James O. Prochaska, PhD
CHAPTER OUTLINE
■ THE STAGES OF CHANGE
■ USING THE STAGES OF CHANGE MODEL TO MOTIVATE PATIENTS
■ CONCLUSIONS
What motivates people to take action? The answer to this key question depends on what type of action is to be taken. What moves people to start therapy? What motivates them to continue therapy? What moves people to progress in therapy or to continue to progress after therapy? Answers to these questions can provide better alternatives to one of the field’s most pressing concerns: What types of therapeutic interventions would have the greatest effect on the entire population at risk for or experiencing addictive disorders?
What motivates people to change? The answer to this question depends in part on where they start. What motivates people to begin thinking about change can be different from what motivates them to begin preparing to take action. Once people are prepared, different forces can move them to take action. Once action is taken, what motivates people to maintain that action? Conversely, what causes people to regress or relapse to their addictive behaviors?
Fortunately, the answers to this complex set of questions may be simpler, or at least more systematic, than are the questions themselves. To appreciate the answers, it is helpful to begin with the author’s model of change (1–3).
THE STAGES OF CHANGE
Change is a process that unfolds over time through a series of stages: precontemplation, contemplation, preparation, action, maintenance, and termination.
Precontemplation is a stage in which the individual does not intend to take action in the foreseeable future (usually measured as the next 6 months). The individual may be at this stage because he or she is uninformed or underinformed about the consequences of a given behavior. Or he or she may have tried to change a number of times and become demoralized about his or her ability to do so. Individuals in both categories tend to avoid reading, talking, or thinking about their high-risk behaviors. In other theories, such individuals are characterized as “resistant” or “unmotivated” or “not ready” for therapy or health promotion programs. In fact, traditional treatment programs were not ready for such individuals and were not motivated to match their needs.
Individuals who are in the precontemplation stage typically underestimate the benefits of change and overestimate its costs, but are unaware that they are making such mistakes. If they are not conscious of making such mistakes, it is difficult for them to change. As a result, many remain “stuck” in the precontemplation stage for years, with considerable resulting harm to their bodies, themselves, and others. There appears to be no inherent motivation for people to progress from one stage to the next. The stages are not like stages of human development, in which children have inherent motivation to progress from crawling to walking, even though crawling works very well and even though learning to walk can be painful and embarrassing. Instead, two major forces can move people to progress.
The first is developmental events. In the author’s research, the mean age of smokers who reach long-term maintenance is 39 years. Those who have passed 39 recognize it as an age to reevaluate how one has been living and whether one wants to die from that lifestyle or whether one wants to enhance the quality and quantity of the second half of life. The other naturally occurring force is environmental events. A favorite example is a couple who were both heavy smokers. Their dog of many years died of lung cancer. This death eventually moved the wife to quit smoking. The husband bought a new dog. So, even the same events can be processed differently by different people.
A common belief is that people with addictive disorders must “hit bottom” before they are motivated to change. So family, friends, and physicians wait helplessly for a crisis to occur. But how often do people turn 39 or have a dog die? When individuals show the first signs of a serious physical illness, such as cancer or cardiovascular disease, those around them usually become mobilized to help them seek early intervention. Evidence shows that early interventions often are lifesaving, and so it would not be acceptable to wait for such a patient to “hit bottom.” In opposition to such a passive stance, a third force that has been created to help patients with addictions progress beyond the precontemplation stage is called planned interventions.
Contemplation is a stage in which an individual intends to take action within the ensuing 6 months. Such a person is more aware of the benefits of changing, but also is acutely aware of the costs. When an addicted person begins to seriously contemplate giving up a favorite substance, his or her awareness of the costs of changing can increase. There is no free change. This balance between the costs and benefits of change can produce profound ambivalence, which may reflect a type of love–hate relationship with an addictive substance, and thus can keep an individual stuck at the contemplation stage for long periods of time. This phenomenon often is characterized as “chronic contemplation” or “behavioral procrastination.” Such individuals are not ready for traditional action-oriented programs.
Preparation is a stage in which an individual intends to take action in the immediate future (usually measured as the ensuing month). Such a person typically has taken some significant action within the preceding year. He or she generally has a plan of action, such as participating in a recovery group, consulting a counselor, talking to a physician, buying a self-help book, or relying on a self-change approach. It is these individuals who should be recruited for action-oriented treatment programs.
Action is a stage in which the individual has made specific, overt modifications in his or her lifestyle within the preceding 6 months. Because action is observable, behavior change often has been equated with action. But in the Transtheoretical Model (TTM), action is only one of six stages (3). In this model, not all modifications of behavior count as action. An individual must attain a criterion that scientists and professionals agree is sufficient to reduce the risk of disease. In smoking, for example, only total abstinence counts. With alcoholism and alcohol abuse, many believe that only total abstinence can be effective, whereas others accept controlled drinking as an effective action.
