Changing for Good

by James O Prochaska

  It took her two months to lose her first pound. But it was the most precious pound she had ever lost. It wasn’t quick and easy. It didn’t involve counting and cutting calories—an approach that had always given her immediate gratification but long-term demoralization. She lost the pound as a consequence of living healthier and living better.

  This gave a tremendous boost to Gail’s morale. She started exercising even more and eating even less fat. The pros of her new lifestyle were increasing the way she had hoped when she first shifted to her new strategy.

  Gail found that she could cover the tennis court better than before. She was a little quicker, and had more stamina. Her moods were more stable, and she was continuing to lose weight, about a pound every one or two weeks. In the past she wouldn’t have tolerated such slow progress. She would have cut calories drastically, stressing her body and herself, seeking a quick fix for a problem that had developed gradually. Now she was applying a sensible solution to her problem based on reasonable and responsible values, not on vanity and a poor self-image.

  After Gail had lost about half of her excess weight, she reached a plateau. Her behavior change program was continuing but she was no longer enjoying the reinforcement that losing weight provided. Dan told her she looked better already, and that she should accept her body at this weight. Gail was tempted to adopt this rationalization (which might have come out of Dan’s personal fears). Twenty-some extra pounds was better than forty, and if this was truly the best she could do then Gail felt she could accept the weight.

  Before she shifted to acceptance, Gail wanted to be sure the modifications she had made were sufficient. She asked for an assessment at the cardiovascular rehabilitation clinic at her state university. The first thing she discovered was that her diet was not in fact as low-fat as she had thought. Her intake of 33 percent of calories from fat was lower than the national average, but it was only half the way to the national low-fat goal of 30 percent.

  The exercise physiologist informed Gail that she could acquire further health benefits by increasing her exercise program, which might lead to additional weight loss.

  Gail had discovered that her self-change plan was good but not good enough. She was moved to redouble her efforts. Not only did she want a fit and low-fat lifestyle, but society supported that lifestyle as well.

  It wasn’t always easy. There were times when Gail lapsed. When she felt unappreciated at work or at home, she was tempted to indulge in a late-night binge. And sometimes she gave in to the temptation. But she didn’t sleep as well afterward, she didn’t feel as well in the morning, and she never felt any more appreciated.

  Gail decided to substitute bingeing with some social support by starting a group for menopausal women like herself. Gail organized the group around tennis. She invited four of her friends, all facing fifty. They could have fun together, they could exercise together, and they could share together some of the trials and tribulations of their changing bodies.

  Gail also announced to Dan that she needed more from him emotionally, socially, and sexually. She told him that she wanted him to get into shape—and that she would help him if he wished. Dan’s own journey through change is another story, but needless to say he greeted Gail’s announcement with mixed emotions at first.

  Gail is now many months into maintenance. She feels healthier and fitter than she has in fifteen years. Her morale is high. She is confident that this is the way she wants to live the rest of her life. And she is happily helping Dan progress through his stages of change.

  CHAPTER 8

  Maintainance—Staying There

  WORKING IN THE YARD one hot summer day, Andrew, an accountant, had quite a scare. He felt flushed and overcome with heat; his heart beat rapidly and his chest hurt. He was only forty-two. Could he really be having a heart attack? He was frightened enough to go to the emergency room. Fortunately, the problem was nothing more than mild heatstroke. Wisely, however, his attending physician took the opportunity to advise Andrew to quit smoking and change his diet. Andrew’s two-pack-a-day habit and his weight of 235 pounds were clear threats to his health; a real heart attack could be right down the road.

  Andrew took the doctor’s advice seriously. He did not touch a cigarette for nine months, and took off some weight. The initial months of quitting smoking were easy—his fear took care of that. But at tax season, when work stress increased dramatically, cigarettes started looking good to him again. On his way to the office one morning, he stopped at a convenience store, thinking that he would buy just one pack of cigarettes to get him through the weekend. After all, he reasoned, he had been successful for nine months. At this point, he could surely control his smoking…

  Rudy hadn’t touched cocaine or alcohol in five months. His hospitalization was long past, he was attending Alcoholics Anonymous and Cocaine Anonymous regularly, things were beginning to level out at work, his social life was improving, and his relationships were the best they had ever been. Rudy no longer drank, and although at first he had worried that might put him in an awkward position with clients, he now felt they hardly noticed when he ordered ginger ale or Perrier as they enjoyed their scotch or beer.

  On a business trip to New York City, Rudy and a client walked into a small, cozy bar in Greenwich Village. In a secluded booth, his client cut three lines of cocaine on the table in front of him; Rudy’s heart started to beat fast and the sweat beaded on his forehead. His thoughts were racing. He began imagining that he could do a line or two and still maintain his sobriety. Since he lived in Atlanta, it occurred to him, even if he did some coke in New York, he would still be sober at home. His reactions surprised him, and momentarily he did not know what to do…

  Annette was discouraged; it had been almost a year since she had felt this depressed. She was thirty-two, divorced after a brief marriage. She had long had trouble getting along with men, but was afraid of being alone. Several visits to a psychotherapist had helped her to become more assertive, both in her relationships and on the job. In the past year, she had been dating more, and getting to know men as people rather than as prospective mates. She had actually begun to like men—and herself.

