We wondered if there might be a connection between drop-out rates and mismatched stages and processes. We wanted to test whether our model could predict the rate at which people would drop out of certain therapies. By this we hoped to demonstrate that people most often quit therapy, not when they are unmotivated but when the therapy fails to meet their stage-specific needs.
Our results were astonishing. Our model was 93 percent predictive of which clients would drop out. This predictive percentage provides strong evidence for the need to match therapeutic treatments to the stages clients are in.
INTEGRATIVE CONCLUSIONS
Efficient self-change depends on doing the right things at the right times. A person’s stage of change provides proscriptive as well as prescriptive information as to which treatment to use. Treatments that are quite effective in one stage may be ineffective or detrimental in another.
We have found two frequent mismatches. Some self-changers rely primarily on those processes that are best adapted for the early stages—consciousness-raising and self-reevaluation—while they are moving into the action stage. They try to modify behaviors by becoming more aware of them. This reminds me of what many critics of the psychoanalytic method say about it: Insight alone does not bring about behavior change. Other self-changers begin with change processes that are most effective in the action stage—reward, countering, environment control—without having first gained awareness and readiness in the early stages. They try to modify behavior without awareness. This echoes a common criticism of behaviorism: Overt action without insight is likely to lead to temporary change.
In professional therapeutic situations, experienced clinicians may make stage assessments intuitively. If they do, they rarely write about it—prior to our work in this field, we found few references on the topic in the literature. However, when we asked a group of psychotherapists how they went about changing themselves, they told us they were very adept at using change processes from other traditions to suit the stages of change they were in. For this reason, we imagine that many therapists may be more heterodox in the consulting room than is apparent from the literature. It is my belief that one of the cardinal virtues of our work is that it will encourage therapists in their heterodoxy. It just makes good sense to use every strategy available out there, as the occasion demands.
Competing systems of psychotherapy have developed apparently rival processes of change. But these ostensibly contradictory processes can be complementary when intelligently applied according to the stages of change. Change processes traditionally associated with the experiential, cognitive, and psychoanalytic persuasions are most useful during the precontemplation and contemplation stages. Those processes associated with the existential and behavioral traditions, by contrast, are most useful during action and maintenance. People who change problem behaviors with and without therapy can be remarkably resourceful in integrating the change processes, even if psychotherapy theorists have been historically unwilling or unable to do so.
Where to go from here
Self-changers are readily able to assess their stages of change, but without guidance may have trouble determining the processes they need to use. A vague notion of the importance of willpower can dominate their perspective on self-change. Still, self-change is a wise and powerful investment of energy. If we can bring reasonable and positive expectations to the cycle of change, our chances of success will be increased. The first step is to grapple with myths that keep us from freeing ourselves from self-defeating behaviors. We will describe and debunk those myths before going any further.
Myth 1: Self-change is simple Self-change is not simple. We all wish it was easier. We try not to become demoralized by our most recent failures, though we are tempted to believe that we can’t really change. We are embarrassed or frustrated when someone tells us how easy it was to quit their habit.
There are, in fact, a privileged few who seem to have a remarkably easy time of changing. Such dramatic recoveries receive undue attention, since most people have to struggle to find effective solutions to their problems. But once you begin to consider stopping smoking or drinking, to conquer your fears or anxieties, to eat moderately, to begin exercising, your options become clear.
Myth 2: It just takes willpower When we ask successful changers, “How did you do it?” the universal answer is, “Willpower.” Our research seemed to confirm what everybody already knew. When we examine what “willpower” means to people, however, two different definitions are given. The first is technical: a belief in our abilities to change behavior, and the decision to act on that belief.
The second, sweeping definition is that willpower represents every single technique, every effort under the sun, one can use in order to change. If this is so, then it is inevitable that it takes willpower to change. This is a classic case of circular reasoning.
Self-changers do indeed use willpower in the first, true sense of the word, but it is only one of nine change processes, the one we call commitment. People who rely solely upon willpower set themselves up for failure. If you believe willpower is all it takes, then you try to change and fail, it seems reasonable to conclude that you don’t have enough willpower. This may lead you to give up. But failure to change when relying only on willpower just means that willpower alone is not enough.
Myth 3: I’ve tried everything—nothing works! As you learn more about the processes of change—the activities that help us understand and overcome problems—you may say, “I already tried that.” The key question is not whether you used a particular process, but whether you used it frequently enough, and at the right times.