Maintenance is a stage in which the individual is working to prevent relapse, but does not need to apply change processes as frequently as one would in the action stage. Such a person is less tempted to relapse and is increasingly confident that he or she can sustain the changes made. Temptation and self-efficacy data suggest that maintenance lasts from 6 months to about 5 years.
One of the common reasons for early relapse is that the individual is not well prepared for the prolonged effort needed to progress to maintenance. Many persons think the worst will be over in a few weeks or a few months. If, as a result, they ease up on their efforts too early, they are at great risk of relapse.
To prepare such individuals for what is to come, they should be encouraged to think of overcoming an addiction as running a marathon rather than a sprint. They may have wanted to enter the 100th running of the Boston Marathon, but they know they would not succeed without preparation and so would not enter the race. With some preparation, they might compete for several miles but still would fail to finish the race. Only those who are well prepared could maintain their efforts mile after mile. Using the Boston Marathon metaphor, people know they have to be well prepared if they are to survive Heartbreak Hill, which runners encounter at about mile 20. What is the behavioral equivalent of Heartbreak Hill? The best evidence available suggests that most relapses occur at times of emotional distress. It is in the presence of depression, anxiety, anger, boredom, loneliness, stress, and distress that humans are at their emotional and psychological weak point.
How does the average person cope with troubling times? He or she drinks more, eats more, smokes more, and takes more drugs to cope with distress (4). It is not surprising, therefore, that persons struggling to overcome addictive disorders will be at greatest risk of relapse when they face distress without their substance of choice. Although emotional distress cannot be prevented, relapse can be prevented if patients have been prepared to cope with distress without falling back on addictive substances.
If so many Americans rely on oral consumptive behavior as a way to manage their emotions, what is the healthiest oral behavior they could use? Talking with others about one’s distress is a means of seeking support that can help prevent relapse. Another healthy alternative is exercise. Physical activity helps manage moods, stress, and distress. Also, 60 minutes per week of exercise can provide a recovering person with more than 50 health and mental health benefits (5). Exercise thus should be prescribed to all sedentary patients with addictions. A third healthy alternative is some form of deep relaxation, such as meditation, yoga, prayer, massage, or deep muscle relaxation. Letting the stress and distress drift away from one’s muscles and one’s mind helps the patient move forward at the most tempting of times.
Termination is a stage at which individuals have zero temptation and 100% self-efficacy. No matter whether they are depressed, anxious, bored, lonely, angry, or stressed, such persons are certain they will not return to their old unhealthy habits as a method of coping. It is as if they never acquired the habit in the first place. In a study of former smokers and alcoholics, fewer than 20% of each group had reached the stage of no temptation and total self-efficacy (6). Although the ideal is to be cured or totally recovered, it is important to recognize that, for many patients, a more realistic expectation is a lifetime of maintenance.
USING THE STAGES OF CHANGE MODEL TO MOTIVATE PATIENTS
The stages of change model can be applied to identify ways to motivate more patients at each phase of planned interventions for the addictions. The five phases are (i) recruitment, (ii) retention, (iii) progress, (iv) process, and (v) outcomes.
Recruitment
Too few studies have paid attention to the fact that professional treatment programs recruit or reach too few persons with addictions. Across all diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (7), fewer than 25% of persons with addictive disorders enter professional treatment in their lifetimes (8,9). With smoking, the deadliest of addictions, fewer than 10% ever participate in a professional treatment program (10).
Given that addictive disorders are among the costliest of contemporary conditions, it is crucial to motivate many more persons to participate in appropriate treatment. These conditions are costly to the addicted individuals, their families and friends, their employers, their communities, and their health care systems. Health professionals no longer can treat addictive disorders just on a case basis; instead, they must develop programs that can reach addicted persons on a population basis.
Governments and health care systems are seeking to treat addictive disorders on a population basis. But when they turn to the largest and best clinical trials of addiction therapies, they find less than completely positive outcomes (11–14). Whether the trials were conducted in work sites, schools, or entire communities, the results are remarkably similar: No significant effects compared with the control conditions.
If we examine more closely one of these trials, the Minnesota Heart Health Study, we can find hints of what went wrong (15). With smoking as one of the targeted behaviors, nearly 90% of the smokers in treated communities reported seeing media stories about smoking, but the same was true with smokers in the control communities. Only about 12% of smokers in the treatment and control conditions said their physicians talked to them about smoking in the preceding year. If one looks at what percentage participated in the most powerful behavior change programs (clinics, classes, and counselors), it is apparent that only 4% of smokers participated in each year of planned interventions. Even when state-of-the-science smoking cessation clinics are offered at no charge, only 1% of smokers are recruited (16). There simply will be little effect on the health of the nation if our best treatment programs reach so few persons with the deadliest of addictions.
How can more people with addictive disorders be motivated to seek the appropriate help? By changing both paradigms and practices. There are two paradigms that need to be changed. The first is an action-oriented paradigm that construes behavior change as an event that can occur quickly, immediately, discretely, and dramatically. Treatment programs that are designed to have patients immediately quit abusing substances are implicitly or explicitly designed for the portion of the population in the preparation stage.