  All that now seemed light years away. About two months ago, she had met Tom. She was relaxed with him, she enjoyed being with him, and the attraction was mutual. But as their intimacy increased, Annette found that she became less assertive and more worried about what Tom thought of her. She was getting back into an old rut, of not liking herself and feeling that she was not good enough for Tom. Some problems at work compounded the difficulty. Annette felt as if she were back at square one.

  The stories of Annette, Rudy, and Andrew illustrate the difficulties of maintaining change. No less important than action, maintenance is often far more difficult to achieve. Successful change means change that is sustained over time—not months, but years, decades, a lifetime. Maintenance is not a static stage in which you hold the line against unwanted behaviors. Rather, it is another busy, active period of change, one that requires you to learn new coping methods. Getting there is only half the battle.

  As everyone knows, it’s easy to slip back into old problems. Some popular sayings about maintenance—“You’re a puff away from a pack a day” “One drink, one drunk”—acknowledge the difficulties. The difference between the short, intense trip of the action stage and the long haul of maintenance is summarized by the facetious comment many smokers make: “Stopping is easy—I do it every day.” Two factors are fundamental to successful maintenance: sustained, long-term effort, and a revised lifestyle.

  This is tough work, but nothing else will do. For example, although many diets succeed in the short run, their long-run success rate is quite low. Many dieters lose weight quickly, but six months after beginning a diet, many people weigh more than they did when they started!

  This is action without maintenance. New Year’s resolutions also typify this phenomenon. About half of all American adults initiate self-change at the beginning of each ne
w year. It is, after, all a traditional and socially reinforced time for changing behavior. Our research has found that a mere 77 percent of these resolutions are successful for one week. The success rate drops to 55 percent after one month, to 40 percent after six months, and to 19 percent after two years.

  No one who has changed successfully, in or out of therapy, will deny that maintenance is difficult. As with the other stages, there are negative responses that lead to an erosion of commitment and failure. There are also basic strategies for long-term maintenance. Yes, staying there is tough; but it is possible and well worth the effort.

  A STRATEGY FOR SUCCESS

  All stages of change require a series of tasks, a stretch of time in which to try them, and a certain amount of energy and dedication. The action stage lasts for several months. The first month or two of this period is the most likely time for relapse. No wonder; just a glance back at the previous chapter will recall all the work involved in successful action.

  Maintenance takes all that required work and builds on it. Difficult as it is, forsaking an undesirable behavior is not enough to overcome it for good. Almost all negative habits essentially become our friends—even, in many cases, our lovers. They play important, sometimes dominating roles in our lives. Andrew’s smoking was his only way of coping with stress; Rudy’s cocaine use kept his life from seeming boring; Annette’s guarded relations with men resulted from her fears of intimacy. At some point, these behaviors aided Andrew, Rudy, and Annette in handling problems; for a time at least, they seemed under control. Eventually, however, our ill-considered strategies become our problems.

  To overcome them fully, we must replace our problem behaviors with a new, healthier lifestyle. This strategy begins with the action-stage process of countering, but it doesn’t end there. That is why the word “maintenance” can be misleading. Maintaining behavior change is not like maintaining a home, which often requires little more than a periodic coat of paint.

  We can break old patterns by removing drugs from our lives, for example, or avoiding certain relationships. But those who do no more than remove an old habit condemn themselves to a life of longing and deprivation. Lifelong tolerance of this deprivation requires unceasing and powerful acts of will. The “dry drunks” of alcoholic treatment circles, the people who stop smoking but who would return to cigarettes tomorrow if they found out they had cancer may be abstaining but they still run a high risk of relapsing.

  For all of us, former problems, especially addictive ones, will hold some attraction long after the habit is broken. To remain strong throughout maintenance requires that you acknowledge you are still vulnerable to the problem even while you’re building a life in which the old behavior has no value. In our long-term follow-up of smokers who quit on their own, those who successfully maintained their change through to termination had learned to devalue the positive aspects of smoking; develop confidence in their ability to abstain from smoking; keep a healthy distance from cigarettes; and, through development of new, desirable habits, find few if any temptations to smoke.

  Danger times, danger signs

  The most common threats to maintenance are social pressures, internal challenges, and special situations. Social pressures come from those around you who either engage in the problem behavior themselves, or don’t recognize its impact on you. Internal challenges usually result from overconfidence and other forms of defective thinking. Special situations arise when you are confronted by an unusual, intense temptation. While many of the more common temptations occur early in the action stage, you learn to deal with them before moving out of the stage. During maintenance, the relatively rarer temptations come into play. They are difficult to anticipate and pose serious threats to your confidence, convictions, and commitment.

  Rudy’s dilemma offers a good example of both social pressure and a special situation—the sudden and unexpected appearance of coke, offered by an important client. During the action stage, Rudy had used environment control a great deal, staying away from places and people associated with his cocaine use. He even agreed to keep clear of alcohol in order to avoid losing control while drinking and falling back to using cocaine.

