Scholar Practitioner Project
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Perspectives
In Search of How People Change: Applications to Addictive Behaviors
By James 0. Prochaska, Ph.D., Carlo C. DiClemente, Ph.D., and John C. Norcross, Ph.0.
Abstract How people intentionally change addictive behav-
iors with and without treatment is not well under- stood by behavioral scientists. This article summa- rizes research on self-initiated and professionally facilitated change of addictive behaviors using the key transtheoretical constructs of stages and pro- cesses of change. Modification of addictive behav- iors involves progression through five stages-pre- contemplation, contemplation, preparation, action, and maintenance-and individuals typically recycle through these stages several times before termination of the addiction. Multiple studies provide strong support for these stages as well as for a finite and common set of change processes used to progress through the stages. Research to date supports a trans- theoretical model of change that systematically inte- grates the stages with processes of change from di- verse theories of psychotherapy.
Introduction Hundreds of psychotherapy outcome studies have
demonstrated that people successfully change with the help of professional treatment (Lambert, Sha- piro, & Bergin, 1986; Smith, Glass, & Miller, 1980). These outcome studies have taught us rela- tively little, however, about how people change with psychotherapy (Rice & Greenberg, 1984). Numer- ous studies also have demonstrated that many people can modify problem behaviors without the benefit of formal psychotherapy (Marlatt, Baer, Donovan, & Divlahan, 1988; Schachter, 1982; Shapiro et al.,
Reprinted from American Psychologist, September 1992, Vol. 47,
Bernadette Gray-Little served as action editor for this article. This research was supported in part by Grants CA27821 and
No. 9.
CA50087 from the National Cancer Institute.
1984; Veroff, Douvan, & Kulka, 1981a, 1981b). These studies have taught us relatively little, how- ever, about how people change on their own.
Similar results are found in the literature on addic- tive behaviors. Certain treatment methods consis- tently demonstrate successful outcomes for alcohol- ism and other addictive behaviors (Miller & Hester, 1980, 1986). Self-change has been documented to occur with alcohol abuse, smoking, obesity, and opiate use (Cohen et al., 1989; Oxford, 1985; Roi- Zen, Cahaland, & Shanks, 1978; Schachter, 1982; Tuchfeld, 1981). Self-change of addictive behaviors is often misnamed “spontaneous remission,” but such change involves external influence and individ- ual commitment (Orford, 1985; Tuchfeld, 1981). These studies demonstrate that intentional modifica- tion of addictive behaviors occurs both with and without expert assistance. Moreover, these changes involve a process that is not well understood.
Over the past 12 years, our research program has been dedicated to solving the puzzle of how people intentionally change their behavior with and without psychotherapy. We have been searching for the structure of change that underlies both self-mediated and treatment-facilitated modification of addictive and other problem behaviors. We have concentrated on the phenomenon of intentional change as opposed to societal, developmental, or imposed change. Our basic question can be framed as follows: Because successful change of complex addictions can be demonstrated in both psychotherapy and self- change, are there basic, common principles that can reveal the structure of change occurring with and without psychotherapy?
This article provides a comprehensive summary of the research on the basic constructs of a model that helps us understand self-initiated and professionally assisted changes of addictive behaviors. The key transtheoretical concepts of the stages and processes
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of change are examined, and their applications to a variety of addictive behaviors and populations are reviewed. This transtheoretical model offers an inte- grative perspective on the structure of intentional change.
Stages of Change
One objective of treatment outcome research in the addictions is to establish the efficacy of interven- tions. However, study after study demonstrates that not all clients suffering from an addictive disorder improve: Some drop out of treatment, and others relapse following brief improvement (Kanfer, 1986; Marlatt & Gordon, 1985). Inadequate motivation, resistance to therapy, defensiveness, and inability to relate are client variables frequently invoked to ac- count for the imperfect outcomes of the change en- terprise. Inadequate techniques, theory, and rela- tionship skills on the part of the therapist are intervention variables frequently blamed for lack of therapeutic success.
In our earliest research we found it necessary to ask when changes occur, in order to explain the relative contributions of client and intervention vari- ables and to understand the underlying structure of behavior change (DiClemente & Prochaska, 1982; Prochaska & DiClemente, 1983). Individuals modi- fying addictive behaviors move through a series of stages from precontemplation to maintenance. A lin- ear schema of the stages was discovered in research with smokers attempting to quit on their own and with smokers in professional treatment programs (DiClemente & Prochaska, 1982). People were per- ceived as progressing linearly from precontempla- tion to contemplation, then from preparation to ac- tion, and finally into maintenance. Precursors of this stage model can be found in the writings of Horn and Waingrow ( 1966), Cashdan ( 1973), and Egan (1975). Variations of and alternatives to our stage model can be found in more recent writings of Beit- man (1986); Brownell, Marlatt, Lichtenstein, and Wilson (1 986); Dryden (1986); and Marlatt and Gor- don (1985).
