Order 1433776: Leadership

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James 0. Prochaska

How Do People Change, and How Can We Change to Help

Many More People?

fascinating finding in all of psychotherapy science is that very different systems of therapy produce very common outcomes (Smith, Glass, & Miller. 1980). This is a mystery of considerable magnitude that has dogged the field. To treat people affectively, behaviorally. cognitively, psycho- dynamically. existentially, humanistically, interpersonally. or medicinally and have the results be the same challenges all the leading theories of psychotherapy. After all. these are alternatives created by the best therapy theorists of this cen- tury. Are they all right or all wrong? Or does the field not know how therapy works?

The "grand tie" across treatments suggests there are common pathways to change, regardless of how people are treated in therapy. At first I thought there would be com- mon factors in therapy. However. I realized that clients spend less than 1 % of their waking hours in therapy ses- sions. Then I learned that less than 2 5 % of people with DSM-IV diagnoses ever participate in psychotherapy. Next, I noted that Jess than 10% of populations plagued by the major killers of our time (e.g., smoking, sedentary lifestyles, and unhealthy diets) ever seek professional assistance. Given how h;w people actually participate in treatment. the search shifted from how do people change in therapy to how do people change. period.

What the field now needs most is an adequate theory of behavior change. The field needs a theory that can help explain how people change within and between therapy sessions. The field needs to know how people change before

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therapy begins. after it ends. and when therapy never occurs. My exploration evolved into one of identifying a more comprehensive theory of change.

This quest began with a comparative analysis of the major systems of psychotherapy (Prochaska, 1979). The transtheoretical approach sought to differentiate common change processes across these leading systems. I found that these systems had much more to say about per- sonality and psychotherapy. That is, they are theories more about why people do not change than how people can change. They emphasize more the content of therapy-such as feelings, fantasies, thoughts, overt behaviors. and relationships-than the process of change.

Nevertheless, l 0 processes were identified that are assumed to be among the most powerful approaches to producing change. We then sought to study empirically how much people applied each of these 10 change processes (DiClemente & Prochaska, 1982). We compared people who participated in professional treatments with those who changed on their own. What we discovered was a phenomenon that was not contained within any of the leading theories of therapy. Ordinary people taught us that change involves progress through a series of stages. At different stages, people apply particular processes to progress to the next stage (Prochaska & DiClemente, 1982, 1983).

Since those original findings. it is now possible to predict who signs up. shows up, finishes up, and ends up better off as a result of therapy. Moreover, my colleagues and I have developed professional practices that can produce significant impacts in entire populations of people with problem behaviors. What was learned about how people change and how we can try to help many more people change is the subject of this chapter.

Stages of Change

We discovered that change is a process that unfolds over time. It involves progression through six stages: precontemplation, contem- plation, preparation, action, maintenance, and termination.

PRECONTEMPLATION

Precontemplation is the stage in which people are not intending to change or take action in the near future, usually measured in terms of #the next 6 months." People may be in this stage because they are uninformed or underinformed about the consequences of their behav- ior. They may have tried to change several times and become demoral- ized about their abilities to do so. They also may be defensive, denying

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How Do People Change? I 229 there is a problem. People in this stage avoid reading, talking, or think- ing about their high-risk behaviors. They are often characterized in other theories as resistant, unmotivated clients or as not ready for therapy or health promotion programs. Traditional treatment pro- grams were not designed for such individuals and, for that matter, were not especially motivated to match their needs.

People in precontemplation underestimate the benefits of chang- ing and overestimate the costs. They typically are not aware that they are making such mistakes. If they are not conscious of making such mistakes, it will be difficult for them to change. Many remain mired in the precontemplation stage for years, doing considerable damage to their bodies, themselves, and others.

No inherent motivation exists for people to progress from one stage to the next. These are ur 1;i,.,. stages of human development, in which children have an innate drive tc.• p:·.>gress from crawling to walking, although crawling works very well and learning to walk can be both difficult and painful. We have identified two major forces, however, that can motivate people to progress. First are developmental events. For example, in our research the mean age of smokers reaching longer- term maintenance (i.e., consistently maintained abstinence) is 39. At this age, people reevaluate how they have been living. They consider whether they want to die from the way they have been living or enhance the quality and quantity of the second half of their lives.

