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  Psychotherapy works. When they have finished with a course of therapy, clients are better off than 80 percent of people with the same problems who are on a waiting list for therapy. However, no one has ever demonstrated that one therapeutic approach is consistently superior to another.

  THE TRANSTHEORETICAL APPROACH

  The lack of an overall guiding theory, the search for the underlying principles, the growing acknowledgment that no single therapy is more “correct” than any other, the proliferation of new therapies, and a general dissatisfaction with their often limited approaches, led many thoughtful psychologists to call for an integrated approach to therapy. Struck by Luborsky’s findings, and finally out of school and practicing, I decided to pursue my own research. Was there, I wondered, a way to combine the profound insights of psychoanalysis, the powerful techniques of behaviorism, the experiential methods of cognitive therapies, the liberating philosophy of existential analysis, and the humane relationships of humanism? Was there a way to exploit fully the essential forces of psychotherapy? Naturally, a few theorists insisted that such integration was philosophically impossible.

  Still, it seemed intolerable that no one understood the process of human change. As the psychotherapist Paul Watzlawick put it. “If that little green man from Mars arrived and asked us to explain our techniques for effecting human change, and if we then told him, would he not scratch his head (or its equivalent) in disbelief and ask us why we have arrived at such complicated, abstruse, and far-fetched theories, rather than first of all investigating how human change comes about naturally, spontaneously, and on an everyday basis?” Rather than shaping the therapy to the needs of the individual client, most therapists assume that the client’s issues will fit into a particular mold—that, for example, all his or her problems will eventually lead to conflicts over sex, or aggression, or whatever.

  I set out to find the common components of the major therapies. The first step was to master the masters. I did what amounted to a “cross-cultural” study of the different schools of psychology, with an eye toward integrating them. I tried to isolate the principles and processes of change that each system advocated and practiced. There was a lot of information available about the origins and theories of the different systems, but comparatively little on how they actually helped people to change.

  After working for some time gathering data, I ended up with what was basically a shopping list of the processes of change available in the different therapies. The data were disorganized and made little sense. I think it is worthwhile to demystify the scientific process somewhat. Too often we fetishize scientific discoveries, offering blind faith to ideas we find difficult to inquire into or understand. Many of us regard science as a definite body of knowledge—as if it were a place whose boundary and geography were well known and easily ascertained. In fact, it is a province whose vast unknown territories are filled in only a little at a time. Guesses are made, conclusions drawn, and regions penciled in accordingly, only to be erased or written over later. Scientists rely as much on creative intuition as any artist does—the difference is that the scientist willfully attempts to disprove or validate his or her insight by the most stringent tests imaginable.

  Eventually I left off trying to make sense of my data, and went to spend a brief weekend’s vacation with my wife, Jan, on Cape Cod. The first morning there, I suddenly received an inspiration, a kind of graphic idea that led to an organizing chart of the data. On my paper mat at the breakfast table I sketched the diagram that had occurred to me. I was able finally to see the connections among the different major theories of psychology. Because of a hunch, and a great deal of work, I had discovered processes that could account for change across all psychotherapies. This led to my first book, Systems of Psychotherapy (1979).

  TABLE 1. SUMMARY OF THE PRINCIPAL THEORIES OF PSYCHOTHERAPY*

  Theory: Psychoanalytic

  Notable Figures: Sigmund Freud Carl Jung

  Primary Processes of Change: Consciousness-raising Emotional arousal

  Representative Techniques†: Analysis of resistance Free association Dream interpretation

  Theory: Humanistic/Existential

  Notable Figures: Carl Rogers Rollo May

  Primary Processes of Change: Social Liberation Commitment Helping Relationships

  Representative Techniques†: Clarification and reflection Empathy and warmth Free experiencing

  Theory: Gestalt/Experiential

  Notable Figures: Fritz Perls Arthur Janov

  Primary Processes of Change: Self-Reevaluation Emotional Arousal

  Representative Techniques†: Choosing and feedback Confrontation Focusing

  Theory: Cognitive

  Notable Figures: Albert Ellis Aaron Beck

  Primary Processes of Change: Countering Self-Reevaluation

  Representative Techniques†: Education Identifying dysfunctional thoughts Cognitive restructuring

  Theory: Behavioral

  Notable Figures: B.F. Skinner Joseph Wolpe

  Primary Processes of Change: Environment Control Reward Countering

  Representative Techniques†: Assertion Relaxation training Managing reinforcements Self-control training

  Very early on in the work, I discovered an irony: Although the major therapies usually disagree about what a client needs to change, and certainly they battle over why a client has a given problem, there is more agreement, albeit unwitting, about how change is effected. All of the hundreds of theories of therapy can be summarized by a few essential principles I call the “processes of change.” These processes can be defined simply: Any activity that you initiate to help modify your thinking, feeling, or behavior is a change process. As you can see from Table 1, not all of the processes are used by all therapies. But all the four hundred or more psychotherapies produce change by applying two or more of these processes. As a self-changer, you have the advantage of being able to choose from among all the processes. You aren’t limited to one theory of therapy.