Several lines of research support the stages of change construct (Prochaska & DiClemente, 1992). Stages of change have been assessed in outpatient therapy clients as well as self-changers (DiClemente & Hughes, 1990; DiClemente & Prochaska, 1985; DiClemente, Prochaska, & Gilbertini, 1985; Lam, McMahon, Priddy, & Gehred-Schultz, 1988; Mc- Connaughy, DiClemente, Prochaska, & Velicer,
1989). Clusters of individuals have been found in each of the stages of change, whether the individuals were presenting for psychotherapy or attempting to change on their own. Stages of change have been ascertained by two different self-report methods: a discrete categorical measure, which assesses the stage from a series of mutually exclusive questions (DiClemente et al., 1991), and a continuous mea- sure, which yields separate scales for precontempla- tion, contemplation, action, and maintenance (Mc- Connaughy et al., 1989; McConnaughy, Prochaska, & Velicer, 1983).
In our original research we had identified five stages (Prochaska & DiClemente, 1982). But in principal component analyses of the continuous measure of stages, we consistently found only four scales (McConnaughy et al., 1983, 1989). We mis- interpreted these data to mean that there were only four stages. For seven years we worked with a four- stage model, omitting the stage between contempla- tion and action (Prochaska & DiClemente, 1983, 1985, 1986). We now realize that in the same studies on the continuous measures, cluster analyses had identified groups of individuals who were in the preparation stage (McConnaughy et al., 1983, 1989). They scored high on both the contemplation and action scales. Unfortunately we paid more atten- tion to principal component analyses rather than the cluster analyses and ignored the preparation stage. Recent research has supported the importance of as- sessing preparations as a fifth stage of change (Di- Clemente et al., 1991; Prochaska & DiClemente, 1992). Following are brief descriptions of each of the five stages.
Precontemplation is the stage at which there is no intention to change behavior in the foreseeable fu- ture. Many individuals in this stage are unaware or underaware of their problems. As G. K. Chesterton once said, “It isn’t that they can’t see the solution. It is that they can’t see the problem.” Families, friends, neighbors, or employees, however, are often well aware that the precontemplators have problems. When precontemplators present for psychotherapy, they often do so because of pressure from others. Usually they feel coerced into changing the addictive behavior by a spouse who threatens to leave, an employer who threatens to dismiss them, parents who threaten to disown them, or courts who threaten to punish them. They may even demonstrate change as long as the pressure is on. Once the pressure is off, however, they often quickly return to their old ways.
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In our studies using the discrete categorization measurement of stages of change, we ask whether the individual is seriously intending to change the problem behavior in the near future, typically within the next six months. If not, he or she is classified as a precontemplator. Even precontemplators can wish to change, but this seems to be quite different from intending or seriously considering change in the next six months. Items that are used to identify precon- templation on the continuous stage of change mea- sure include “As far as I’m concerned, I don’t have any problems that need changing” and “I guess I have faults, but there’s nothing that I really need to change.” Resistance to recognizing or modifying a problem is the hallmark of precontemplation .
Contemplation is the stage in which people are aware that a problem exists and are seriously think- ing about overcoming it but have not yet made a commitment to take action. People can remain stuck in the contemplation stage for long periods. In one study of self-changers, we followed a group of 200 smokers in the contemplation stage for two years. The modal response of this group was to remain in the contemplation stage for the entire two years of the project without ever moving to significant action (DiClemente & Prochaska, 1985; Prochaska & Di- Clemente, 1984).
The essence of the contemplation stage is commu- nicated in an incident related by Benjamin (1987). He was walking home one evening when a stranger approached him and inquired about the whereabouts of a certain street. Benjamin pointed it out to the stranger and provided specific instructions. After readily understanding and accepting the instructions, the stranger began to walk in the opposite direction. Benjamin said, “You are headed in the wrong direc- tion.” The stranger replied, “Yes, I know. I am not quite ready yet.” This is contemplation: knowing where you want to go but not quite being ready yet.
Another important aspect of the contemplation stage is the weighing of the pros and cons of the problem and the solution to the problem. Contem- plators appear to struggle with their positive evalua- tions of the addictive behavior and the amount of effort, energy, and loss it will cost to overcome the problem (DiClemente, 1991 ; Prochaska & Di- Clemente, 1992; Velicer, DiClemente, Prochaska, & Brandenburg, 1985). On discrete measures, indi- viduals who state that they are seriously considering changing the addictive behavior in the next six months are classified as contemplators. On the con- tinuous measure these individuals would be endors-
ing such items as “I have a problem and I really think I should work on it” and “I’ve been thinking that I might want to change something about myself.” Se- rious consideration of problem resolution is the cen- tral element of contemplation.
Preparation is a stage that combines intention and behavioral criteria. Individuals in this stage are in- tending to take action in the next month and have unsuccessfully taken action in the past year. As a group, individuals who are prepared for action report some small behavioral changes, such as smoking five cigarettes less or delaying their first cigarette of the day for 30 minutes longer than precontemplators or contemplators (DiClemente et al., 1991). Al- though they have made some reductions in their problem behaviors, individuals in the preparation stage have not yet reached a criterion for effective action, such as abstinence from smoking, alcohol abuse, or heroin use. They are intending, however, to take such action in the very near future. On the continuous measure they score high on both the con- templation and action scales. Some investigators prefer to conceptualize the preparation stage as the early stimngs of the action stage. We originally called it decision-making.