Environmental events are the other naturally occurring force. A favorite example is a couple we followed who were both heavy smok- ers. Their dog of many years died of lung cancer. This eventually moved the wife to quit smoking. For his part, the husband bought a new dog. Even the same events can be processed differently by different people.

For many years, a belief circulated among professionals and non- professionals alike that people with addictions must hit bottom before they will be motivated to change. As a result, family, friends, and physicians waited helplessly for a crisis to occur. In reality, however, how often does an individual turn 39 or have a dog die? When peo- ple show the first signs of a serious physical illness (e.g., cancer or car- diovascular disease), concerned others may rapidly rally to help them seek early intervention. Early interventions are often life-saving, and waiting for such patients to hit bottom is unthinkable. Similarly, a third option now exists to help addicted, precomemplative patients to progress. The third option, a planned intervention, is discussed later in the chapter.

CONTEMPLATION

Contemplation is the stage in which people intend to change in the next 6 months. Although more aware of the pros of changing, they

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also are acutely aware of the cons. When people begin to contemplate acting seriously, their awareness of the costs of changing can increase. There is no "free change."' The balance between the costs and benefits of changing can provoke profound ambivalence. This ambivalence can reflect a type of love-hate relationship, as with an addictive substance or destructive relationship, and it can keep people immobilized in this stage for long periods. We often characterize this phenomenon as chronic contemplation or behavioral procrastination. These individu- als, like those in the precontemplation stage, are not ready for tradi- tional action-oriented programs, the prevailing paradigm for treatment.

PREPARATION

In this stage, people intend to take action in the immediate future, usu- ally measured in terms of "the next month." 'I)'Pically, they have taken some significant action in the past year. Individuals in preparation have a plan for action, such as going to a recovery group, consulting a counselor, talking to their physician, buying a self-help book, or rely- ing on a self-change approach. These are the people best recruited for brief action-oriented treatment programs. They are ready to use them.

ACTION

Action is the stage in which people have made specific, overt modifi- cations in their lifestyles within the past 6 months. Because action is observable, behavior change often has been equated with the action stage. In the transtheoretical model, however, action is only one of six stages. Not all modifications of behavior count as action. Nor does mere statistical improvement count. Rather, there must be real clini- cal improvement, with recovery being the ideal criterion for action.

Accepting weak criteria for successful action can have serious con- sequences. For example, in Scotland a colleague carried out an inno- vative clinical program for controlled drinking. He announced his pro- gram in the papers and within a week, was flooded with more than 800 recruits. In time, he was pleased with his completion rates, but not his outcomes: The dramatic reduction in drinking as anticipated did not occur. My wife proposed that his criteria for controlled drink- ing might be the problem. In response, he considered the suggestion ethnocentric, an instance of imposing U.S. standards on Scottish citi- zens. As it turns out, the criteria he used for controlled drinking in Scotland was fewer than 50 drinks per week for men and fewer than 35 for women!

The criteria chosen also have consequences for the mental health professions. The finding of common outcomes among diverse thera-

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How Do People Change? I 231

pies is the impetus for this volume. Yet the finding of common out- comes originates. in part, from a reliance on statistical versus actual clinical improvement. Using statistical criteria allowed the field to con- clude that a grand tie across therapeutic systems exists. It was then reasonable to say, M All had won, and all must have prizes. w

On the other hand, the meta-analyses using such criteria also con- cluded that such outcomes depended on neither the duration of ther- apy nor the education or experience of the therapists. Thus, the con- clusion that managed care has embraced: They will fund the briefest therapies and cheapest therapists. Some prize we have won!

MAINTENANCE

In maintenance, people are working to prevent relapse, but they do not apply change processes as frequently as do people in action. They are less tempted to relapse and are increasingly more confident that they can continue their changes. Based on clients' reports of self- efficacy and temptation experienced, it is estimated that maintenance lasts from 6 months to about 5 years.

A common reason that people relapse early in action is that they are not well prepared for the prolonged effort needed to progress to maintenance. Many think the worst will be over in a few weeks or a few months. If they ease up on their efforts too early, they are at great risk of relapse.

