. We have found, in a representative sample across more than fifteen high-risk behaviors, that fewer than 20 percent of a problem population are prepared for action at any given time. And yet, more than 90 percent of behavior change programs are designed with this 20 percent in mind.

  Our scientific approach to self-change requires that you know what stage you are in for the problem you want to overcome. The key to success is the appropriately timed use of a variety of coping skills. During our studies, we have found much that is encouraging, including the fact that even people who are not ready to act can set the change process into motion. Our model can benefit individuals in any stage of a problematic behavior, fr
om those who don’t want to change to those who have spent years hoping to change…someday.

  The model is being applied by researchers to help understand how people change in a remarkable range of circumstances. The stages of change are employed in rehabilitation programs designed for delinquent adolescents, cocaine and heroin addicts, and patients with brain injury; in therapeutic courses for clients suffering from interpersonal problems or depression, and for alcoholics and alcohol abusers; and in clinical trials of psychotropic medications for patients with anxiety and panic disorders. The model has also been used to change behaviors of sedentary people and people with high-fat diets, people who allow themselves to be overexposed to the sun, adolescent and adult smokers, and dozens of other groups.

  Up until now, only a minority of psychotherapists were intuitively aware of how to guide self-changers through the different stages. This explains why so few people with problems go to excellent action-oriented treatment programs; fewer than 5 percent of smokers, 10 percent of alcoholics or obese individuals, and 25 percent of people with mental health disorders ever seek psychotherapy. It also helps to explain why over 45 percent of clients drop out of psychotherapy prematurely, since treatments too often don’t match the stage clients are in.

  Contrary to what many people believe, self-changers are just as successful in their efforts to change as those individuals who choose to enter therapy or join a professionally run program. The vast majority of people who change never visit a mental health professional or participate in an organized program. They cope with their difficulties themselves, using their own capacities and resources, drawing on others for support, and developing strategies based on hard experience. After years of ongoing work, we have gathered and evaluated data from thousands of these successful self-changers. And it is their experience upon which we have based our book, rather than on academic theory or “expert opinion.”

  Although psychotherapy can provide an excellent environment for change, there are fewer differences between therapy-changers and self-changers than was once believed, and many more similarities. In fact, it can be argued that all change is self-change, and that therapy is simply professionally coached self-change. Even when seeing a therapist, a client does all the work in the 99 percent of the week that he or she is not in the consulting room. Certainly many people need assistance in order to change, but that help can come from within, from nonprofessionals, or from a book such as this one; the key is always to use the right strategy at the right time.

  Too many people look for easy solutions in the wrong places. There are no magic pills, magic pins, or magic plans. People progress through the same stages of change whether they are overcoming problems with substance abuse, anxiety, depression, or weight control. The result is that the principles that address one particular problem can be transferred to many other problems. In these pages, we will show you exactly what those stages of change are, and which processes you need to work your way through each stage.

  Our system is simple to understand; indeed, it makes so much sense that most people grasp it immediately. This book will help to introduce our work to those therapists and health professionals who wish to know more about our model of self-change. It will be especially helpful to those of you (psychotherapists included!) who have a problem you would like to change.

  Following the example set by successful self-changers, you can learn new skills, draw upon your inner strength, enhance your self-sufficiency, and avoid becoming dependent on others for solutions, thus building your self-confidence for the future. As behavioral psychologist B. F. Skinner once remarked, one thing wrong with the Western world is that we too often help those who can help themselves.

  Though not all self-change is successful, very often failure is due to a lack of guidance. Most self-changers are so busy reinventing the wheel—discovering the passage through change by themselves—that they become exhausted during the course of their struggle. This book will help you to avoid repeating the errors others have made before you. We will chart the path that successful self-changers have followed. We cannot take you down it, of course, but we can provide you with the explicit directions you need.

  To begin to be effective, the process described in these pages requires only that you be open and willing to learn. You will eventually make change a top priority. Armed with understanding and newly developed skills, you will have the best possible chance of success when the time comes for you to take action. Just as professional therapy can provide you with an hour a week to concentrate on change, this book provides you with a structure you can use to stimulate, guide, reflect upon and evaluate your progress. All you need do is make a commitment to read it.

  —JAMES O. PROCHASKA, PH.D.

  University of Rhode Island

  Kingston, R.I.

  Part One

  THE SCIENCE

  For every complex problem there is an easy answer, and it is wrong.

  —H. L. MENCKEN

  CHAPTER 1

  How You Change

  IF ONE SYSTEM of psychotherapy had ever demonstrated clear superiority over the others in helping humans shed undesirable behavior, the name of that system would be a household word by now. But until recently, change has remained enigmatic, and none of the several hundred different existing therapies can effectively explain just how it occurs. Furthermore, no therapy is any more successful than the change strategies that determined, persistent, and hardworking individuals develop for themselves.

  My colleagues and I have made it our life’s work to investigate how people change on their own, without the benefit of psychotherapy. This is work that began, for me, with a terrific frustration at my inability to help a certain man overcome the depression and alcoholism that were killing him. Because this man distrusted psychotherapy, and denied that his depression and addiction were problems, it fell to his loved ones to help him. And although we tried to help, nothing worked.

  The man was my father. After he died, in my junior year of college, I began to study psychology in earnest in an effort to make sense of what had happened. I wondered if there wasn’t some better way to help people like my father change themselves. Too few people with addictions or other self-destructive problems either can or will seek out professional help. I wanted to find some way to bring the wonderful insights of psychology to the mass of people who don’t ordinarily benefit from them, those people who are self-changers. As I studied, I was confronted—just as the layperson seeking therapy is confronted today—with a bewildering array of psychotherapeutic systems from which to choose.

  Therapy is a complex topic: Think of the range of possibilities you confront when you combine an individual client, with one or more complicated problems, with a therapist schooled in a particular theory. A relationship develops between the two, unlike any other relationship even this therapist has with other clients. He or she may employ one of any number of treatment techniques, and must continually decide what to do and when and how to do it. No single system of therapy adequately addresses all of these variables.

  As often happens when a complex subject remains inadequately explained, new theories are developed. When my colleagues and I began our work, the field of psychotherapy was becoming fragmented. In the 1950s, it was estimated that there were some thirty-six distinct systems of psychotherapy; today, there are more than four hundred! Many of these approaches are narrow. Each has its own dogma, with its own saints and heretics along with its more or less faithful followers. Too often these followers are blind to the considerable affinities between their own theories and the theories that issue from other systems. They see only the differences. These differences command, it seems to me, far too much attention.

  As I continued my studies, I became terrifically frustrated again. Now the frustration came from the feeling that I was spending all my time doing other people’s research. And why was so much of this research aimed at bolstering one theory at the expense of another? I had to remember my basic reason for
studying psychology in the first place—I wanted to learn what kinds of ways there were to help people change themselves. Could it be, I wondered, that the hundreds of extant theories reflected the existence of hundreds of unique processes of change, some more valuable than others?

  It seemed more likely that no single approach could be clinically adequate for all problems, patients, and situations. And in 1975, Lester Luborsky, a psychologist from the University of Pennsylvania, declared the grand psychotherapy sweepstakes a tie, citing the Dodo’s verdict in Alice in Wonderland: “Everyone has won and all must have prizes!” Subsequent studies have supported Luborsky’s conclusion that all legitimate psychological therapies produce favorable and nearly equivalent outcomes.