Action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires consid- erable commitment of time and energy. Modifica- tions of the addictive behavior made in the action stage tend to be most visible and receive the greatest external recognition. People, including profession- als, often erroneously equate action with change. As a consequence, they overlook the requisite work that prepares changers for action and the important ef- forts necessary to maintain the changes following action.
Individuals are classified in the action stage if they have successfully altered the addictive behavior for a period of from one day to six months. Successfully altering the addictive behavior means reaching a par- ticular criterion, such as abstinence. With smoking, for example, cutting down by 50% and changing to lower tar and nicotine cigarettes are behavior changes that can better prepare people for action but do not satisfy the field’s criteria for successful ac- tion. On the continuous measure, individuals in the action stage endorse statements such as “I am really working hard to change” and “Anyone can talk about changing; I am actually doing something about it.” They score high on the action scale and lower on the
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other scales. Modification of the target behavior to an acceptable criterion and significant overt efforts to change are the hallmarks of action.
Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. Traditionally, maintenance was viewed as a static stage. However, maintenance is a continuation, not an absence, of change. For addic- tive behaviors this stage extends from six months to an indeterminate period past the initial action. For some behaviors maintenance can be considered to last a lifetime. Being able to remain free of the addic- tive behavior and being able to consistently engage in a new incompatible behavior for more than six months are the criteria for considering someone to be in the maintenance stage. On the continuous mea- sure, representative maintenance items are “I may, need a boost right now to help me maintain the changes I’ve already made” and “I’m here to prevent. myself from having a relapse of my problem.” Stabi- lizing behavior change and avoiding relapse are the hallmarks of maintenance.
Splral Pattern of Change. As is now well- known, most people taking action to modify addic- tions do not successfully maintain their gains on their first attempt. With smoking, for example, successful self-changers make an average of from three to four action attempts before they become long-term main- tainers (Schachter, 1982). Many New Year’s resolv- ers report five or more years of consecutive pledges before maintaining the behavioral goal for at least six months (Norcross & Vangarelli, 1989). Relapse and recycling through the stages occur quite frequently as individuals attempt to modify or cease addictive behaviors. Variations of the stage model are being used increasingly by behavior change specialists to investigate the dynamics of relapse (e.g., Brownell et al., 1986; Donovan & Marlatt, 1988).
Because relapse is the rule rather than the excep- tion with addictions, we found that we needed to modify our original stage model. Initially we con- ceptualized change as a linear progression through the stages; people were supposed to progress simply and discretely through each step. Linear progression is a possible but relatively rare phenomenon with addictive behaviors.
Figure 1 presents a spiral pattern that illustrates how most people actually move through the stages of change. In this spiral pattern, people can progress from contemplation to preparation to action to main- tenance, but most individuals will relapse. During relapse, individuals regress to an earlier stage. Some
TERYINATION a YAHTENANCE
PRECONTEYPLATIOW CONTEYPLATKJN PREPARATKJ
FIG. 1. A spiral model of the stages of change.
relapsers feel like failures-embanassed, ashamed, and guilty. These individuals become demoralized and resist thinking about behavior change. As a re- sult, they return to the precontemplation stage and can remain there for various periods of time. Ap- proximately 15% of smokers who relapsed in our self-change research regressed back to the precon- templation stage (Prochaska & DiClemente, 1986).
Fortunately, this research indicates that the vast majority of relapsers--85% of smokers, for exam- ple-recycle back to the contemplation or prepara- tion stages (Prochaska & DiClemente, 1984). They begin to consider plans for their next action attempt while trying to learn from their recent efforts. To take another example, fully 60% of unsuccessful New Year’s resolvers make the same pledge the next year (Norcross, Ratzin, & Payne, 1989; Norcross & Vangarelli, 1989). The spiral model suggests that most relapsers do not resolve endlessly in circles and that they do not regress all the way back to where they began. Instead, each time relapsers recycle through the stages, they potentially learn from their mistakes and can try something different the next time around (DiClemente et al., 1991).
On any one trial, successful behavior change is limited in the absolute numbers of individuals who are able to achieve maintenance (Cohen et al., 1989; Schachter, 1982). Nevertheless, in a cohort of indi- viduals, the number of successes continues to in- crease gradually over time. However, a large num- ber of individuals remain in contemplation and precontemplation stages. Ordinarily, the more action taken, the better the prognosis. Much more research is needed to better distinguish those who benefit from recycling from those who end up spinning their wheels.
Additional investigations will also be required to explain the idiosyncratic patterns of movement through the stages of change. Although some transi-
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tions, such as from contemplation to preparation, are much more likely than others, some people may move from one stage to any other stage at any time. Each stage represents a period of time as well as a set of tasks needed for movement to the next stage. Although the time an individual spends in each stage may vary, the tasks to be accomplished are assumed to be invariant.