The problem is that, with most unhealthy behaviors, fewer than 20% of the affected population is prepared to take action. Among smokers in the United States, for example, about 40% are in the precontemplation stage, 40% in the contemplation stage, and 20% in the preparation stage (17). Among college students who abuse alcohol, about 85% are in the precontemplation stage, 10% in the contemplation stage, and 5% in the preparation stage (18).
When only action-oriented interventions are offered, fewer than 20% of the at-risk population is being recruited. To meet the needs of the entire addicted population, interventions must meet the needs of the 40% in the precontemplation and the 40% in the contemplation stages.
In the clinical guidelines for the treatment of tobacco, however, there were only evidence-based programs for motivated smokers in the preparation stage (19). In spite of there being more than 6,000 studies on tobacco, research had excluded the vast majority from treatment studies.
By offering stage-matched interventions and applying proactive or outreach recruitment methods in three large-scale clinical trials, the author and others have been able to motivate 80% to 90% of smokers to enter a treatment program (20,21). Comparable participation rates were generated with college students who abuse alcohol, even though 75% were in the precontemplation stage (18). These results represent a quantum increase in our ability to move many more people to take the action of starting therapy.
A treatment program for addicted gamblers in Windsor, Ontario, used creative communications to let their prospective population know, wherever they are, the program can work with them. This program had generous support of 2% of earnings from local casinos, but they were not reaching many people. So, on the back of city buses, they placed ads with a traffic light logo: red light not ready, yellow light getting ready, and green light ready. Not only did they dramatically increase their recruitment, some clients would take pride in saying, “Hey, there goes my bus!”
The second paradigm change that is required is movement from a passive–reactive approach to a proactive approach. Most professionals have been trained to be passive–reactive: to passively wait for patients to seek their services and then to react. The problem with this approach is that most persons with addictive disorders never seek such services.
The passive–reactive paradigm is designed to serve populations with acute conditions. The pain, distress, or discomfort of such conditions can motivate patients to seek the services of health professionals. But the major killers today are chronic lifestyle disorders such as the addictions. To treat the addictions seriously, professionals must learn how to reach out to entire populations and offer them stage-matched treatments.
There are a growing number of national disease management and disease prevention companies who train health professionals in these new paradigms. Thousands of nurses, counselors, and health coaches have been trained to proactively reach out by telephone to interact at each stage of change with entire patient and employee populations with high-risk behaviors including smoking, alcohol abuse, and obesity. With the major movement toward integrated care in patient-centered medical homes, providers on multidisciplinary teams are being trained in how to deliver such stage-based interventions within primary care settings.
What happens if professionals change only one paradigm and proactively recruit entire populations to action-oriented interventions? This experiment has been tried in one of the largest US managed care organizations (16). Physicians spent time with every smoker in an effort to persuade him or her to enroll in a state-of-the-art action-oriented clinic. If that did not work, nurses spent up to 10 minutes encouraging the smoker to enroll, followed by 12 minutes with a health educator and a counselor call to the home. The base rate was 1% participation.
This most intensive recruitment protocol motivated 35% of smokers in precontemplation to enroll. However, only 3% actually entered the program, 2% completed it, and none showed improved outcomes. From a combined contemplation and preparation group, 65% enrolled, 15% entered the program, 11% completed it, and some had an improved outcome.
In the face of this evidence, there may be several answers to the question: What can move a majority of people to enter a professional treatment program for an addictive disorder? One is the availability of professionals who are motivated and prepared to proactively reach out to entire populations and offer them interventions that match whatever stage of change they are in.
Retention
What motivates patients to continue in therapy? Or conversely, what moves clients to terminate counseling quickly and prematurely, as judged by their counselors? A meta-analysis of 125 studies found that nearly 50% of clients drop out of treatment (22). Across studies, there were few consistent predictors of premature termination. Although addictive disorder, minority status, and lower education predicted a higher percentage of dropouts, these variables did not account for much of the variance.
At least five studies are available on dropouts from a stage model perspective on addictive disorder, smoking, obesity, and a broad spectrum of psychiatric disorders. These studies found that stage-related variables were more reliable predictors than demographics, type of problem, severity of problem, and other problem-related variables. Figure 55-1 presents the stage profiles of three groups of patients with a broad spectrum of psychiatric disorders (2,23). In that study, the investigators were able to predict 93% of the three groups: premature terminators, early but appropriate terminators, and those who continued in therapy (23).
FIGURE 55-1 Pretherapy stage profiles for premature terminators, appropriate terminators, and continuers. (From Brogan ME, Prochaska JO, Prochaska JM. Predicting termination and continuation status in psychotherapy using the transtheoretical model. Psychotherapy 1999;36:105–113.)
Figure 55-1 shows that the before-therapy profile of the entire group who dropped out quickly and prematurely (40%) was a profile of persons in the precontemplation stage. The 20% who finished quickly but appropriately had a profile of patients who were in the action stage at the time they entered therapy. Those who continued in long-term treatment were a mixed group, with most in the contemplation stage.