To prepare people for what is to come, they may be encouraged to compare overcoming chronic problems, like addictions, to running a marathon. They may have wanted to enter the I OOth running of the Boston Marathon. Yet if they had little or no preparation, they know they would not succeed and so not enter the race. If they had made some preparation, they might make it for several miles before dropping out. Only those well prepared could sustain their efforts mile after mile.

Continuing with the Boston Marathon metaphor, people know that they have to be well prepared if they are to survive Heartbreak Hill, hitting after 20 miles into the race. We can then ask, what is the behavioral equivalent of Heartbreak Hill? The best evidence we have across problems is that most relapses occur at times of emotional dis- tress. Times of depression, anxiety, anger, boredom, loneliness, stress, and distress are the moments when individuals are at their emotional and psychological weakest.

In the face of emotional pressures, how do Americans cope? The average American routinely drinks, eats, smokes, and takes drugs to manage distress (Mellinger, Balter, Manheimer, Cisin, & Perry, 1978). It is not surprising, therefore, that people struggling to overcome chronic conditions will be at greatest risk of relapse when they face

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psycholog ica l pain and up set. We ca nnot prevent em o t io n a l distress fro m occurring. Nonetheless, we can help prevent relapse if patients a re prepared for cop ing w ith distress without re lia nce on a ddi ct ive substances o r other unh e alth y alte rnatives .

If so m any Am e ri cans re ly o n o ra l consump ti ve beha vi o r as a way to manage thei r emotions, what is the hea lth ies t o ra l be h av ior th ey could use? Talking with others abo u t one's distress is a means of seek - ing support tha t can h e lp prevent re lapse. Th e rap y is one of th e exce l- lent wa ys of dealin g with distress. Another h ea lth y alte rn a ti ve that can use d by many people is exercise. Not only does physical acti vity he lp man age mood s, stress. and d istress, bu t also for 60 m inutes per week, a m o re acti ve clie nt ca n rece ive more t ha n 50 hea lth a n d m ental health ben e fi ts. Exerci se should be pre scribe d ro a ll sede nt ary patie n ts. A third hea lth y a lternative is some fo r m of deep relaxat ion, such as medita ti on, yoga, prayer, massage, or deep muscle re laxation. Lening the stress a nd di stress d r ift away fro m o n e's muscles and m ind h e lps to a dvan ce progress a t the mos t te m p ting of Lim es.

TERMINATIO N

In this las t stage, ind ividua ls exp e rience ze ro te mptation and 100 % se lf-e ffi cacy. No ma n e r wh e ther th ey are depressed, anx io u s, bored, lonely, angry, o r stressed, they are confident that they ' '"ill no t re turn t0 the ir old unh eal th y pattern as a way of coping. lt is as tho ugh they n e ve r acq uire d th e pa ttern in th e fi rs t p lace. In a stu d y of form e r sm oke rs an d alco ho lics. we fo und that less th a n 20 % of each g ro up h ad reached the crite ri a of no temptation and total self-efficacy (Snow, Prochaska, & Rossi, 1992) . Although the idea l goal is to be cured or recove red, fo r ma ny people th e bes t that can be accomplished is a life- time of mai ntenan ce.

-......._-IJ1ases of Planned In terventions '-...... -------

--------- ~ . The ;tages....e.! change model reviewed above can bS_9.ppi 1ed to h elp m an y more ~pje a t each ph ase of ther~.....-rTeiitment, o r o t he r pla n n ed interventi~'fhe five phases i c: re cru itm e nt .. re tent io n, progress, process, and outc~~

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To o studies h ave pa id a tten ti on to recrui tme~keJ.eton long t he closet of profess ional trea t ment programs. Historica-lr)';'{hese

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How Do People Change? I 239

~their chances of taking effective action by 3 to 4 ti1 'S (Prochaska. \,r~icer. Fava. Ruggiero, e t al.. 1997}. Setting realis · goa ls can e nabl e mah'}'~,o~e people to enter therapy, remain, pr 0 ress in th erapy, and cont~u~o progress once treatment is compl ed.