Treatment Impiicatlons. Professionals fre- quently design excellent action-oriented treatment and self-help programs but then are disappointed when only a small percentage of addicted people register, or when large numbers drop out of the pro- gram after registering. To illustrate, in a major health maintenance organization (HMO) on the West Coast, over 70% of the eligible smokers said they would take advantage of a professionally developed self-help program if one was offered (Orleans et al., 1988). A sophisticated action-oriented program was developed and offered with great publicity. A total of 4% of the smokers signed up. As another illustra- tion, Schmid, Jeffrey, and Hellerstedt (1989) com- pared four different recruitment strategies for home- based intervention programs for smoking cessation and weight control. The recruitment rates ranged from 1 %-5% of those eligible for smoking cessation programs and from 3%-12% for those eligible for weight control programs.
The vast majority of addicted people are not in the action stage. Aggregating across studies and popula- tions (Abrams, Follick, & Biener, 1988; Gottlieb, Galavotti, McCuan, 8c McAlister, 1990; Pallonen, Fava, Salonen, & Prochaska, in press), 10%-15% of smokers are prepared for action, approximately 30%-40% are in the contemplation stage, and 50%- 60% are in the precontemplation stage. If these data hold for other populations and problems, then pro- fessionals approaching communities and worksites with only action-oriented programs are likely to un- derserve, misserve, or not serve the majority of their target population.
Moving from recruitment rates to treatment out- comes, we have found that the amount of progress clients make following intervention tends to be a function of their pretreatment stage of change (e.g., Prochaska & DiClemente, 1992; Prochaska, Nor- cross, Fowler, Follick, & Abrams, 1992). Figure 2 presents the percentage of 570 smokers who were not smoking at four follow-ups over an 18-month period as a function of the stage of change before random assignment to four home-based self-help programs, Figure 2 indicates that the amount of suc- cess smokers reported after treatment was directly
--c- PIA
/=:I --c- PIA /
PlQISt 1 6 12 18
ASSESSMENT PERIODS
FIG. 2. Percentage abstinent over 18 months for smokers in precontemplation (PC), contemplation (C), and preparation (P/A) stages before treatment (n = 570).
related to the stage they were in before treatment (Prochaska & DiClemente, 1992). To treat all of these smokers as if they were the same would be naive. And yet, that is what we traditionally have done in many of our treatment programs.
If clients progress from one stage to the next dur- ing the first month of treatment, they can double their chances of taking action during the initial six months of the program. Of the precontemplators who were still in precontemplation at one month follow-up, only 3% took action by six months. For the precontemplators who progressed to contempla- tion at one month, 7% took action by six months. Similarly, of the contemplators who remained in contemplation at one month, only 20% took action by six months. At one month, 41% of the contempla- tors who progressed to the preparation stage at- tempted to quit by six months. These data demon- strate that treatment programs designed to help people progress just one stage in a month can double the chances of participants taking action on their own in the near future (Prochaska & DiClemente, 1992).
Mismatching Stage and Treatment. A person’s stage of change provides proscriptive as well as prescriptive information on treatments of choice. Action-oriented therapies may be quite ef- fective with individuals who are in the preparation or action stages. These same programs may be ineffec-
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tive or detrimental, however, with individuals in precontemplation or contemplation stages.
An intensive action- and maintenance-oriented smoking cessation program for cardiac patients was highly successful for those patients in action and ready for action. This same program failed, how- ever, with smokers in the precontemplation and con- templation stages (Ockene, Ockene, & Kristellar, 1988). Patients in this special care program received personal counseling in the hospital and monthly tele- phone counseling calls for six months following hos- pitalization. Of the patients who began the program in action or preparation stages, an impressive 94% were not smoking at six-month follow-up. This per- centage is significantly higher than the 66% non- smoking rate of the patients in similar stages who received regular care for their smoking problem. The special care program had no significant effects, how- ever, with patients in the precontemplation and con- templation stages. For patients in these stages, regu- lar care did as well or better.
Independent of the treatment received, there were clear relationships between pretreatment stage and outcome. Twenty-two percent of all precontempla- tors, 43% of the contemplators, and 76% of those in action or prepared for action at the start of the study were not smoking six months later.
A mismatched stage effect occurred with another smoking program. An HMO-based self-help smok- ing cessation program for pregnant women was suc- cessful with patients prepared for action but had neg- ligible impact on those in the precontemplation stage. Of the women in the preparation stage who received a series of seven self-help booklets through the mail, 38% were not smoking at the end of preg- nancy (which was approximately 6 months post- treatment). This was triple the 12% success rate ob- tained for those who received regular care of advice and fact sheets. For precontemplators, however, 6% of those receiving special care and 6% receiving regular care were not smoking at the end of preg- nancy (Ershoff, Mullen, & Quinn, 1987). These two illustrative studies portend the potential importance of matching treatments to the client’s stage of change (DiClemente, 1991; Prochaska, 1991).
