Prochaska - Why Don't Continents Move Why Don't People Change

Journal of Psychotherapy Integration, Vol. 9, No. 1,1999

Why Don't Continents Move? Why Don'tPeople Change?

James O. Prochaska1 and Janice M. Prochaska2,3

People don't change because they can't, don't want to, don't know how, ordon't know what to change. The transtheoretical model provides an integ-rative model for understanding reasons for not changing, as well as readinessto change. Stages and levels of change guide therapists in their work inhelping clients change. Clients in the precontemplative stage typically cannotchange without special help. Those in the contemplation stage are not surethey want to change. Those in the preparation stage are afraid they do notknow how to successfully change. The levels of change help guide therapistsand clients on what to change.

KEY WORDS: transtheoretical model; resistance to change; noncompliance.

INTRODUCTION

As a 10 year-old, Jim explored an atlas and discovered that SouthAmerica could fit against Africa like two pieces of a puzzle. Similarly,North America could fit against Europe as if they were once united. Hethought that the continents must have moved apart at some time in thepast. But that didn't make sense; continents don't move. If there is anythingstable in this world, it is massive continents that provide humans with afirm foundation. The complementary shapes of continents must have beenjust a strange coincidence, Jim concluded. It wasn't until he took a geologycourse in college that he learned about the phenomena of continental drift.So continents can move, often imperceptibly, sometimes disruptively.1Psychology Department and Director of the Cancer Prevention Research Center, Universityof Rhode Island, Kingston, Rhode Island.

2Pro-Change Behavior Systems, W. Kingston, Rhode Island.3Correspondence should be directed to Janice M. Prochaska, Pro-Change Behavior Systems,P. O. Box 755, W. Kingston, Rhode Island 02892.

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1053-0479/99/0300-0083$16.00/0 © 1999 Plenum Publishing Corporation

Just as we seldom see continents move, so too do we seldom observepeople changing. Change is a process that occurs over an extended periodof time, often imperceptibly, sometimes disruptively. People can be chang-ing even when they appear to be standing still. Others can appear to bemoving even when they are running in place.

WHY DON'T PEOPLE CHANGE?

(a) They can't. (b) They don't want to. (c) They don't know how to. (d)They don't know what to change. (e) All of the above. Let us examineeach of these alternatives to better understand why people don't change.

Can't Change

Under what conditions are people unable to change? We cannot changethose conditions of ourselves that cannot be brought under voluntary con-trol. We cannot intentionally change the aspects of ourselves that are fixed,closed, and are determined entirely by forces outside of our control. Ourgenetic makeup, our time in history, our biochemistry, and the social statusof our families of origin are givens that were determined for us not by us.They are relatively static variables that are not usually open to inten-tional change.

Changes that we are referring to are intentional changes in whichindividuals apply psychological processes to improve their own psychologi-cal functioning, including overt behaviors, covert experiences, and broaderpatterns of personality. We can prevent pedophiliacs from abusing childrenby imprisoning them and converting them into convicts. But such changeis necessarily coercive and not volitional. It involves the rise of legal orpolitical processes to modify behavior.

People also cannot change aspects of themselves that are not conscious.Alcoholism is commonly called a disease of denial since many troubleddrinkers are not aware that alcohol is damaging or destroying their lives.

People cannot change if they believe they cannot change. As an oldsaying goes, "If you believe you can't change, you're right!" People canbecome demoralized about their abilities to change and can conclude thatthey don't have the willpower or inner strength to change.

Why don't more physicians try to help their patients change health-related behaviors like smoking, which put them at high risk for death anddisease? Orleans and her colleagues (1985) found that the number onebarrier to a physician's practicing preventive medicine is that 65% of physi-

Prochaska and Prochaska84

cians believe that people can't change. These beliefs continue in spite ofthe frequent finding that even brief interventions by physicians can doublethe number of patients who quit smoking (Kotte, Battista, DeFriese, &Brekke, 1988).

If people believe that their particular problem behaviors are underbiological control, they may conclude that they cannot control such behav-iors. Believing that alcoholism is due to one's genetic makeup, obesity isdue to one's fat cells, smoking is due to nicotine addiction, depression isdue to one's neurochemistry, can lead to people concluding that their ownbehavior is not under their control. To the extent that some problems, suchas schizophrenia, may be primarily genetic and/or biochemical in origin,then people are not going to be able to overcome their problems just byapplying psychological processes.