  Although environment control is an important strategy for breaking free of an addiction, it has its limitations. It is simply impossible to remain free of tempting cues forever. Faced with the opportunity to do coke and the encouragement of a drug-using “friend,” Rudy faced a real challenge. The presence of the drug triggered an intense physical craving. And the situation was so charged that Rudy’s old patterns of thinking—rationalization and minimization—returned. This is not uncommon: External dangers often trigger defective thinking, along with physical and psychological craving.

  In Andrew’s case, defective thinking posed the greatest threat to his smoking abstinence. Faced with escalating stress—with which he used to cope by smoking—Andrew engaged in denial and indulged a false sense of confidence. Andrew’s thoughts on his way to the convenience store eroded his commitment and any efforts at environment control. Buying a pack of cigarettes signaled the second step toward the collapse of maintenance efforts and a relapse to regular smoking.

  By becoming more assertive, Annette was able to change how she related to men. And everything seemed to work well, as long as her involvements remained casual. But old patterns, as we know, die hard. When she began to develop a more intimate relationship, intense fears were triggered and earlier patterns reemerged. Such situations, though dangerous, are signs of success, not failure—they can be experienced only after significant and sustained changes have been made.

  In a study of smokers who abstained for months, we found that one group returned to smoking after visiting hospital emergency rooms. Serious illness to a family member created a level of stress that had not been reckoned with in the earlier action stage. While these individuals had previously handled many diverse stresses without smoking, they were overwhelmed by the sudden anxiety created by the emergency room visit. Once again, extreme stress enabled them to justify a return to smoking—“just for the moment”—that ultimately led to relapse.

  It is difficult to prepare for the extreme, the accidental, and the unexpected. This is what makes maintenance such a great challenge.

  Courting relapse

  There are three common internal challenges that are closely related to slips, or brief lapses: overconfidence, daily temptation, and self-blame. Each is a mind game, played by people who are subconsciously courting relapse. Awareness of these responses, and vigilance against them, are important in successful maintenance.

  Several years ago, one of our clients remarked that maintenance reminded her of Charles Dickens’s opening line in A Tale of Two Cities. “It was the best of times, it was the worst of times.” Her successful weight loss and slimmer self made her feel great. But times were tough because she was beginning to feel complacent and cocky about her hard-earned svelte appearance. She feared the prospect of overconfidence.

  A statement such as “I’ve got this beat forever” is a telltale sign of overconfidence. Such self-changers sometimes brush aside the concerns of their friends, insisting, “I can handle one.” However, the sad truth of addictive problems, borne out by scientific research and clinical experience, is that most people cannot handle “one” of any problem product. Remaining mindful of this natural propensity toward overconfidence can prevent you from taking those first few steps down the road to relapse.

  Overconfidence can also beget daily temptation, to which you intentionally and unnecessarily subject yourself regularly. Overconfident alcoholics keep a bottle of booze in their desk drawer, to “remind” themselves. Ex-smokers stash a pack or two at home to “test willpower.” Dieters buy high-calorie goodies “just in case company drops in.” Intentionally exposing yourself to substances or situations you are trying to avoid is not a sign of strength, a measure of willpower, or a positive reminder. Sooner or later temptation wins and you lose. We have yet to meet a self-changer who p
layed the daily temptation game early in maintenance and won.

  Beyond overconfidence and daily temptation is the final pitfall, self-blame. In several studies, including our own, the severity of misplaced self-blame is one of the best predictors of failed maintenance. Ironically, occasional and appropriate self-blame may actually rekindle your commitment to change. Frequent, inappropriate self-blame backfires. Far from being the motivator or activator it is held to be, self-blame is demoralizing and it stymies commitment.

  PROCESSES FOR MAINTAINING

  CHANGE

  As you move through the maintenance stage, you won’t need to use the processes of change quite as much as you did during contemplation, preparation, or action. In a very real way, maintenance refers not only to maintaining change but also to maintaining the use of the change processes. During the action stage, for example, you relied on self-liberation to help you use the strategies necessary to break a problem habit; in maintenance you must continue to use them.

  You must keep up your commitment. Challenges make it not only easy but natural to let your guard down. The erosion of commitment is subtle. Since threats to maintenance occur infrequently (unlike threats during action, which occur almost constantly), complacency can easily take hold. Humans have the ability to forget painful passages in their lives. Usually, this is a blessing, but selective memory is detrimental to maintaining change.

  If you forget the tremendous effort it took to change, everything begins to look easier than it was and all arguments against indulging “just for the weekend” fail. Why not taste a little of that forbidden fruit, when you can change right back again on Monday?

  Many people find success difficult to accept, and their tendency to attribute success to others—God, a spouse, a therapist—challenges their commitment. Giving credit to others is admirable to a degree, but it has its dangers. By not accepting responsibility and credit for liberating yourself, you undermine your self-confidence, your self-esteem, and your commitment. If you think others are responsible for your success, how can you maintain it yourself?