Stage Movements During Treatment. What progress do patients in formal treatment ev-
idence on the stages of change? In a cross-sectional study we compared the stages of change scores of 365 individuals presenting for psychotherapy with 166 clients currently engaged in therapy (Prochaska & Costa, 1989). Patients entering therapy could usu- ally be characterized as prepared for action because
their highest score was on the contemplation scale and second highest was on the action scale. The contemplation and action scores crossed over for patients in the midst of treatment. Patients in the middle of therapy could be characterized as being in the action stage because their highest score was on the action scale. Compared with patients beginning treatment, those in the middle of therapy were signif- icantly higher on the action scale and significantly lower on the contemplation and precontemplation scales.
We interpreted these cross-sectional data as indi- cating that, over time, patients who remained in treatment progressed from being prepared for action into taking action. That is, they shifted from thinking about their problems to doing things to overcome them. Lowered precontemplation scores also indi- cated that, as engagement in therapy increased, pa- tients reduced their defensiveness and resistance. The vast majority of the 166 patients who were in the action stage were participating in more traditional insight-oriented psychotherapies. The progression from Contemplation to action is postulated to be es- sential for beneficial outcome, regardless of whether the treatment is action oriented or insight oriented (also see Wachtel, 1977, 1987).
This crossover pattern from contemplation to ac- tion was also found in a longitudinal study of a behavior therapy program for weight control (Prochaska, Norcross, et al., 1992). Figure 3 pre- sents the stages of change scores at pre- and midtreatment. As a group, these subjects entering treatment could be characterized as prepared for ac- tion. During the first half of treatment, members of this contingent progressed into the action stage, with their contemplation scores decreasing significantly and their action scores increasing significantly.
The more clients progressed into action early in therapy, the more successful they were in losing weight by the end of treatment. The stages of change scores were the second best predictors of outcome; they were better predictors than age, socioeconomic status, problem severity and duration, goals and ex- pectations, self-efficacy , and social support. The only variables that outperformed the stages of change as outcome predictors were the processes of change the clients used early in therapy.
Processes of Change The stages of change represent a temporal dimen-
sion that allows us to understand when particular shifts in attitudes, intentions, and behaviors occur.
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STAGES OF CHANGE-WEIGHT r
35
31
CONTEMPLATION
/ / ACTION
_.-.-.-. -.-.-.-. MAINTENANCE
29 F t
27 k N = 5 3 ~
I 5
FIG. 3. A longitudinal comparison of stages of change scores for clients before (week 1) and midway through (week 5) a behavioral program for weight reduction.
WEEKS
The processes of change are a second major dimen- sion of the transtheoretical model that enable us to understand how these shifts occur. Change processes are covert and overt activities and experiences that individuals engage in when they attempt to modify problem behaviors. Each process is a broad category encompassing multiple techniques, methods, and in- terventions traditionally associated with disparate theoretical orientations. These change processes can be used within therapy sessions, between therapy sessions, or without therapy sessions.
The change processes were first identified theoret- ically in a comparative analysis of the leading sys- tems of psychotherapy (Prochaska, 1979). The pro- cesses were selected by examining recommended change techniques across different theories, which explains the term transtheoretical. At least 10 subse- quent principal component analyses on the processes of change items, conducted on various response for- mats and diverse samples, have yielded similar pat- terns (Norcross & Prochaska, 1986; Prochaska & DiClemente, 1983; Prochaska & Norcross, 1983; Prochaska, Velicer, DiClemente, & Fava, 1988). Extensive validity and reliability data on the pro- cesses have been reported elsewhere (Prochaska et al., 1988). The processes are typically assessed by means of a self-report instrument but have also been
reliably identified in transcriptions of psychotherapy sessions (O’Connell, 1989).
Our research discovered that naive self-changers used the same change processes that have been at the core of psychotherapy systems (DiClemente & Prochaska, 1982, 1985; Prochaska & DiClemente, 1984). Although disparate theories will emphasize certain change processes, the breadth of processes we have identified appear to capture basic change activities used by self-changers, psychotherapy cli- ents, and mental health professionals.
The processes of change represent an intermediate level of abstraction between metatheoretical assump- tions and specific techniques spawned by those theo- ries. Goldfried (1980, 1982), in his influential call for a rapprochement among the therapies, indepen- dently recommended change principles or processes as the most fruitful level for psychotherapy integra- tion. Subsequent research on proposed therapeutic commonalities (Grencavage & Norcross, 1990) and agreement on treatment recommendations (Giunta, Saltzman, & Norcross, 1991) has supported Gold- fried’s view of change processes as the content area or level of abstraction most amenable to theoretical convergence. Although there are 250-400 different psychological therapies (Herink, 1980; Karasu, 1986), based on divergent theoretical assumptions, we have been able to identify only 12 different pro- cesses of change based on principal component anal- ysis. Similarly, although self-changers use over 130 techniques to quit smoking, these techniques can be summarized by a much smaller set of change pro- cesses (Prochaska et al., 1988).