  THE PROCESSES OF CHANGE

  In change, as in many other aspects of life, timing is everything. You will apply different processes to your problems at different stages of change. These stages will be introduced in the next chapter, and far greater detail will be provided as to how the processes of change work within the stages. First, here is a summary of the nine major processes of change.

  Consciousness-raising

  The most widely used change process, consciousness-raising, was first described by Sigmund Freud, who said that the basic objective of psychoanalysis was “to make the unconscious conscious.” Today, almost all major therapies begin by trying to raise your level of awareness, increasing the amount of information available to you, and thus improving the likelihood of your making intelligent decisions concerning your problem.

  Consciousness-raising is not, however, limited to uncovering hidden thoughts and feelings. Any increased knowledge about yourself or the nature of your problem, regardless of the source, raises your consciousness. If, for example, you are trying to lose weight but are unaware that your body can adjust quickly to dieting by lowering its basal metabolism—which in turn leads to burning fewer calories—then you may be baffled when your diet doesn’t work immediately. Your elevated consciousness may help you to make adjustments in your approach to weight loss.

  Social liberation

  This process involves any new alternatives that the external environment can give you to begin or continue your change efforts. No-smoking areas, an alternative atmosphere for nonsmokers—and those struggling to become nonsmokers—are an obvious example of social liberation. Low-fat menu items in fancy restaurants are another.

  Because social liberation is an external force, you will perceive it quite differently depending on the stage of change you are in. Some people resist and resent no-smoking areas. Others struggle to create them. Any individual can act as an advocate for his or her own rights, striving to alter the social environment in ways that can help othe
rs change themselves. Advocacy organizations, such as mental health associations, gay and lesbian alliances, or women’s rights groups, all lend support to personally empowering behaviors. Social liberation not only makes more actions possible, but it can also increase self-esteem as practitioners come to believe in their own power and ability to change.

  Emotional arousal

  This important tool, which forms the basis of so many therapies, can enable you to become aware of your defenses against change. Emotional arousal parallels consciousness-raising, but works on a deeper, feeling level and is equally important in the early stages of change. Known also as dramatic release—or, more traditionally, catharsis—emotional arousal is a significant, often sudden emotional experience related to the problem at hand. It is an extremely powerful process.

  Emotional arousal sometimes results from real-life tragedies. Carlo DiClemente’s brother was a cigarette smoker who had occasionally considered quitting but had made no definite plans. When his sister was diagnosed with ovarian cancer and asked him to give up smoking, he was so moved and so concerned about her and her illness that he finally did quit. Similar stories can be told of driving accidents involving one drunken family member that have stimulated an end to the drinking problem of another.

  Obviously, it is preferable to generate emotional arousal through films, dramatic public-education spots, and fear-arousal methods. Psychodrama is a useful technique that attempts to portray events or relationships in a dramatic setting. The goal of all these techniques is to increase awareness and depth of feeling and to move individuals toward action.

  Self-reevaluation

  This process requires you to give a thoughtful and emotional reappraisal of your problem, and an assessment of the kind of person you might be once you have conquered it. Self-reevaluation enables you to see when and how your problem behavior conflicts with your personal values. The result is that you come not only to believe but truly to feel that life would be significantly better without the problem. How do you perceive yourself as a gambler, a drinker, or a sedentary person? How do you see yourself if you change your behavior? What will be the cost of that change, in time, energy, pleasure, stress, or image? What, overall, are the pros and cons of trying to overcome your problem? These are the emotional and rational questions people ask themselves when applying self-reevaluation.

  Commitment

  Once you choose to change, you accept responsibility for changing. This responsibility is the burden of commitment, sometimes called “self-liberation.” It is an acknowledgment that you are the only one who is able to respond, speak, and act for yourself.

  The first step of commitment is private, telling yourself you are choosing to change. The second step involves going public—announcing to others that you have made a firm decision to change. This amounts to a self-applied pressure to stick with your program, because if you do not succeed in changing, you may feel ashamed or guilty in front of those with whom you have shared your decision. You may prefer to keep your commitment private, so others won’t know if you fail. Although this protects you from embarrassment, it also weakens your will; public commitments are much more powerful than private ones.

  Countering

  The technical term for substituting healthy responses for unhealthy ones is countering, or counterconditioning. All of our behavior is conditional: We are more likely to overeat when dining out than when eating at home, to abuse alcohol when anxious than when relaxed, to smoke when bored than when active, or to feel emotionally distressed when alone than when with friends.

  Almost any healthy activity can be an effective countering technique. For example, a drug user may choose to go jogging to counter the urge to get high, or a sedentary person may seek out a family member to spend time with instead of disappearing into the couch. There are many different good countering activities—the trick lies in finding the ones that will work for you.