The lesson is clear: Persons in the precontemplation stage cannot be treated as if they are starting in the same place as those in the action stage. If they are pressured to take action when they are not prepared, they simply will leave therapy.
For patients in the action stage who enter therapy, what would be an appropriate approach? One alternative would be to provide relapse prevention strategies like those described by Dr. Alan Marlatt. But would relapse prevention strategies make any sense with the 40% of patients who enter in the precontemplation stage? What might be a good match for them? Experience suggests a dropout prevention approach, because such patients are likely to leave early if they are not helped to continue.
With patients who begin therapy in the precontemplation stage, it is useful for the therapist to share key concerns: “I’m concerned that therapy may not have a chance to make a significant difference in your life, because you may be tempted to leave early.” The therapist then can explore whether the patient has been pressured to enter therapy. How do such patients react when someone tries to pressure or coerce them into quitting an addiction when they are not ready? Can they tell the therapist if they feel pressured or coerced? It is only feasible to encourage them to take steps when they are most ready to succeed.
Here is a brief case illustration of a therapist sharing his concern with a patient in precontemplation.
A renowned artist in his late thirties started therapy with multiple problems, including a chronic addiction to cocaine, a troubled marriage, career at risk of collapsing, and affective problems with depression and aggression. With his help, we are able to assess that he was in the precontemplation stage, and his therapist knew that he was at high risk for terminating treatment prematurely. So, the therapist shared his concern: “I appreciate your helping me to understand that you are currently in the initial stage of change that we call precontemplation. Our first concern needs to be that you might drop out of treatment before we have a chance to make a significant difference in your life. What pressures were there for you to come to therapy?” “My wife threatened to leave if I didn’t show up,” he responded. “If you feel me pressuring you to do something you are not ready to do, would you let me know?” the therapist asked. “You will know!” he snapped. “How will I know?” “Because I will get angry as hell!” the patient said. “That’s O.K. I can work with that. What I can’t work with is you not coming back.” “That’s cool,” he said.
The author and others have conducted four studies with stage-matched interventions in which retention rates of persons entering interventions in the precontemplation stage can be examined. What is clear is that, when treatment is matched to stage, persons in the precontemplation stage will remain in treatment at the same rates as those who start in the preparation stage (19,20). This result was consistent in clinical trials in which patients were recruited proactively (the therapist reached out with an offer of help) as well as in trials in which patients were recruited reactively (they asked for help). What motivates people to continue in therapy? Receiving treatments that match their stage of readiness to change.
Another strategy is to begin therapy with a single session of motivational interviewing. Connors et al. (24) found that a single session reduced dropouts from their intensive alcohol treatment program from 75% to 50%. A session of role induction designed to prepare people for what to expect from therapy made no difference, even though, clinically, it has been most widely used to try to prevent premature dropout.
Progress
What moves people to progress in therapy and to continue to progress after therapy? Figure 55-2 presents an example of what is called the stage effect. The stage effect predicts that the amount of successful action taken during and after treatment is directly related to the stage at which the person entered treatment (2). In the study cited, interventions with smokers ended at 6 months. The group of smokers who started in the precontemplation stage showed the least amount of effective action, as measured by abstinence at each assessment point. Those who started in the contemplation stage made significantly more progress, whereas those who entered treatment already prepared to take action were most successful at every assessment.
FIGURE 55-2 Percentage of smokers who maintained abstinence over 18 months. Note: Groups were in the following stages at the time of entry into treatment: precontemplation (PC), contemplation (C), and preparation (C/A) (n = 570).
The stage effect has been found across a variety of problems and populations, including rehabilitative success for brain injury and recovery from anxiety and panic disorders after random assignment to placebo or effective medication (25,26). In the latter clinical trial, the psychiatrist leading the trial concluded that patients need to be assessed for their stage of readiness to benefit from medication and to be helped through the stages so that they are well prepared before being placed on the medication.
One strategy for applying the stage effect clinically involves setting realistic goals for brief encounters with patients at each stage of change. A realistic goal is to help patients progress one stage in brief therapy. If a patient moves relatively quickly, he or she may be able to progress two stages. The results to date indicate that, if a patient progresses one stage in 1 month, the likelihood of his or her taking effective action by 6 months is doubled. If the patient progresses two stages, the likelihood that he or she will take effective action increases three to four times (19). Setting realistic goals thus can enable many more people to enter therapy, continue in therapy, progress in therapy, and continue to progress after therapy.
One result for health professionals trained in this approach to the addictions can be a dramatic increase in the morale of the health professionals involved (personal communication). They can see progress with most of their patients, where they once saw failure when immediate action was the only criterion for success. They are much more confident that they have treatments that can match the stages of all of their patients rather than the small number who are prepared to take immediate action.
A lesson here is that the models of therapy selected should be good for the mental health of the therapist as well as the patient. After all, the professional is engaged in therapy for a lifetime, while most patients are involved for only a brief time.