Table 1 presents the 10 processes receiving the most theoretical and empirical support in our work, along with their definitions and representative exam- ples of specific interventions. A common and finite set of change processes has been repeatedly identi- fied across such diverse problem areas as smoking, psychological distress, and obesity (Prochaska & Di- Clemente, 1985). There are striking similarities in the frequency with which the change processes were used across these problems. When processes were ranked in terms of how frequently they were used for each of these three problem behaviors, the rankings were nearly identical. Helping relationships, con- sciousness-raising, and self-liberation, for example, were the top three ranked processes across problems, whereas contingency management and stimulus con- trol were the lowest ranked processes.
Significant differences occurred, however, in the absolute frequency of the use of change processes
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Table 1. Titles, Definitions, and Representative Interventions of the Processes of Change
Process Definitions: Interventions
Consciousness-raising
Self-reevaluation
Self-liberation
Counter-conditioning
Stimulus control
Reinforcement management
Helping relationships
Dramatic relief
Environmental reevaluation Social liberation
Increasing infomation about self and problem: observations, confrontations, interpretations, bibliotherapy
Assessing how one feels and thinks about oneself with respect to a problem: value clarification, imagery, corrective emotional experience
Choosing and commitment to act or belief in ability to change: decision-making therapy, New Year’s resolutions, logotherapy techniques, commitment-enhancing techniques
Substituting alternatives for problem behaviors: relaxation, desensitization, assertion, positive self-statements
Avoiding or countering stimuli that elicit problem behaviors: restructuring one’s environment (e.g., removing alcohol or fattening foods), avoiding high risk cues, fading techniques
Rewarding one’s self or being rewarded by others for making changes: contingency contracts, overt and convert reinforcement, self-reward
Being open and trusting about problems with someone who cares: therapeutic alliance, social support, self-help groups
Experiencing and expressing feelings about one’s problems and solutions: psychodrama, grieving losses, role playing
Assessing how one’s problem affects physical environment: empathy training, documentaries Increasing alternatives for nonproblem behaviors available in society: advocating for rights of
repressed, empowering, policy interventions
across problems. Individuals relied more on helping relationships and consciousness-raising for over- coming psychological distress than they did for weight control and smoking cessation. Overweight individuals relied more on self-liberation and stimu- lus control than did distressed individuals (Pro- chaska & DiClemente, 1985).
Processes as Predictors of Change. The processes have been potent predictors of change for both therapy changers and self-changers. As indi- cated earlier, in a behavioral weight control pro- gram, the processes used early in treatment were the single best predictors of outcome (Prochaska, Nor- cross, et al., 1992). For self-changers with smoking, the change processes were better predictors of progress across the stages of change than were a set of 17 predictor variables, including demographics, problem history and severity, health history, with- drawal symptoms, and reasons for smoking (Prochaska, DiClemente, Velicer, Ginpil, & Nor- cross, 1985; Wilcox, Prochaska, Velicer, & Di- Clemente, 1985).
The stages and processes of change combined with a decisional balance measure were able to pre- dict with 93% accuracy which patients would drop out prematurely from psychotherapy. At the begin- ning of therapy, premature terminators were much more likely to be in the precontemplation stage. They rated the cons of therapy as higher than the
pros, and they relied more on willpower and stimu- lus control than did clients who continued in therapy or terminated appropriately (Medieros & Prochaska, 1992).
Integrating the Processes and Stages of Change
The prevailing zeitgeist in psychotherapy is the integration of leading systems of psychotherapy (Norcross & Goldfried, 1992; Norcross, Alford, & DeMichele, 1992). Psychotherapy could be en- hanced by the integration of the profound insights of psychoanalysis, the powerful techniques of behav- iorism, the experiential methods of cognitive thera- pies, and the liberating philosophy of existentialism. Although some psychotherapists insist that such the- oretical integration is philosophically impossible, or- dinary people in the natural environment can be re- markably effective in finding practical means of synthesizing powerful change processes.
The same is true in addiction treatment and re- search. There are multiple interventions but little integration across theories (Miller & Hester, 1980). One promising approach to integration is to begin to match particular interventions to key client charac- teristics. The Institute of Medicine’s (1989) report on prevention and treatment of alcohol problems identifies the stages of change as a key matching
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variable. A National Cancer Institute report of self- help interventions for smokers also used the stages as a framework for integrating a variety of interven- tions (Glynn, Boyd, & Gruman, 1990). The trans- theoretical model offers a promising approach to in- tegration by combining the stages and processes of change.
A Cross=Sectional Perspective. One of the most important findings to emerge from our self- change research is an integration between the pro- cesses and stages of change (DiClemente et d . , 1991; Norcross, Prochaska, & DiClemente, 1991; Prochaska & DiClemente, 1983, 1984). Table 2 demonstrates this integration from cross-sectional research involving thousands of self-changers repre- senting each of the stages of change for smoking cessation and weight loss. Using the data as a point of departure, we have interpreted how particular pro- cesses can be applied or avoided at each stage of change. During the precontemplation stage, individ- uals used eight of the change processes significantly less than people in any of the other stages. Precon- templators processed less information about their problems, devoted less time and energy to reevaluat- ing themselves, and experienced fewer emotional reactions to the negative aspects of their problems. Furthermore, they were less open with significant others about their problems, and they did little to shift their attention or their environment in the direc- tion of overcoming problems. In therapy, these would be the most resistant or the least active clients.