Just as people can place or displace the entire responsibility for theirbehavior onto internal biological processes, so too can people project allof the controls onto external forces, such as family, society, or destiny. Ifpeople believe that their particular problems are under social control, thenthey may conclude that they are not powerful enough to control socialforces that are causing their problems. To the extent that some problems,such as poverty, may be primarily social in origin, then people are notgoing to be able to overcome their problems just by applying psychologi-cal processes.

One of the intriguing issues for the field of psychopathology and psy-chotherapy is the relative strengths of biological controls, social controls,and self-controls. While this issue is beyond the scope of this paper, webelieve that people cannot change as long as they believe that self-controlis too weak to change psychological phenomenon that are partially underthe control of biology or society.

Don't Want to Change

Even if people believe in their power to change, there are conditionsunder which they may not want to change. People do not want to changewhen they perceive the benefits of problem behaviors as outweighing thecons of those behaviors. Similarly, people usually do not want to changewhen the benefits of changing only equal the costs of changing. We hearpeople saying, "I know my behavior may kill me someday, but I reallyenjoy my habit and it helps me deal with stress." People are less likely towant to change when they would have to trade immediate benefits, likepleasure and reduction of stress, in order to reduce the risks of long-term consequences, like death and disease. We can understand people not

Why Don't Continents Move? 85

wanting to make these changes from a psychoanalytic perspective, whichviews the pleasure principle as primary to and more powerful than thereality principle. We can also understand this condition from a behavioralperspective in which immediate consequences have much more controlover behavior than do delayed consequences (Prochaska & Norcross, 1998).

Individuals are also likely to not want to change when they perceiveother people as trying to pressure them or coerce them into changing. Thedesire to be in control of ourselves and our environment can cause us toresist changes that might otherwise be to our advantage Even wild miceseem to have motivation to be in control. Calhoun (1975) brought Norwe-gian mice from the wild but open environment into controlled laboratoryconditions. When allowed to control their environment, the mice wouldconsistently switch on a dim light in preference to a bright light or no light.When the experimenter turned on the dim light, however, the mice wouldswitch on one of the other lights. Similarly, when the mice were able toswitch on a revolving wheel, they would do so and run for hours, apparentlyto stay active and healthy. When the experimenter switched on the revolvingwheel, however, the mice would switch it off. The wild mice seemed intenton being in control even when forced to live in the dark or live passiveand unhealthy lives. Husbands who are forced into therapy by their wives,adolescents who are brought to therapy by their parents, and offenderswho are sent to therapy by judges may not want to change even if remainingin control is self-defeating.

Don't Know How to Change

People may want to change but they may not know how to change.Even with the best therapies available, the majority of alcoholics, drugaddicts, obese individuals and smokers will return to their addictions withina year or two after treatment (Hunt & Matarazzo, 1973). Many obsessiveshave tried to overcome their compulsive rituals but they, too, tend to relapseback to old patterns.

Many people enter therapy believing they can change and that's whythey are there. They want to change and that's why they are there. Butthey don't know how to change and that's why they are there. A 52-year-old man returned to therapy because of a recent onset of impotency. Heknew he could change. With the help of therapy and Alcoholics Anonymoushe was celebrating nine years of sobriety. He certainly wanted to change.His sexuality and his love relationships were essential aspects of his senseof self. But as smart as he was and as successful as he had been with hisalcoholism, he just could not find the solution to control his erections.


This strong-willed individual was frustrated to find that the willpowerhe had used to control his drinking was not successful with sex. If anything,trying to will an erection was only making matters worse. He felt impotent,lacking the power to change. He was pleased to discover that he was justlacking knowledge about how to overcome this particular problem. Withina week he was functioning fine.

Unfortunately, all too many people enter therapy believing that thera-pists have the knowledge to help them change chronic problems quickly.Acute problems, like this fellow's recent onset of impotence, can be reversedquickly. But, as we shall see, chronic problems take much longer to change.On the average, clients remain in therapy for a median of three sessions.As a result, they don't give therapy or therapists much chance to help themchange. If people don't know how to change, including how long it takesto change, then they are not likely to recover from chronic behavioralproblems.