The firs~ results reported back from E la nd. where 4,000 health professional~sve been trai n ed in u ng a stage -based treatment model. show a c matic increase in e morale of the health profes - sions. They can nov, ee prog re ss ith th e majori ty of their patients. whereas before they sa failur hen immediate action was the only criteria of success. They are ch more confid ent that they have trea t- m ents that ca n match the ag of all of the ir pa tients. ra th e r than th e 20% prepared to ta ke i e diate ction.

It is no overs tate enr tO sa y t t the m odels of treatment that th erapists choose s ould be go od for t ir own menta l health as we ll as tbe men tal he th of cl ients . After all, icians are involved in ther- apy for a lifer' e. whereas most of clients are ·nvolved for a brief time.

Unfonu1 tely. as managed ca re organ izati o s move to br iefe r and bri efer the a pi es. a clanger exists th at mos t hcalt professionals will feel pres ired inw having to produce immedia te ac ·on . rr this pres- sure is hen transferred to patie nts who a re no t pre red for such actio . th e past wi ll be repeated: Therapists will be neith no retaining enough patients. A majority of patients can be p og ress in br ief encounters. but o nl y if rea li stic goals a re cstab~· ·heel

! or the treatment ep isode. Otherwise, ris k is heightened for demo 1-

izing and demotivating boih patients and th e therapists who wor w ith rhcm.

~-------~-t1...._~~­- PROCESS

To help patie nts to progress from one stage to the n ext, the principles and processes of change that can produce such progress need to be applied.

Principle I. T/ze pros of changing must increase for people 10 progress from precontemplation . We found that in 12 out of 12 studies the pros were higher in contemplation than in precontem plation (Prochaska, Yclicer. e t a l.. 1994) . Th is pattern held tru e across 12 behaviors : quitting cocaine , smoking. de li nq u ency, obesity, co nsi stent condom use. safer sex, sedentary lifestyles. high-fat diets, sun expos ure, radon testing, mammography screening. and even with phys icians practicing behav- io ral medicine.

To initiate movement ou t of precontemplarion, patients may be asked to iden ti fy a ll the benefits o r pros of changing. such as sta rti ng to exercise. Typ icaJly, th ey list four or five. Th en. i hey can be informed there are 8 to I 0 times tha t amo unt and challenged to double o r triple their li st before their n ex t mee ti ng. If th e ir li st of pros for exercising

240 I JAMES o. PROCHASKA

starts to indicate many more motives, like a healthier heart. healthier lungs, more energy, healthier immune system, better moods, less stress, better sex life, and enhanced self-esteem, they will be more seri- ously motivated to begin to contemplate changing.

Principle 2. The cons of changing must decrease for people to progress form contemplation to action. In 12 out of 12 studies, we found that the cons of changing were lower in action than in contemplation (Prochaska, Velicer, et al., 1994).

Principle 3. The pros and cons must Ncross over" for people to be prepared to take action. Jn 12 out of 12 studies, the cons of changing were higher than the pros in precontemplation, but in 11 out of 12, the pros were higher than the cons in the action stage. The one exception to this pat- tern was with patients quitting cocaine, the only population with a large percentage treated as inpatients. We interpret this exception to mean these individuals' actions may have been influenced more by external controls or constraints than by their own motivation to change. At a minimum, their pattern would not bode well for imme- diate discharge.

It is noteworthy that if we used raw scores to assess these patterns, we would often find that the pros of changing are higher than the cons, even for people in precontemplation. It is only when we use standardized scores that we find the clear pattern of the cons of chang- ing always being higher than the pros. This means that compared with their peers in other stages, people in precontemplation underestimate the pros and overestimate the cons. (We interpret this to mean that they are not particularly conscious of making these mistakes, because they do not know how they compare with their peers.)

In a more recent study. we found the same pattern for the pros and cons of being in therapy. Heroin and cocaine addicts who were in the precontemplation stage, evaluated the cons of therapy as greater than the pros. The pros increased for those in contemplation. And, there was a crossover between the pros and cons for those in prepara- tion and beyond (Tsoh & Prochaska, 1998). These data indicate that continuing in therapy and progressing in therapy is, in part, related to people's misevaluation of the pros and cons of being in therapy. In this respect, our field has not done a thorough job educating the public on the benefits of therapy beyond help with a particular problem. Such benefits as decreased defensiveness, increased expressiveness. better relationships, increased self-esteem. and increased incomes should be emphasized in preparing patients for completing therapy.