  Environment control

  Like countering, environment control is action oriented. In this instance, however, you do not seek to control internal reactions but to restructure your environment so that the probability of a problem-causing event is reduced. (Technically, countering adjusts an individual’s responses to certain stimuli; environment control regulates the stimuli.) Environment-control techniques can be as simple as removing narcotics or alcohol from your home. A positive reminder, such as a NO SMOKING sign or a warning on the refrigerator door, is another technique.

  Rewards

  Punishment and rewards are opposite sides of the same coin: You can punish problem behavior or reward desirable behavior. Punishment is rarely used by successful self-changers or therapists. Not only is it ethically questionable, it tends to suppress problem behavior temporarily rather than lead to lasting change.

  Rewards, on the other hand, are often successfully used to change behavior. Self-praise is one simple form of reward. A present would be another, one that you give yourself upon reaching a certain goal, or that you purchase with the money you would otherwise have spent on the problem. Rewards can also be under the control of other people: Your family may shower you with praise for losing weight, or you may win a bet with a friend when you quit smoking.

  Here in New England we have frequently encountered a negative reaction to rewards, perhaps reflecting the region’s historical legacy. Too many puritanical people believe that they have no right to be rewarded for modifying behaviors that they should never have acquired, such as abusing alcohol, food, or tobacco. These people deprive themselves of reinforcements for progressing along positive paths. If you are such a person, check your responses against the perspectives of those who are close to you as you work with the next change process.

  Helping relationships

  Self-change refers to your own attempts to modify your behavior without professional assistance. It does not, repeat not, refer to refusing care, support, or other forms of assistance from significant people in your life. This clarification avoids the age-old misconception of self-change as “going it alone.” Throughout the cycle of change, others can be enlisted to assist you. While we cannot control how our friends and family members act toward us, we can certainly request their support, offer them our preferences, and educate them about our experiences. This is what we mean by “enlisting” or “eliciting” helping relationships.

  The helping relationship is the most frequently enlisted change process in psychotherapy, and it is also of critical importance to self-changers. Whether you turn to a professional, friend, member of the family, or the clergy, the helping relationship provides support, caring, understanding, and acceptance.

  Unfortunately, many people are inadequately trained in even the simplest helping skills, such as listening and reflecting. Helping is not always easy. Many of us are uncomfortable relating to loved ones when they are in emotional pain. But because helping relationships are of such primary value to self-changers, this book includes in the first five chapters of Part Two detailed information intended specifically for helpers.

  Processes versus techniques

  Do not make the mistake of confusing these nine processes of change with techniques of change. Each process involves a broad strategy that may employ any number of techniques. For each process, there are dozens, even hundreds of techniques. We found that a group of self-changers who were quitting smoking, for example, relied on more than 130 different techniques to quit permanently. Table 2 outlines a few techniques used by psychotherapists to apply each process.

  TABLE 2. SUMMARY OF SOME CHANGE PROCESS TECHNIQUES

  Process: Consciousness-Raising

  Goals: Increasing information about self and problem

  Techniques*: Observations, confrontations, interpretations, bibliotherapy

  Process: Social Liberation

  Goals: Increasing social alternatives for behaviors that are not problematic

  Techniques*: Advocating for rights of repressed, empowering, policy interventions

  Process:
Emotional Arousal

  Goals: Experiencing and expressing feelings about one’s problems and solutions

  Techniques*: Psychodrama, grieving losses, role playing

  Process: Self-Reevaluation

  Goals: Assessing feelings and thoughts about self with respect to a problem

  Techniques*: Value clarification, imagery, corrective emotional experience

  Process: Commitment

  Goals: Choosing and commiting to act, or belief in ability to change

  Techniques*: Decision-making therapy, New Year’s resolutions, logotherapy

  Process: Countering

  Goals: Substituting alternatives for problem behaviors

  Techniques*: Relaxation, desensitization, assertion, positive self-statements

  Process: Environment Control

  Goals: Avoiding stimuli that elicit problem behaviors

  Techniques*: Environmental restructuring (e.g., removing alcohol or fattening foods), avoiding high-risk cues

  Process: Reward

  Goals: Rewarding self, or being rewarded by others, for making changes

  Techniques*: Contingency contracts, overt and covert reinforcement

  Process: Helping Relationships

  Goals: Enlisting the help of someone who cares

  Techniques*: Therapeutic alliance, social support, self-help groups

  The following anecdote from a smoking cessation group run by John Norcross illustrates the distinction between process and technique: Group members were discussing successful ways to resist urges to overeat. One elderly woman said that when she earnestly played the piano, her temptations vanished. A young man reported that jogging reduced his urges. Upon hearing this, a middle-aged woman in the group cried out in frustration, “Well, what the hell am I going to do? I don’t play the piano or jog!” She had confused two techniques, piano playing and jogging, with their corresponding process, countering. However, countering is one of the broadest processes of change. It incorporates an almost infinite variety of techniques—relaxing, studying, gardening, walking, working, swimming, and so on.