Don't Know What to Change

Many individuals enter therapy not knowing what to change. They areconfused about the causes and cures of their problems. Alcohol-troubledpeople, for example, can be confused about the causes and controls of theirdysfunctional drinking, and may not know what to change in order torecover from alcohol abuse. If they consult a behavior therapist, they maybe encouraged to analyze the immediate antecedents and consequences oftheir problem drinking. These situational stimuli are seen as the key causesor controls of behavior and will need to be changed if problem drinkingis to be modified. Cognitive therapists, on the other hand, would encouragethese same clients to analyze key cognitions or beliefs related to theirdrinking. For cognitive therapists, it is not the events preceding or followingdrinking that are critical but how people process or think about these events.

Consulting an interpersonal therapist will lead clients to think abouttheir interpersonal patterns and conflicts that are assumed to be the basisof most psychopathology. Most emotional, behavioral, and personality dis-orders are believed to be the result of unresolved interpersonal conflicts,such as communication and control conflicts. A 33-year-old author wasdriven to therapy by his wife who was preoccupied with his dysfunctionaldrinking. He was extremely sensitive to being controlled by others, espe-cially women. Could he gain lasting control over his alcoholism withoutresolving his chronic conflicts over being controlled?

Family therapists who focus on famines of origin would encourageclients to understand their early family rules and relationships more than


their current interpersonal patterns. Adult children of alcoholics, for exam-ple, can become alcoholics themselves with little awareness of how theircurrent problems are ruled by unresolved conflicts with their families oforigin.

Psychoanalytic and psychodynamic therapists would help clients ana-lyze intrapersonal conflicts that can be the basis of symptoms like dysfunc-tional drinking. Conflicts over unresolved oral dependency needs can beacted out through bouts with the bottle. Or an inadequate sense of selfcan lead to an inadequate lifestyle driven by drinking rather than ego needs,such as mastery and competency.

No wonder many people can be confused about what to change, if fivedifferent types of therapists would attribute their problems to five differentcauses. And we haven't even discussed biologically or spiritually orientedtherapists or other orientations from the more than 400 therapies thatcurrently exist (Prochaska & Norcross, 1998). If professional therapistscannot agree on what needs to he changed in order to help people overcomeproblems like alcohol abuse, then how can we expect lay people to knowwhat to change?

A TRANSTHEORETICAL INTEGRATION OF WHY PEOPLEDON'T CHANGE

Thus far, we have analyzed a rather eclectic set of reasons why peopledon't change, ranging from not being able to, not wanting to, not knowinghow to, and not knowing what to change. We believe we can develop amore systematic understanding of why people don't change, by examiningan integrative model of how people do change.

The transtheoretical model has emerged from research on how peoplechange on their own, as well as how they change with the help of therapy(Prochaska & DiClemente, 1983, 1984, 1986a,b; Prochaska & Norcross,1983; Norcross & Prochaska, 1986; Norcross, Prochaska, & DiClemente,1986). This model has been applied to understanding how people changehealth-related behaviors, such as alcohol abuse, obesity, smoking, and riskysexual behaviors (DiClemente & Hughes, 1990; Prochaska, Rossi, & Vel-icer, 1990; Prochaska & DiClemente, 1982; Prochaska, DiClemente, Velicer,Ginpil, & Norcross, 1985; Prochaska et al., 1994). It has also been basedon research on how people change mental health problems, such as anxiety,depression, alcohol abuse, and a broad range of Diagnostic Statistical Man-ual (4th ed.) disorders (Prochaska & Norcross, 1983; McConnaughy, Pro-chaska, & Velicer, 1989; McConnaughy, DiClemente, Prochaska, & Velicer,1989; Norcross & Prochaska, 1986; Norcross, Prochaska & DiClemente,

88 Prochaska and Prochaska

1986; Prochaska, Rossi, & Wilcox, 1991; Beitman, Beck, Carter, David-son, & Maddock, 1994).

Our first discovery was that people change by progressing througha series of stages. The stages we have identified are Precontemplation,Contemplation, Preparation, Action, and Maintenance (Prochaska &DiClemente, 1983; DiClemente, Prochaska, Velicer, Fairhurst, Rossi, &Velasquez, 1991).

Precontemplation Stage

Precontemplation is a stage in which people are not intending to changetheir behavior in the foreseeable future. People can be in the precontempla-tion stage because they are unaware that their behaviors are problems. Alack of awareness can be due to ignorance: they don't know that smokingcan kill them, that their diets can destroy them, or that their sexual behaviorsmay infect them with deadly diseases.

People can also be unaware that they have problems because of defen-siveness. We have already discussed alcoholism as a disease of denial inwhich people can defend their drinking even though it is damaging ordestroying their lives. Paranoid and psychopathic personalities often per-ceive others as needing to be changed, but not themselves. On the Stagesof Change Questionnaire, precontemplators entering therapy are likely toagree with an item like "I'm not the one with problems and don't reallyneed to be here."