Principle 4. The Nstrong principle" of progress holds that to progress from precontemplation to effective action, the pros of changing must increase one standard deviation (Prochaska, 1994).

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Principle 5. The "weak principle" of progress holds that to progress from contemplation to effective action, the cons of changing must decrease one half standard deviation.

Because the pros of changing must increase twice as much as the cons decrease, therapists should place twice as much emphasis on the benefits of changing than on the costs. What is striking here is the belief that mathematical principles have discovered for how much pos- itive motivations must increase and how much negative motivations must decrease. Such principles can produce much more sensitive assessments for guiding interventions, giving therapists and patients feedback for when therapeutic efforts are producing progress and when they are failing. Together, therapists and clients can modify their methods if they are not seeing as much movement as is needed for becoming adequately prepared for action.

Principle 6. Particular processes of change need to be matched to specific stages of change. Table 1 presents the empirical integration that we have found between processes and stages of change (Prochaska & Di Clemente, 1983 ). Guided by this integration, we would apply the following nine processes with patients in specific stages of change:

1. Consciousness raising involves increased awareness and information about the causes, consequences, and cures for a particu- lar problem. Interventions that can increase awareness include obser- vations, confrontations, interpretations, feedback, and education, such as bibliotherapy. Some techniques, such as confrontation, are high- risk for retention and are not recommended as much as motivational

The Stages of Change in Which Particular Processes of Change Are Emphasized

Stages of change Precontemplation Contemplation Preparation

Consciousness raising Dramatic relief

Environmental reevaluation Self-reevaluation

Self-liberation

Note. Processes of change are centered between columns to show overlap between stages.

Action Maintenance

Contingency management Helping relationships Counterconditioning

Stimulus control

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enhancement methods such as personal feedback about the current and long-term consequences of continuing with the chronic pattern. Increasing the cons of not changing is the corollary of raising the pros of changing. So, clearly part of the purpose in applying consciousness raising is to increase the pros of changing.

2. Dramatic relief invoh;es emotional arousal about one's cur- rent behavior and relief that can come from changing. Fear, inspira- tion, guilt. and hope are some of the emotions that can move people to contemplate changing. Psychodrama, role playing, grieving, and personal testimonies are examples of techniques that can move peo- ple emotionally.

Earlier behavior-change literature concluded that interventions such as education and fear arousal did not motivate behavior change. Unfortunately, many interventions were evaluated by their ability to move people to immediate action. Processes such as consciousness raising and dramatic relief are intended to move people to contempla- tion, not immediate action. Therefore, effectiveness of processes should be assessed by whether they produce the progress they are expected to produce for the client's stage of change.

3. Environmental reevaluation combines both emotional and cognitive assessments of how one's behavior affects one's social envi- ronment and how changing would affect that environment. Empathy training, value clarification. and family or network interventions can facilitate such reevaluation.

A brief media intervention aimed at smokers in precomemplation is instructive here. A man clearly in grief says, "I always feared that my smoking would lead to an early death. I always worried that my smoking would cause Jung cancer. But I never imagined it would hap- pen to my wife." Beneath his grieving face appears this statistic: 50,000 deaths per year are caused by passive smoking. the California Department of Health.

In the 30 seconds that it takes to read and process the message, consciousness raising, dramatic relief. and environmental reevalua- tion are introduced. It is little surprise that such media interventions have been evaluated as an important part of California's successful ini- tiative to reduce smoking.

4. Self-reevaluation combines both cognitive and affective assessments of one's self-image free from a particular problem. Imagery, healthier role models, and values clarification are techniques that can move people. Clinically, we find people first looking back and reevaluating how they have been as troubled individuals. As they progress into preparation, they begin to develop more of a future focus as they imagine more how their life will be free from the problem.

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5. Self-liberation includes both the belief that one can change and the commitment and recommitment to act on that belief. Techniques that can enhance such willpower make greater use of pub- lic rather than private commitments. Motivational research also sug- gests that if people have only one choice, they are not as motivated as if they have two choices (Miller, 1985). Three is even better, but four does not seem to enhance motivation.