As health care organizations move to briefer and briefer therapies for addictions and other disorders, there is a danger that most health professionals will feel pressured to produce immediate action. If this pressure is transferred to patients who are not prepared for such action, most patients will not be reached or not retained in treatment. A majority of patients can be helped to progress in treatment through relatively brief encounters, but only if realistic goals are set for both patient and therapist. Otherwise, there is a risk of demoralizing and demotivating both patient and therapist. Given the vast public health needs described above, another misuse of the model is for health care organizations or health professionals to limit treatment only to patients who are prepared to take immediate action.
Process
To help motivate patients to progress from one stage to the next, it is necessary to know the principles and processes of change that can produce such progress.
Principle 1
The benefits from changing must increase if patients are to progress beyond precontemplation. In a review of 12 studies, all showed that the perceived benefits were higher in the contemplation than in the precontemplation stage (27). This pattern held true across 12 problem behaviors: use of cocaine, smoking, delinquency, obesity, inconsistent condom use, unsafe sex, sedentary lifestyles, high-fat diets, sun exposure, radon testing, mammography screening, and physicians practicing behavioral medicine.
A technique that can be used in population-based programs involves asking a patient in the precontemplation stage to describe all the benefits of a change such as quitting smoking or starting to exercise. Most persons can list four or five. The therapist can let the patient know that there are 8 to 10 times that number and challenge the patient to double or triple the list for the next meeting. If the patient’s list of benefits of exercise begins to indicate many more motives, such as a healthier heart, healthier lungs, more energy, healthier immune system, better moods, less stress, better sex life, and enhanced self-esteem, he or she will be more motivated to begin to seriously contemplate such a change.
Principle 2
The “cons” of changing must decrease if patients are to progress from contemplation to action. In 12 of 12 studies, the author and colleagues found that the perceived costs of changing were lower in the action than in the contemplation stage (27).
Principle 3
The relative weight assigned to benefits and costs must cross over before a patient will be prepared to take action. In 12 of 12 studies, the costs of changing were assessed as higher than the rewards in the precontemplation stage, but in 11 of 12, the rewards were assessed as higher than the costs in the action stage. The sole exception involved quitting cocaine. In that study, a large percentage of treatment was delivered to inpatients. We interpret this exception to mean that the actions of these patients may have been more under the social control of residential care than under their self-control. At a minimum, their pattern would not bode well for immediate discharge. It should be noted that, if raw scores are used to assess these patterns, it would appear that the rewards for changing are seen as greater than the costs, even by persons in the precontemplation stage. It is only when standardized scores are used that clear patterns emerge, with the costs of changing always perceived as greater than the rewards. This suggests that, compared with their peers at other stages of change, persons in the precontemplation stage underestimate the rewards and overestimate the costs of change.
Principle 4
The strong principle of progress holds that, to progress from precontemplation to effective action, the rewards for changing must increase by one standard deviation (SD) (28).
Principle 5
The weak principle of progress holds that, to progress from contemplation to effective action, the perceived costs of changing must decrease by one-half SD.
Because the perceived benefits for changing must increase twice as much as the perceived costs decrease, twice as much emphasis must be placed on the benefits than the costs of changing. What is striking here is that the author and colleagues believe they have discovered mathematical principles for the degree to which positive motivations must increase and negative motivations must decrease. In a recent meta-analyses of nearly 140 studies on 48 behaviors, the pros of changing increased by exactly 1.00 SD, whereas the cons decreased by 0.54 SD (29). Such principles can produce much more sensitive assessments to guide interventions, giving therapists and patients feedback for when therapeutic efforts are producing progress and when they are failing. Together, they can modify methods if movement is needed for the patient to become adequately prepared for action.
Principle 6
It is important to match particular processes of change with specific stages of change. Table 55-1 presents the empirical integration found between processes and stages of change. Guided by this integration, the following processes would be applied to patients in the precontemplation stage:
TABLE 55-1 STAGES OF CHANGE IN WHICH CHANGE PROCESSES ARE EMPHASIZED
1. Consciousness raising involves increased awareness of the causes, consequences, and responses to a particular problem. Interventions that can increase awareness include observations, confrontations, interpretations, feedback, and education. Some techniques, such as confrontation, pose considerable risk in terms of retention and are not recommended as highly as motivational enhancement methods such as personal feedback about the current and long-term consequences of continuing the addictive behavior. Increasing the costs of not changing is the corollary of raising the rewards for changing. So consciousness raising should be designed to increase the perceived rewards for changing.
2. Dramatic relief involves emotional arousal about one’s current behavior and the relief that can come from changing. Fear, inspiration, guilt, and hope are some of the emotions that can move persons to contemplate changing. Psychodrama, role-playing, grieving, and personal testimonies are examples of techniques that can move people emotionally. It should be noted that earlier literature on behavior change concluded that interventions such as education and fear arousal did not motivate behavior change. Unfortunately, many interventions were evaluated in terms of their ability to move people to immediate action. However, processes such as consciousness raising and dramatic relief are intended to move people to the contemplation rather than the action stage. Therefore, their effectiveness should be assessed according to whether they lead to the expected progress.