Precontemplators can also be demoralized about their abilities tochange. They may have truly tried to change but failed. They don't believethey can change so they don't even want to think about it.

It is clear that many people in the precontemplation stage cannotchange. At least they cannot change without outside help. Ignorance, defen-siveness, and demoralization are major barriers to being able to change.Some of these barriers can be particularly self-defeating because they canmake precontemplators resistant to outside help that can facilitate change.

Precontemplators often present for therapy because they are pressuredby spouses, parents, employees, schools, or courts. Needless to say, theyare at high risk for dropping out (Brogan, Prochaska, & Prochaska, 1999),even though they may need therapy more than people in any other stageof change.

We tried to predict who would terminate therapy prematurely. Usingthe best predictors in the therapy outcome literature, such as the nature,severity, and intensity of the problem, socioeconomic status, age, and gen-der, we were unable to predict who would terminate prematurely. Using


stage-related measures, we were able to correctly predict 93% of the therapydropouts. The premature terminators clearly had stage profiles of pre-contemplators (Brogan et al., 1999). As therapists, we cannot help peoplechange, if we do not enable them to be in therapy.

Not only are many precontemplators not able to change, most do notwant to change. As a group, they evaluate the pros of their problem behav-iors as clearly outweighing the cons. For example, while most people inour society tend to judge the hazards of smoking as clearly outweighingthe benefits, smokers in the precontemplation stage report the oppositepattern (Velicer, DiClemente, Prochaska, & Brandenburg, 1985). Theyjudge the benefits as clearly outweighing the cons. Their imbalance couldalso emerge in pare from demoralization with cognitive dissonance, leadingpeople to value behaviors they are stuck with. Finally, the imbalance couldderive from defensiveness, with people rationalizing behavior that placesthem at greatly increased risk for disease and death. On the other hand,there are some well-informed precontemplators who believe they couldchange but do not want to because in their rational judgement the benefitsof their behavior clearly outweigh the costs (Prochaska, Norcross, &DiClemente, 1994).

Contemplation Stage

Contemplation is a stage in which people are intending to changeproblems in the foreseeable future, usually within six months. They havesignificantly higher self-efficacy or confidence than precontemplators thatthey can change (DiClemente et al., 1991). While contemplators are in-tending to change and are confident they can change, many do not change.For example, a sample of 800 smokers who were in the contemplation stageindicated that they were seriously intending to quit smoking in the nextsix months. Yet, following participation in a state-of-the-art, self-help pro-gram, the majority did not even try to quit for one day (Prochaska, DiClem-ente, Velicer, & Rossi, 1990).

Why don't contemplators change? As a group, contemplators evaluatethe pros of their problem as just about equal to the cons. So, while theyare aware of, or admit more to the negatives of their behavior than doprecontemplators, contemplators are very ambivalent about changing. Theydoubt that the benefits of changing will clearly outweigh the costs. And, therule of thumb for the contemplation stage is when in doubt, don't change.

Given the intense ambivalence that can characterize contemplation,people in this stage often end up not wanting to change. At least they don'twant to change enough to risk taking action and to risk giving up the


immediate benefits of their problem behavior. They often go on thinkingabout changing, telling themselves someday they will take action. Peoplewho substitute thinking for acting we call chronic contemplators.

Preparation Stage

Preparation is a stage in which people are intending to take action inthe near future, usually within a month. As the name of the stage indicates,they see themselves as more prepared for action. They are more confidentthan contemplators that they can control their problem behavior. Thepros of changing clearly outweigh the cons. They have a concrete plan tochange and may be taking small steps to reduce their problem behaviors(DiClemente et al., 1991). And, in the next six months, the large majorityof people in the preparation stage will take action to change. But, as withmany problems, the vast majority of people who take action will fail. Theywill either quickly or eventually relapse back to their old patterns. Manyof these people do not know how to change.

In our research on how people change, we have discovered that oneof the secrets of success is that people must use appropriate processes ofchange to progress through particular stages of change. To progress fromprecontemplation to contemplation involves the application of affectiveand cognitive processes, like dramatic relief and consciousness raising(DiClemente et al., 1991; Prochaska & DiClemente, 1983). Movement fromcontemplation to preparation involves the use of cognitive and evaluativeprocesses like consciousness raising and self-reevaluation.