Individuals in the contemplation stage were most open to consciousness-raising techniques, such as observations, confrontations, and interpretations, and they were much more likely to use bibliotherapy and other educational techniques (Prochaska & Di- Clemente, 1984). Contemplators were also open to dramatic relief experiences, which raise emotions and lead to a lowering of negative affect if the person
changes. As individuals became more conscious of themselves and the nature of their problems, they were more likely to reevaluate their values, prob- lems, and themselves both affectively and cogni- tively. The more central their problems were to their self-identity, the more their reevaluation involved altering their sense of self. Contemplators also re- evaluated the effects their addictive behaviors had on their environments, especially the people with whom they were closest. They struggled with questions such as “How do I think and feel about living in a deteriorating environment that places my family or friends at increasing risk for disease, poverty, or imprisonment?’
Movement from precontemplation to contempla- tion and movement through the contemplation stage entailed increased use of cognitive, affective, and evaluative processes of change. Some of these changes continued during the preparation stage. In addition, individuals in preparation began to take small steps toward action. They used counter-condi- tioning and stimulus control to begin reducing their use of addictive substances or to control the situa- tions in which they relied on such substances (Di- Clemente et al., 1991).
During the action stage, people endorsed higher levels of self-liberation or willpower. They increas- ingly believed that they had the autonomy to change their lives in key ways. Successful action also en- tailed effective use of behavioral processes, such as counter-conditioning and stimulus control, in order to modify the conditional stimuli that frequently prompt relapse. Insofar as action was a particularly stressful stage, individuals relied increasingly on support and understanding from helping relation- ships.
Just as preparation for action was essential for success, so too was preparation for maintenance. Successful maintenance builds on each of the pro-
Table 2. Stages of Change in Which Particular Processes of Change Are Emphasized
Precontemplation Contemplation Preparation Action Maintenance Consciousness-raising Dramatic relief Environmental reevaluation
Self-reevaluation Self-liberation
Reinforcement management Helping relationships Counter-conditioning Stimulus control
ADDICTIONS NURSING NETWORKNOLUME 5, NUMBER 1,1993 11
cesses that came before. Specific preparation for maintenance entailed an assessment of the condi- tions under which a person was likely to relapse and development of alternative responses for coping with such conditions without resorting to self-defeating defenses and pathological responses. Perhaps most important was the sense that one was becoming the kind of person one wanted to be. Continuing to apply counter-conditioning and stimulus control was most effective when it was based on the conviction that maintaining change supports a sense of self that was highly valued by oneself and at least one significant other.
A Longitudinal Perspective. Cross-sec- tional studies have inherent limitations for assessing behavior change, and we, therefore, undertook re- search on longitudinal patterns of change. Four ma- jor patterns of behavior change were identified in a two-year longitudinal study of smokers (Prochaska, DiClemente, Velicer, Rossi, & Guadagnoli, 1992): (a) Stable patterns involved subjects who remained in the same stage for the entire two years; (b) pro- gressive patterns involved linear movement from one stage to the next; (c) regressive patterns involved movement to an earlier stage of change; and (d) recycling patterns involved two or more revolutions through the stages of change over the two-year pe- riod.
The stable pattern can be illustrated by the 27 smokers who remained in the precontemplation stage at all five rounds of data collection. Figure 4 presents these precontemplators’ standardized scores (M = 50, SD = 10) for the 10 change processes be- ing used at six-month intervals over the two-year period. All 10 processes remained remarkably stable over the two-year period, demonstrating little in- crease or decrease over time.
This figure graphically illustrates what individuals resistant to change were likely to be experiencing and doing. Eight of 10 change processes, like self- reevaluation and self-liberation, were between 0.4 and 1.4 standard deviations below the mean (i.e., 50). In brief, these subjects were doing very little to control or modify themselves or their problem be- havior.
This static pattern was in marked contrast to the pattern representing people who progressed from contemplation to maintenance over the two-year study. Significantly, many of the change processes did not simply increase linearly as individuals pro- gressed from contemplation to maintenance. Self- reevaluation, consciousness-raising , and dramatic
relief-processes most associated with the contem- plation stage4emonstrated significant decreases as self-changers moved through the action stage into maintenance. Conversely, self-liberation, stimulus control, contingency control, and counter-condition- ing-processes most associated with the action stageevidenced dramatic increases as self-chang- ers moved from contemplation to action. These change processes then leveled off or decreased when maintenance was reached (Prochaska, DiClemente, et al., 1992).
Progressive self-changers demonstrated an almost ideal pattern of how change processes can be used most effectively over time. They seemed to increase the particular cognitive processes most important for the Contemplation stage and then to increase more behavioral processes in the action and maintenance stages. Before over-idealizing the wisdom of self- changers, note that only 9 of 180 contemplators found their way through this progressive pattern without relapsing at least once.