3. Environmental reevaluation combines both affective and cognitive assessments of how an addiction affects one’s social environment and how changing would affect that environment. Empathy training, values clarification, and family or network interventions can facilitate such reevaluation. For example, a brief media intervention aimed at a smoker in precontemplation might involve an image of a man clearly in grief saying, “I always feared that my smoking would lead to an early death. I always worried that my smoking would cause lung cancer. But I never imagined it would happen to my wife.” Beneath his grieving face appears this statistic: “50,000 deaths per year are caused by passive smoking.” In 30 seconds, this message achieves consciousness raising, dramatic relief, and environmental reevaluation.
4. Self-reevaluation combines both cognitive and affective assessments of an image of one’s self free from addiction. Imagery, healthier role models, and values clarification are techniques that can move individuals in this type of intervention. Clinically, patients first look back and reevaluate how they have lived as addicted individuals. As they progress into the preparation stage, they begin to develop a focus on the future as they imagine how life could be if they were free of addiction.
5. Self-liberation involves both the belief that one can change and the commitment and recommitment to act on that belief. Techniques that can enhance such willpower include public rather than private commitments. Motivational research also suggests that individuals who have only one choice are not as motivated as if they have two choices (30). Three choices are even better, but four choices do not seem to enhance motivation. Wherever possible, then, patients should be given three of the best choices for applying each process. With smoking cessation, for example, there are at least three good choices: quitting “cold turkey,” using nicotine replacement therapy, and using nicotine fading. Asking clients to choose which alternative they believe would be most effective for them and which they would be most committed to can enhance their motivation and their self-liberation.
6. Counterconditioning requires the learning of healthier behaviors that can substitute for addictive behaviors. Counterconditioning techniques tend to be quite specific to a particular behavior. They include desensitization, assertion, and cognitive counters to irrational self-statements that can elicit distress.
7. Contingency management involves the systematic use of reinforcements and punishments for taking steps in a particular direction. Because successful self-changers rely much more on reinforcement than punishment, it is useful to emphasize reinforcements for progressing rather than punishments for regressing. Contingency contracts, overt and covert reinforcements, and group recognition are methods of increasing reinforcement and incentives that increase the probability that healthier responses will be repeated. To prepare patients for the longer term, they should be taught to rely more on self-reinforcements than social reinforcements. Clinical experience shows that many patients expect much more reinforcement and recognition from others than they actually receive. Relatives and friends may take action for granted. Average acquaintances typically generate only a few positive consequences early in the action stage. Self-reinforcements obviously are much more under self-control and can be given more quickly and consistently when temptations to lapse or relapse are resisted.
8. Stimulus control involves modifying the environment to increase cues that prompt healthy responses and decrease cues that lead to relapse. Avoidance, environmental reengineering (such as removing addictive substances and paraphernalia), and attending self-help groups can provide stimuli that elicit healthy responses and reduce the risk of relapse.
9. Helping relationships combine caring, openness, trust, and acceptance, as well as support for changing. Rapport building, a therapeutic alliance, counselor calls, buddy systems, sponsors, and self-help groups can be excellent resources for social support. If patients become dependent on such support to maintain change, the support will need to be carefully faded, lest termination of therapy becomes a condition for relapse.
Competing theories of therapy have implicitly or explicitly advocated alternative processes of enhancing motivation for change. Is it ideas or emotions that move people? Is it values, decisions, or dedication? Do contingencies incentivize humans, or is behavior determined by environmental conditions or habits? Or is it the therapeutic relationship that is the common healer across all therapeutic modalities?
The answer to each of these questions is “yes.” Therapeutic processes originating from competing theories can be compatible when they are combined in a stage-matched paradigm. With patients in earlier stages of change, motivation can be enhanced through more experiential processes that produce healthier cognitions, emotions, evaluations, decisions, and commitments. In later stages, it is possible to build on such solid preparation and motivation by emphasizing more behavioral processes that can help condition healthier habits, reinforce these habits, and provide physical and social environments that support healthier lifestyles freer from addictions.
Outcomes
What is the result when all of these principles and processes of change are combined to help patients and entire populations move toward action on their addictions? A series of clinical trials applying stage-matched interventions offers lessons about the future of behavioral health care generally and treatment of the addictions specifically.
In a large-scale clinical trial, the author and colleagues compared four treatments: (a) a home-based action-oriented cessation program (standardized), (b) stage-matched manuals (individualized), (c) a computerized expert system plus manuals (interactive), and (d) counselors plus an expert system and manuals (personalized). Patients (739 smokers) were randomly assigned by stage to one of the four treatments (31).