Action Stage

To progress to the action stage, people must apply more existentialprocesses like self-liberation, more humanistic processes like helping rela-tionships, and more behavioral processes like counterconditioning, stimuluscontrol, and reinforcement management (Prochaska & DiClemente, 1983).In the action stage, people use these processes to overtly modify theirproblem behavior to at least some minimum criterion of success. The actionstage is the busiest time involving the greatest use of particular processesof change. The action stage lasts longer than most people expect, usuallyabout six months of concentrated effort before risks for relapse aregreatly reduced.

If people move from preparation to action and continue to rely onprocesses like consciousness raising and self-reevaluation, they are much


more likely to fail. They are not matching the appropriate processes ofchange to the stage they are in. These people do not know how to change.

Therapists who do not match appropriate processes to the client's stageof change do not know how to help people change. Behavior therapists,for example, who apply counterconditioning and stimulus control withprecontemplators or contemplators are likely to generate resistance ratherthan progress. Similarly, psychodynamic therapists who want to continueto increase consciousness with clients who are prepared for action are likelyto increase resistance to therapy.

Table I summarizes the relationships that our research has foundbetween the stages people are in and the processes of change they ap-ply to progress to the next stage (DiClemente et al., 1991; Prochaska &DiClemente, 1983; Prochaska & DiClemente, 1984).

Not only must people apply appropriate processes of change, theymust apply them frequently enough and for long enough duration if theyare to succeed. Too often we hear people saying they went to therapy andit didn't do them any good. But how frequently did they go to therapy?Research on dose-response relationships indicate that most people whostay for less than six sessions of therapy do not receive enough of a doseto have an effect (Howard, Kopta, Krause, & Orlinksy, 1986). People whostay in therapy for less than six months are not likely to receive the fullbenefit of therapy. We say to precontemplators who are at risk of droppingout of therapy before it begins, "Give us six sessions and we can make asignificant difference; give us six months and we can make a substantialdifference." By significant difference we mean we can help them progressat least one stage in six sessions. Our research on smokers indicates thatpeople who progress one stage in one month are twice as likely to be notsmoking at six months. With six months of therapy we usually can helppeople to be more effective action with greatly reduced risks of relapse.

Increasingly more informed consumers want to know what procedures


Table I. Stages by Processes of Change

Processes

Stages of Change

Precontemplation Contemplation

Consciousness-raisingDramatic reliefEnvironmental reevaluation

Preparation

Self-reevaluation

Action Maintenance

Self-LiberationContingency managementHelping relationshipCounterconditioningStimulus control

we will apply with their particular problems. In some treatment programspotential participants will say that they have already tried what the thera-pists had to offer and it didn't work. Therapists can become demoralizedabout their abilities to help such people change. They can conclude thatthey need to refer such clients to a different type of therapy. That may becorrect in some cases. But if a patient with major depression reportedhaving tried and failed with antidepressants, that doesn't mean we wouldrule out the use of such medications. We would need to assess the amount,duration, and type of antidepressant used. If a patient used the medicationfor only a week and we know it takes at least 10 days to get an effect, wewould conclude that the medication had not been given a fair trial. If apatient used only 50 mg a day and we knew 150 mg was an optimal averagedose, we would conclude that the medication had not been given a fairtrial.

But how frequently and how long do people need to apply conscious-ness-raising and self-reevaluation processes before they are adequatelyprepared for action? How frequently and how long did they need torely on self-liberation, helping relationships, and counterconditioningbefore they are relatively free from risks of relapse? Unfortunately, withmost problems, we have little or no data on how much processes mustbe used in order to progress. The fact is, as scientists and as practitionerswe know all too little about how to help people change.

With smoking cessation we have gathered much more data about howfrequently people apply particular processes of change to progress fromone stage to the next. We are able to use computers to generate individualprogress reports to give people feedback about which processes of changethey are underutilizing, which processes they are overutilizing, and whichprocesses they are applying appropriately. After 18 months of follow-upwe are finding that such feedback is continuing to nearly triple the outcomesof the best self-help programs previously available (Prochaska et al.,1993).

Without adequate data and without systematic feedback, many peopleare forced to rely on trial and error learning to discover how to change.We believe this is a major reason why relapse is the rule rather than theexception when it comes to changing chronic problems and patterns. Wereframe relapse as an excellent opportunity to learn rather than being areason to fail. In fact, people who take action and fail are twice as likelyto succeed over the next six months than those who don't take action duringthe first month of intervention (Prochaska et al., 1993). The average personwho eventually succeeds in getting free from smoking takes 3-4 seriousaction attempts distributed over 7-10 years before they make it to long-term maintenance.