The longitudinal results of the 53 clients complet- ing a behavior therapy program for weight control provide additional support for an integration of the processes and stages of change (Prochaska, Nor- cross, et al., 1992). As mentioned earlier, this group progressed from contemplation to action during the 10-week therapy program. Figure 5 presents the six change processes that evidenced significant differ- ences over the course of treatment. As predicted by the transtheoretical model, clients reported signifi- cantly greater use of four action-related change pro- cesses; counter-conditioning, stimulus control, in- terpersonal control, and contingency management. They also increased their reliance on social libera- tion and decreased their reliance on medications, wishful thinking, and minimizing threats. In other words, these clients were substituting alternative re- sponses for overeating; they were restructuring their environments to include more stimuli that evoked moderate eating; they reduced stimuli that prompted overeating; they modified relationships to encourage healthful eating; and they paid more attention to so- cial alternatives that allow greater freedom to keep from overeating.
Integrative Conclusions Our search for how people intentionally modify
addictive behaviors encompassed thousands of re- search participants attempting to alter, with and without psychotherapy, a myriad of addictive behav-
12 ADDICTIONS NURSING NETWORKNOLUME 5, NUMBER 1,1993
64
62
60
58
56
54
*
52
50
4 8
46
44
42
40
38
36
34
PRECONTEMPLATORS
Process
I 1 I I 1
1 2 3 4 5
ROUND FIG. 4. points over two years.
Use of change processes (T scores) for 23 smokers who remained in the precontemplation stage at each of five assessment
iors, including cigarette smoking, alcohol abuse, and obesity. From this and related research, we have discovered robust commonalities in how people modify their behavior. From our perspective the un- derlying structure of change is neither technique- oriented nor problem-specific. The evidence sup- ports a transtheoretical model entailing (a) a cyclical pattern of movement through specific stages of change, (b) a common set of processes of change, and (c) a systematic integration of the stages and processes of change.
Probably the most obvious and direct implication of our research is the need to assess the stage of a client's readiness for change and to tailor interven- tions accordingly. Although this step may be intu- itively taken by many experienced clinicians, we have found few references to such tailoring before our research (Beutler & Clarkin, 1990, Norcross, 1991). A more explicit model would enhance effi- cient, integrative, and prescriptive treatment plans. Furthermore, this step of assessing stage and tailor- ing processes is rarely taken in a conscious and
ADDICTIONS NURSING NETWORKNOLUME 5, NUMBER 1,1993 13
Y
3 a w oc LL
2
1 -
I
- sTlMuLuscoNTRoL
MERPERSONAL CONTROL
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0 - ................ /-.- CONDITIONING
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meaningful manner by self-changers in the natural environment. Vague notions of willpower, mysti- cism, and biotechnological revolutions dominate their perspectives on self-change (Mahoney & Thoreson, 1972).
We have determined that efficient self-change de- pends on doing the right things (processes) at the right time (stages). We have observed two frequent mismatches. First, some self-changers appear to rely primarily on change processes most indicated for the contemplation stage+onsciousness-raising, self- reevaluation-while they are moving into the action stage. They try to modify behaviors by becoming more aware, a common criticism of classical psy- choanalysis: Insight alone does not necessarily bring about behavior change. Second, other self-changers rely primarily on change processes most indicated for the action stage-reinforcement management, stimulus control, counter-conditioning-without the requisite awareness, decision-making, and readiness provided in the contemplation and preparation stages. They try to modify behavior without aware- ness, a common criticism of radical behaviorism: Overt action without insight is likely to lead to tem- porary change.
We have generated a number of tentative conclu- sions from our research that require empirical confir- mation. Successful change of the addictions involves a progression through a series of stages. Most self- changers and psychotherapy patients will recycle
several times through the stages before achieving long-term maintenance. Accordingly, intervention programs and personnel expecting people to progress linearly through the stages are likely to gather disappointing and discouraging results.
With regard to the processes of change, we have tentatively concluded that they are distinct and mea- surable both for self- and therapy changers. Similar processes appear to be used to modify diverse prob- lems, and similar processes are used within, be- tween, and without psychotherapy sessions. Dy- namic measures of the processes and stages of change outperform static variables, like demograph- ics and problem history, in predicting outcome.
Competing systems of psychotherapy have pro- mulgated apparently rival processes of change. However, ostensibly contradictory processes can be- come complementary when embedded in the stages of change. Specifically, change processes tradition- ally associated with the experiential, cognitive,and psychoanalytic persuasions are most useful during the precontemplation and contemplation stages. Change processes traditionally associated with the existential and behavioral traditions, by contrast, are most useful during action and maintenance. People changing addictive behaviors with and without ther- apy can be remarkably resourceful in finding practi- cal means of integrating the change processes, even if psychotherapy theorists have been historically un- willing or unable to do so. Attending to effective self-changers in the natural environment and inte- grating effective change processes in the consulting room may be two keys to unlocking the elusive structure of how people change..
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Dr. Prochasku is with the Cancer Prevention Re- search Consortium, University of Rhode Island. Dr. DiClemente is at the University of Houston, and Dr. Norcross is at the University of Scranton.