The effectiveness of change processes is dependent on the method and timing of their application. If a profoundly depressed person tells me that an antidepressant medication doesn’t work, I do not immediately reject the medication. Rather, I ask, “How much are you taking? How long did you take it? Were you taking other drugs at the same time?” Any physician knows how much the dosage, the length of the trial, and the other drugs a patient may be taking can affect the efficacy of a given drug. Psychological change efforts are similarly affected by such considerations. Determining precise measures of how much, how long, and when each process needs to be used to be effective is one aim of our continuing research.
Myth 4: People don’t really change Our work simply blows this myth out of the water. We have studied thousands of successful self-changers. Nonetheless, Dr. Tracy Orleans (1986), a health psychologist at the Fox Chase Cancer Control Center in Philadelphia, discovered that two thirds of physicians were pessimistic about their patients’ ability to change. This pessimism is the single biggest obstacle to getting physicians to help their patients with their health problems. Yet studies show that if doctors take preventive medicine more seriously—spending just one or two minutes to counsel their patients about quitting smoking, for example—they can double the number of patients who are not smoking at the end of a year.
If all physicians acted similarly, it could save literally millions of lives. With such power, why are doctors so pessimistic? First, successful self-changers usually do not seek professional help. This means that professionals see primarily those individuals who are unwilling or unable to change on their own, and whose problems may seem intractable. They then mistakenly generalize from the failures of these people.
Second, as a nation we seek formal, expert solutions to our problems (the first stage in almost any big project is a study by experts). Self-change, by comparison, is a commonsense approach. The prominent psychiatrist Aaron Beck has commented on the ways in which many psychotherapists gloss over their clients’ attempts to define problems in their own terms and use their own rationality to solve them. By doing so, these therapists denigrate the often accurate ideas and effective practices of self-changers, dismissing them as shallow and unsubstantial. This can erode a client’s confidence in everyday methods of coping with difficulties. So, although some therapists in practice acknowledge the importance of th
eir clients’ efforts, others are inhibited by their theories from encouraging and aiding them to draw on their own resources.
Third, although society only looks at a single self-change attempt, most triumphant self-changers take more than one crack at a problem before they are finished with it. Success can only be achieved over the long haul, and through hard work. And finally, the self-esteem, legal mandate, and economic survival of many therapists depends on their unique and somewhat mythical ability to help people change. The convincing evidence of a self-changer’s success threatens them and is thus frequently dismissed.
This does not mean that we oppose professional therapy, of course; we are, after all, practicing psychologists. In fact, our work can be valuable even to those changers who attend weekly sessions; self-changers and therapy-changers have much in common. Reading about the stages and processes of change while in therapy can have a synergistic effect. This is the reason why the majority of psychologists prescribe reading self-help books to their clients, and why approximately 70 percent of those clients report being “really helped” by them.
Although we predict that many self-changers will be successful if they follow the advice contained in these pages, no self-help book can benefit everyone. Self-help books have definite limitations. No book can help you if you have a severe mental disorder. Emotional problems that seriously interfere with your energy level, thinking ability, or experience of reality usually require direct professional help. This book is not a substitute for such help. Chapter 9 presents guidelines on when and how to seek professional guidance.
KNOWING YOUR STAGE
The first step along the journey of change is to know the stage you are in. You can learn this by completing the self-assessment in Chapter 3. Although you may think you already know what stage you are in, a thorough self-assessment is important for accuracy. The processes of change are stage-dependent; where you enter the cycle of change determines what processes you must use to move upward. An incorrect assessment will result in a misapplication of processes, which may in turn slow your movement through the cycle of change.
Self-assessments are an integral part of our program, and you will find them throughout this book. Stage of change predicts the likelihood of success in people’s change attempts with more accuracy than anything else about them. This assessment applies to behavior patterns over the next eighteen months. In an extensive study of smokers, we examined the relationship between a person’s stage at the start of an action-based treatment and the progress made over the course of treatment; the findings were nothing short of remarkable.
Figure 3 shows the relationship between a specific stage of change before treatment, and successful maintenance over eighteen months. As you can see, the stages are wonderful predictors of which self-changers will be successful. Only 6 percent of those who jumped from precontemplation to the action stage were abstinent at eighteen months, compared with the 15 percent who began in contemplation, and the 24 percent who began in the preparation stage. There is no variable that relates as directly to treatment success as the stage of change. Similar effects have been discovered in studies of Mexican-American smokers, smokers with cardiovascular disease, smokers with cancer, middle-aged Finnish male smokers, patients with anxiety and panic disorders, patients recovering from brain injuries, and clients undergoing different therapies.