Maintenance Stage

Maintenance is the stage in which people are working to consolidatethe gains they made during action in order to be free from risks for relapse.In the transtheoretical model, maintenance begins after six months of con-certed action. Maintenance used to be thought of as a stable stage in whichpeople do not have to work at changing. We now know that people continueto apply particular processes of change, such as counterconditioning andstimulus control to keep from relapsing (Prochaska & DiClemente, 1983).

How long does maintenance last? For some problems, like obesity, itmay be a lifetime. For other problems like alcoholism, smoking, and certainanxiety and mood disorders, people may be able to entirely terminate theirproblems and not have to do anything to prevent relapse.

The criteria we use for termination is that people attain maximumself-efficacy or confidence and minimum temptation to engage in theirproblem behavior across all previously risky situations. Many smokers getto the point where they experience no desire to smoke, are fully confidentthat they will never smoke again, and report having to do nothing to keepfrom smoking. How long does it take to complete the maintenance stage?We used to think that for a smoker, 12 months of continuous abstinencemeant they were home free. We now know that even after a year of neversmoking, 37% of the people will relapse back to regular smoking over thecourse of their lifetimes. After five years of continuous abstinence the risksfor relapse finally drop to 7% (U.S. Department of Health and HumanServices, 1990). So, maintenance lasts for six months to 5 years after actionis taken.

Integrating Stages and Reasons for Not Changing

To integrate the most common reasons why people don't change, wecan use the stage model. Table II illustrates the most common reasons whypeople at different stages are most likely not to change. Precontemplatorsas a group cannot change and most also do not want to change. Contempla-


Table II. Stage X Reasons Why People Don't Change

Precontemplation ->

Can't change

Contemplation -> Preparation ->

Don't want to change

Action ->

Don't know how to changeDon't know what to change

Maintenance ->

tors, as a group, do not want to change, at least not enough to take action.Individuals in the preparation and action stages do not know how to changeor do not know what to change and thus are at high risk for relapse.

What To Change Depends on the Levels of Change

The field of psychotherapy cannot agree on what to change in orderto help people overcome their problems. As discussed earlier, causal attribu-tions of clients and therapists about a single problem, like alcoholism,can range from immediate situations to maladaptive cognitions to currentinterpersonal conflicts to past families of origin issues to intrapersonaldynamics. Are clients left with a potpourri of causal attributions that canvary arbitrarily depending on the particular therapist they consult? Or canwe integrate these alternative attributions into a framework that providesmore systematic strategies for deciding what to change in order to alterthe troubled parts of life?

The transtheoretical model uses the levels of change as the dimensionfor organizing the content of therapy; that is, what we are trying to change inorder to resolve problems. The stage dimension represents when particulartypes of changes can be accomplished. The processes dimension representshow particular changes can be accomplished. And the levels dimensionrepresents which particular type of changes need to be accomplished.

The levels dimension organizes the psychological causes and controlsof problem behaviors on a hierarchy that ranges from most to least availableto consciousness and from most to least contemporary in origin. The follow-ing five levels have received the most clinical and empirical support todate (Norcross, Prochaska, Guadagnoli, & DiClemente, 1989; Norcross,Prochaska, & Hambrecht, 1985):

1. Symptom/Situational Level.2. Maladaptive Cognitions.3. Interpersonal Conflicts.4. Family of Origin Conflicts.5. Intrapersonal Conflicts.

What is the key level of content for psychotherapy? The answer obvi-ously depends on the therapist's preferred theory of personality and psycho-pathology and/or the client's implicit theory of problems. As an eclecticperspective, the transtheoretical approach appreciates the validity of eachlevel of problems. How critical each level is can vary for different clientseven when they are presenting the same type of problem (Prochaska &DiClemente, 1984).


While therapists of different theoretical persuasions can present a casefor attributing problems to at least five different levels, is it not the casethat clients attribute problems to only one or two levels of causality? Re-search based on attribution theory, for example, suggest that the naivepsychology of the public attributes behavior to either situational or disposi-tional causes (Jones & Nisbett, 1972). Similarly, locus of control researchreports people attributing both functional and dysfunctional behavior tovariables under either external or internal locus of control (Rotter, 1970).