Wherever possible, transtheoretical therapists try to provide peo- ple with three of the best choices for applying each process. With smok- ing cessation, for example, we used to believe only one commitment really counted, and that was quitting "cold turkey.# We now know there are at least three good choices: cold turkey. nicotine replacement, and nicotine fading. Asking clients to choose which alternative they believe would be most effective for them, and to which they would be most committed, enhances their motivation and self-liberation.

6. Counterconditioning requires the learning of healthier behaviors to replace problem behaviors. Three healthier alternatives to smoking were discussed in the previous section. Earlier, three healthier alternatives for coping with emotional distress and prevent- ing relapse were introduced. Counterconditioning techniques are spe- cific to a particular behavior and include desensitization. assertion. and cognitive counters to irrational, distress-provoking self-statements.

7. Contingency management involves the systematic use of reinforcements and punishments for taking steps in a particular direc- tion. Because we find that successful self-changers rely much more on reinforcement than punishment, we emphasize reinforcements for progressing over punishments for regressing. Contingency contracts, overt and covert reinforcements, and group recognition are proce- dures for increasing reinforcement. They also provide incentives that increase the probability that healthier responses will be repeated.

To prepare people for the longer term, we teach them to rely more on self-reinforcements than social reinforcements (Prochaska, Norcross, & DiClemente. 1994). We find that many clients expect much more reinforcement and recognition from others than what oth- ers actively provide. Too many relatives and friends can take action for granted too quickly, and average acquaintances typically generate only a couple of positive consequences early in action. Self-reinforcements are much more under self-control and can be dispensed more quickly and consistently when temptations to lapse or relapse are resisted.

8. Stimulus control involves modifying the environment to increase cues that prompt healthier responses and decrease cues that are tempting. Avoidance. environmental reengineering (e.g .. remov- ing addictive substances and paraphernalia), and attending self-help

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groups can provide stimuli that elicit healthier responses and reduce

risks for re lapse.

9. He l p ing r e lations hip s combine caring. openness, trust, and acceptance as well as support for changing. Rapport building, a thera- peutic alliance, counselor calls. buddy systems. sponsors, and self-help groups can be excellem resources. If people become dependent on social support for maintaining change, care is needed in fading out that support lest the termination of therapy becomes an unwelcome con -

dition for relapse.

In{egrating the Processes of Ch'tJ~e Vvith C01nn1on Factors

peting th eories or therapy have implicitly or explicitly adv ated

ative processes for producing change. Arc cognitions w

peopl or emotions? Are values. decisions, or dedication? gencies hat motivate us, or are we controlled by enviro ental con - dition s or ond iti oned habits? Is it the therapeutic rel ionsh ip that is

the comm on ~eat er a cross a ll t he rapemic moda li ties An ~eclecu #answer to each o f these questio9 is yes. An integra-

tive answer is th therapeutic processes origi 4'ting from competing

theories can be com tible when they are ma hed to the client's stage o f change. With pa ti e ts in earlier stages f change, therapi sts can enhance progress throu \! more experi tial processes that produce h ea lthier cog niti o ns, emol'l~s, evalu ions. decis ions, and commi t- m e nt s. ln later s tages, we see to bu· don such solid preparation and motivation by emphasizing mo ehavioral processes that can help condition healthier habit s, reinf e these habits. and provide physi - cal and social environ ments su porti of hcalt hi er I if est ylcs.

One of the qua liti es I va l c most ao u t the t ranstheore ti cal model

is that it can provide an ntcgrarion o ome of the best c hange processes derived from th orics th a t are u sua 'seen as competing and

in compatible. So. tao. believe that this mode can p rovide an inte- gration of commo n ~ tors derived from cmpirica omparisons across competing therapjs and medical and social sen · es. Weinberger (1995) has idcnt i ed fi ve common factors thil t he bell ves have ade - quate empmc support: expectations, th erapeu tic a ·ancc. con- frontin g st rat · ies , mastery techn iques, and attributions.

H ypoth cs o f h ow the common factors delineated by Wei erger

are likely be related to and integrated within the stage dimension of the tra stheoretical model follow (Prochaska, 1995). People in pre-

cont/plation are likely to hilve the poorest expectations for change

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