Figure 3. Percentage of smokers who became abstinent over 18 months, classified according to the precontemplation, contemplation, and preparation stages at the start of the study.
Sometimes family members with identical problems are at quite different stages in the cycle of change. One of our self-change studies included an elderly married couple in Texas who professed an interest in quitting smoking. When their beloved dog died of lung cancer, the wife quit smoking. The husband bought a new dog! Both began in the contemplation stage and both were given added incentive by the same occurrence. But while the wife was propelled into the action stage, the husband remained a contemplator. So, don’t assume you know your stage. If you are at different stages for different problems—you have terminated work on smoking, for example, and have become a nonsmoker, but remain a contemplator concerning weight control, or you have conquered depression and maintained a stable mood, but continue to recycle through the action stage on workaholism—evaluate each problem separately.
Assessing your stage
It can be deceivingly simple to assess your stage of change for a particular problem. You will need to answer only four questions about taking action in order to assess your stage. The tricky part is that, before answering the questions, you must know what constitutes recovery for your particular problem.
Many people believe that by simply improving a problem, they are taking sufficient action. All of our research is geared toward discovering how people can become free from their problems. Our hope and goal for you is that you take action to solve your problem, not just improve it. It is not enough to switch to low-tar-and-nicotine cigarettes, or even to cut your number of cigarettes in half; solving this problem means quitting—period.
A problem behavior can be considered solved once you attain the criteria that health professionals agree place you at zero or minimal risk from the particular behavior. The “risk” includes both the health risks your problem poses and that of relapse, if your solution is less than complete. Cutting in half the number of cigarettes you smoke reduces the risk, but does not minimize it. Table 4 presents the action criteria for fifteen of the most important and most prevalent problem behaviors.
TABLE 4. ACTION CRITERIA FOR 15 PROBLEM BEHAVIORS
Problem Behavior: Smoking
Action Criteria: Abstinence
Problem Behavior: Drug abuse
Action Criteria: Abstinence
Problem Behavior: Gambling
Action Criteria: Abstinence
Problem Behavior: Alcoholism
Action Criteria: Abstinence
Problem Behavior: Troubled drinking
Action Criteria: Abstinence, at times; or no more than 14 drinks per week, with no more than 5 drinks ever at any sitting
Problem Behavior: Sex (high risk)
Action Criteria: Always use condoms
Problem Behavior: Depression
Action Criteria: No more than 2 days of the blues at any time
Problem Behavior: Panic attacks
Action Criteria: No panic attacks in any normal situation
Problem Behavior: Physical abuse
Action Criteria: Never hit anyone and never be hit
Problem Behavior: Obesity (health criteria)
Action Criteria: Less than 20% over standard weight tables
Problem Behavior: Diet (high fat)
Action Criteria: Less than 30% of calories from fat
Problem Behavior: Sedentary life
Action Criteria: Minimal: physical activity 3 times weekly, 20 minutes at a time
Optimal: vigorous exercise 3 times weekly, 20 minutes at a time
Problem Behavior: Dental hygiene
Action Criteria: Brush twice a day and floss each tooth
Problem Behavior: Procrastinating
Action Criteria: Never put off anything that hurts you or others
Problem Behavior: Sun exposure
Action Criteria: Always use sunscreens when exposed for more than 15 minutes
If your problem behavior is included in Table 4, you will see what recovery requires of you. We recognize that some people have to settle for a less than total solution. If significant improvement is the best you can do for now, then that is still something worth doing. But don’t set your goals too low. Aim for full freedom from your problem.
With some problem behaviors, unfortunately, either there is no agreement among professionals on the criteria for recovery, or there is no easy or adequate measure for assessing recovery. If your problem behavior is not included in Table 4, then you will have to imagine what it will mean to be free from your problem. Usually it means
never engaging in a high risk or troubling behavior, such as never engaging in high-risk sex, or it means consistently practicing a preventive behavior, such as always wearing seat belts.
Once you have a fairly clear idea of what action you need to take, respond to the following four simple statements to assess the stage you are in for a particular problem behavior.
I solved my problem more than six months ago.
I have taken action on my problem within the past six months.
I am intending to take action in the next month.
I am intending to take action in the next six months.
If you answered no to all statements, you are in the precontemplation stage. Contemplators will have answered yes to statement 4 and no to all the others. Those in the preparation stage will have answered yes to statements 3 and 4, and no to the others. If you answered yes to statement 2 and no to statement 1, you are in the action stage. You’ve reached the maintenance stage when you can answer yes truthfully to statement 1.
Changing for Good Page 5