The problem is that attribution research and locus of control researchlimit their research to only two levels. These theories artificially dichotomizethe causal world of clients. The fact is that people perceive their problemsin much more complex and confusing ways than suggested by most theoriesof behavior, including theories of troubled behavior.

In research with college students suffering from problems like depres-sion, anxiety, and academic difficulties, we found that students did indeedattribute problems to the five levels emphasized in the transtheoreticalmodel. In fact, the students discriminated not 5 but 10 different causesof personal problems. The students also discriminated between spiritualdeterminism, bad luck, biological deficiencies, chosen lifestyle, and insuffi-cient effort as causes of personal problems. Table III lists the 10 levels thataccounted for 67% of the variance of the Levels of Change Questionnaire.Two of the categories, spiritual determinism and bad luck, were used byonly a small minority of the sample (Norcross et al., 1985). Similarly, clinicalresearch suggests that only about 5% of clients construe their problems asprimarily due to religious or spiritual causes (Bergin, 1983). Furthermore,people who experience their problems as spiritual in origin are much morelikely to go to religious healers for help. On the other hand, people whoattribute their problems to biological reasons are likely to seek help from aninternist or health specialist rather than a psychotherapist. Where someone

Table III. The 10 Levels of Change and Reliability Coefficient

Level

1.2.3.4.5.6.7.8.9.

10.

Symptom and situational difficultiesMaladaptive cognitionsInterpersonal conflictsFamily/systems conflictsInterpersonal conflictsSpiritual determinismBiological deficienciesBad luckChosen lifestyleInsufficient effort

Alpha

.87

.89

.89

.91

.88

.92

.89

.87

.79

.87


turns to change bad luck is an open question, though some fatalists seekguidance from astrologers or fortune-tellers.

People who attribute their problems primarily to insufficient effort arelikely to try harder and may succeed as self-changers before they seek atherapist. Those who perceive problems as a consequence of their chosenlifestyles are likely to cope with such stresses by accepting them as theproblems that are inherent in a particular lifestyle. On the other hand,there are enough clients whose problems are that they want to go on livingthat way they have been living but want the consequences to different.Workaholics often want to go on working 70 or 80 hours a week withouthaving their marriages or families being distressed. Clients like these tendto be seeking magic rather than therapeutic change, and this can be areason they don't change.

Most clients and most therapists are prepared to work at one or moreof the five levels emphasized in the transtheoretical approach. This is notto say that people do not have genuine problems at the spiritual, biological,or luck levels of existence, but rather that psychotherapists would not beparticularly well prepared to help them at these levels. Our professionalresponsibility and our ability to help people change tend to be limited tothe psychological levels of change. Beyond that, we would refer clients toother professionals or helpers better prepared for problems at nonpsycho-logical levels.

From a levels perspective, then, people don't change if they don'tknow what to change. This includes having no idea what to change andhaving the wrong idea what to change, if people misattribute problems toincorrect causes they are not likely to change. Hypochondriacal clients whoinsist on attributing their symptoms to undiagnosed biological origins inthe face of feedback from medical specialists that their problems are psycho-logical in origin can be very resistant to psychotherapeutic interventionsand are not likely to change. They are likely to go on seeking assessmentsfrom different medical specialists because they are convinced that theysuffer from physical rather than psychological problems.

People who misattribute problems at one level to causes at a differentlevel are also not likely to change. People don't change interpersonallybased problems by changing their immediate situations. Travel therapy is acommon example of misattributing one's problems to immediate situations,moving to a new environment only to discover that one's problems werepacked inside one's self.

Conversely, people don't change if they spend years contemplatingearly childhood causes of problems that are controlled by more contempo-rary cognitions or situations. Masters and Johnson (1970) demonstrated howmany sexual dysfunctions that were once attributed to distant unconscious


intrapersonal conflicts could be readily reversed by modifying more im-mediate sexual situations and cognitions.

People don't change in therapy very well if their attributions don'tmatch their therapists' attributions or vise versa. If clients are convincedthat their problems are interpersonal in origin and their therapists are tryingto change intrapersonal conflicts, then resistance is likely to be the result.Similarly, if therapists are trying to solve situational problems that clientsare convinced are rooted in unresolved family of origin issues, then resis-tance is likely to result. It is like the woman who told her student therapistthat trying to solve her obsession with desensitization was like trying tocure cancer with an aspirin.