In the expert system condition, participants completed 40 questions by mail or telephone. Their responses were entered into a central computer, from which feedback reports were generated. These reports informed participants about their stage of change, the benefits and costs of changing, and change processes appropriate to their stages of change. At baseline, participants were given positive feedback on what they were doing correctly and guidance on which principles and processes they needed to apply to progress. In two progress reports delivered over the following 6 months, participants also received positive feedback on any improvement in any of the variables relevant to progress. Thus, demoralized and defensive smokers could begin to progress without having to quit and without having to work too hard. Smokers in the contemplation stage could begin to take small steps, such as delaying their first cigarette in the morning for an additional 30 minutes. They could choose small steps that would increase their self-efficacy and help them become better prepared for quitting.
In the personalized condition, smokers received four proactive counselor calls over the 6-month intervention period. Three of the calls were based on the expert system’s reports. Counselors reported much more difficulty in interacting with participants without any progress data. Without scientific assessments, it was more difficult for both patients and counselors to know whether any significant progress had occurred since their last interaction.
Figure 55-3 presents point-prevalence abstinence rates for each of the four treatment groups over 18 months, with treatment ending at 6 months. Results with the two self-help manual conditions were parallel for 12 months, but the stage-matched manuals achieved better results at 18 months. This is an example of a delayed action effect, which often is observed with stage-matched programs and which others have observed with self-help programs. It takes time for participants in early stages to progress all the way to action. Therefore, some treatment effects as measured by action will be observed only after considerable time has elapsed. But it is encouraging to find treatments producing therapeutic effects months and even years after active treatment has ended. The expert system alone and expert system plus counselor conditions produced comparable results for 12 months.
FIGURE 55-3 Point-prevalence abstinence (%) for four treatment groups at pretest and at 6, 12, and 18 months. ALA×, standardized manuals; TTT, individualized stage-matched manuals; ITT, interactive computer reports; PITT, personalized counselor calls.
Then, the effects of the counselor condition flattened out, whereas the expert system condition effects continued to increase. Potential reasons for the delayed differences between these conditions include the possibility that participants in the personalized condition may have become somewhat dependent on the social support and social control of the counselor calling. The last call occurred after the 6-month assessment, and benefits would be observed at 12 months. Termination of the counselor calls could result in no further progress because of the loss of social support and control. The classic pattern in smoking cessation clinics is rapid relapse that begins as soon as treatment is terminated. Some of this rapid relapse could well be due to the sudden loss of social support or social control provided by the counselors and other participants when active treatment ends.
The next test was to demonstrate the efficacy of the expert system when applied to an entire population recruited proactively. With more than 80% of 5,170 smokers participating and less than 20% in the preparation stage, this study demonstrated significant benefits of the expert system at each 6-month follow-up (20). Moreover, the advantages over proactive assessment alone increased at each follow-up for the full 2 years assessed. The implications here are that expert system interventions in a population can continue to demonstrate benefits long after the intervention has ended.
The efficacy of the expert system intervention was demonstrated again in a health maintenance organization (HMO) population of 4,000 smokers, with 85% participation (19). In the first population-based study, the expert system was 34% more effective than was assessment alone; in the second, it was 31% more effective. These differences were clinically significant as well. Although working on a population basis, the investigators were able to show a level of success normally found only in intensive clinic-based programs with low participation rates of more carefully selected samples of smokers. The implication is that, after expert systems are developed and show effectiveness with one population, they can be transferred to, and show replicable results in, other populations.
A recent meta-analysis of 54 studies on computer-based interventions across a broad range of behaviors has found that tailoring treatment on each of the TTM variables (stage, pros and cons, processes or self-efficacy) produces greater effects than do treatments that do not tailor on these variables. Tailoring on some treatment variables, such as perceived susceptibility to negative consequences, produced worse effects. Some other theoretical variables, such as social norms and behavior intentions, made no difference (32).
Enhancing Interactive Interventions
In recent benchmarking research, the author and colleagues have been attempting to create enhancements to the expert system to produce even better outcomes. In the first enhancement, which involved a study of an HMO population, a personal digital assistant designed to bring the behavior under stimulus control was added (19). However, this action-oriented intervention did not enhance the study outcomes on a population basis. In fact, the original expert system alone was twice as effective as the system plus the personal digital assistant enhancement. This result suggests that more is not necessarily better and providing interventions that are mismatched to stage can make outcomes markedly worse.
Counselor Enhancements
In the HMO population, counselors plus expert system computer-based interventions were outperforming expert systems alone at 12 months. But at 18 months, results for the counselor enhancement had declined, whereas those for the expert systems alone had increased. Both interventions were producing identical outcomes of 23.2% abstinence, which are excellent for an entire population. Why did the effect of the counselor condition drop after the intervention? A leading hypothesis is that patients can become dependent on counselors for social support and social monitoring. Withdrawing those social influences may place such patients at increased risk of relapse. The expert system, in contrast, tends to maximize self-reliance. In a current clinical trial, the author and colleagues are “fading out” the counselor intervention over time in an effort to minimize dependence on the counselor. If fading is effective, it will have implications for how counseling should be terminated: gradually over time rather than suddenly.