In the face of a lack of consensus about the causes of most commonclinical conditions, how can therapists proceed most systematically andeffectively? There are three strategies that are used most often in thetranstheoretical approach (Prochaska & DiClemente, 1984).

The first is the key level strategy. In this strategy clinical assessmentsare used to determine if there is a key level that is causing or controllingthe client's particular problems. If the available clinical evidence points tothe problem as interpersonal in origin, the therapeutic efforts are likely tobe more effective when focused on resolving interpersonal conflicts. Thekey level strategy can proceed most smoothly if the client concurs or canbe convinced that the problems are indeed interpersonal in origin.

All too often, the clinical data are complex and confusing, and noone key level emerges as the cause of a particular condition. The secondalternative is the shifting level strategy. In this strategy we intervene at thehighest level that the clinical data can justify, such as the symptom/situa-tional or the cognitive levels. We prefer to intervene at these higher levelsbecause change tends to occur more quickly at these more conscious andcontemporary levels. The further down the hierarchy we focus, the furtherremoved from awareness are the determinants of the problem likely to be.The less awareness there is about what needs to be changed, the earlierthe stage the person will be in. People can be prepared to take action atthe symptom and situational level, for example, while having no intentionsto change their relationships to their families of origin.

We predict from the transtheoretical model that the deeper the levelthat needs to be changed, the longer and more complex therapy is likelyto be. Given that average clients give us all too little time to make animpact, we are better off to begin at the levels that are most easily changed.If the problem can be resolved at the highest levels, then therapy can beterminated most efficiently and can best match most clients' preference forbriefer therapies.

Unfortunately, all too many problems cannot be resolved just by focus-


ing on situational or cognitive variables. If insufficient progress is made atthese levels, then an alternative is to shift to the next deeper level, such asthe interpersonal level. Therapy can proceed more systematically shiftingfrom one level to the next until enough change has been accomplished.

The third alternative is the maximum impact strategy, which is usedwith problems that are clearly caused or controlled by variables at multiplelevels of change. With multilevel problems, change processes are appliedin a manner designed to facilitate progress at each relevant level of change.Consciousness-raising, for example, can be used to help clients becomemore aware of the immediate antecedents and consequences of their prob-lem behaviors; the cognitions used to process these antecedents and conse-quences; the interpersonal conflicts that are part of the problem; the familyof origin issues that originally produced the problem, and the intrapersonaldynamics that may have caused the problem to become integrated as apare of one's identity or sense of self.

The maximum impact strategy has the potential to help clients processchange at each level of their existence. By being aware of change occurringat each level, they can develop a deeper sense of themselves and thecomplexities of their problems. By making changes at each level, theyare less likely to relapse when faced with disturbing situations, distressingcognitions, interpersonal conflicts, dysfunctional family patterns, or thedeeper dynamics of themselves.

We need to remember, however, that the further removed from con-sciousness and the further back in time are the determinants of a problem,the greater resistance there will be to trying to change those determinants.One of the reasons for greater resistance is that deeper attributions tendto be more threatening to self-esteem than are higher level attributions. Itis more threatening, for example, to believe that sexual dysfunctions aredue to hostility toward one's spouse or one's parents than to believe thatsexual situations elicit performance anxiety. One of the rules of the transthe-oretical approach is to use the least threatening attributions that can bejustified, since our clinical formulations have the potential for producingresistance as well as the power to facilitate change.

PEOPLE CAN CHANGE

Let us conclude with some of the conditions under which people canchange. People can change:

1. When they progress one stage at a time rather than before theyare prepared.


2. When they apply processes that are appropriate to their currentstage of conditions under which trying to leap to action change.

3. When they are in a therapy that matches their stage of changerather than trying to match the therapy's preferred stage of change.

4. When they learn from their relapses rather than becoming demor-alized.

5. When they understand the complexities of change rather thanreducing it all to one process, such as consciousness-raising, count-erconditioning, willpower, or a therapeutic relationship.

6. When they work at the highest levels that are appropriate totheir problems.

7. When they shift to deeper levels when further progress is needed.8. When they understand their inability to change as often due to

misattribution to levels of change that are not appropriate totheir problem.

9. When they understand resistance to change is often due to mis-matches between the clients' and therapists' stages and/or levelsof change.

10. When they have better roadmaps and models to help guide themthrough the stages and levels of change.

ACKNOWLEDGMENTS

The research in this paper was supported by Grants CA 27821 andCA 50087 from the National Cancer Institute.

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