It seems clear that the most powerful change programs will combine the personalized benefits of counselors and consultants with the individualized, interactive, and databased benefits of expert system computer-based interventions. However, studies have not demonstrated that the more costly counselors, who have been the most powerful change agents, actually add value over expert system interventions alone. These findings have clear implications for the cost-effectiveness of expert systems for entire populations in need of health promotion programs.
Interactive versus Noninteractive Interventions
Another important goal of the HMO study was to assess whether an interactive intervention (specifically, a computer-based expert system) is more effective than are non-interactive communications (such as self-help manuals) when the results are adjusted to control for the number of intervention contacts (33). At 6, 12, and 18 months for groups of smokers receiving a series of one, two, three, or six interactive versus noninteractive contacts, the interactive interventions (expert system) outperformed the noninteractive manuals. The difference at 18 months was at least 5%—a difference between treatment conditions assumed to be clinically significant. These results clearly support the hypothesis that interactive interventions will outperform the same number of noninteractive interventions.
These results support the assumption that the most powerful health promotion programs for entire populations will be interactive. Reports in the clinical literature support the hypothesis that interactive interventions such as behavioral counseling produce better long-term abstinence rates (20% to 30%) than do noninteractive interventions such as self-help manuals (10% to 20%). In assessing these results, it should be kept in mind that traditional action-oriented programs were implicitly or explicitly recruiting for populations of individuals in the preparation stage, whereas the studies cited here involved proactively recruited smokers, of whom fewer than 20% were in the preparation stage. Even so, long-term abstinence rates were in the 20% to 30% range for the interactive interventions and in the 10% to 20% range for noninteractive interventions. The implications are clear. Providing interactive interventions through the use of computer-based expert systems is likely to produce better outcomes than relying on noninteractive communications such as newsletters, media, or self-help manuals.
Multiple Behaviors
A series of studies applied our best practice of TTM-tailored expert systems plus a stage-based self-help manual for multiple behaviors. Consistent across all studies was that the TTM treatments produced significant impacts on multiple behaviors (34–36). The studies also produced abstinence rates for smoking cessation that were in the same narrow 24% range found when the single behavior of smoking was treated. This is the first body of research that has demonstrated that multiple behavior treatments can be as effective as treating single behaviors, but the impacts are greater because more behaviors are treated effectively. The other treated behaviors, such as diet and prevention of skin cancer, were even more effective, with the percentages in the action–maintenance stage at long-term follow-up ranging from 35% to 40%.
With male perpetrators of partner violence, TTM-tailored treatments were added to the best practice of mandatory 6-month weekly group therapy. At the 6-month follow-up with the first 200 participants, the addition of the TTM tailoring produced significant reduction in a variety of physical and emotional abuse behaviors compared with the weekly group counseling alone. With the addition of TTM tailoring, only 3% of the female partners of the perpetrators had been beaten in the past 6 months compared to 23% of the women whose partners received only the group therapy (37). With the TTM treatment, about twice as many perpetrators (most of whom also had addiction problems) had progressed to the action or maintenance stage at the 6-month assessment. Particularly encouraging was that more than twice as many of the perpetrators in the TTM treatment had voluntarily sought additional therapy.
CONCLUSIONS
It seems clear that the future of health promotion programs lies in stage-matched, proactive, interactive interventions. Much greater effects can be generated through the use of proactive programs because participation rates are increased, even if efficacy rates are lower. But proactive programs also can produce outcomes comparable to those of traditional reactive programs. Although it is counterintuitive to suggest that outcomes for groups that are proactively recruited can match those of individuals who reach out for help, that is what informal comparisons strongly suggest. For example, in a comparison of results at 18-month follow-up for all subjects who received three expert system interventions in a study of reactive intervention and a study of proactive intervention, the abstinence curves were remarkably similar (20,32). The results with the counseling plus expert system conditions were even more impressive. Proactively recruited smokers, working with both counselors and the expert system, achieved higher rates of abstinence at each follow-up than did the smokers who had called for help. These results are partially attributable to the fact that the proactive counseling protocol has been revised and, it is to be hoped, improved on the basis of previous data and experience. But the point is that if it is possible to reach out and offer people improved behavior change programs that are appropriate for their stage of readiness to change, it ought to be possible to produce efficacy or abstinence rates at least equal to those seen with individuals who reach out for help. Unfortunately, there is no experimental design that would make it possible to assign study subjects randomly to proactive versus reactive recruitment programs. Thus, one is left with informal but provocative comparisons.
Results with multiple behavior interventions using some type of TTM tailoring and proactive recruitment have found as good effects as when smoking alone is treated. The results with the other treated behaviors were even better.
If these results continue to be replicated, therapeutic programs will be able to produce unprecedented effects on entire populations. To do so will require scientific and professional shifts: (a) from an action paradigm to a stage paradigm, (b) from reactive to proactive recruitment, (c) from expecting participants to match the needs of programs to having programs match the needs of patients, (d) from single to multiple behavior interventions, and (e) from clinic-based to population-based programs that apply individualized and interactive intervention strategies.
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