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PSYCHOTHERAPY: THEORY, RESEARCH AND PRACTICE

VOLUME 19, # 3 , FALL, 1982

TRANSTHEORETICAL THERAPY: TOWARD A MORE INTEGRATIVE


MODEL OF CHANGE1
JAMES O. PROCHASKA* CARLO C. DI CLEMENTE
University of Rhode Island Texas Research Institute of Mental Sciences

ABSTRACT: Transtheoretical therapy is presented thinking has been characterized by Guilford


as one alternative within the Zeitgeist seeking a (1956), among others, as a necessary part of
synthesis for the increasing proliferation of ther- creativity. The increased divergence in psy-
apeutic systems. From a comparative analysis of chotherapy thus provides the potential for a
18 leading systems,fivebasic processes of change new wave of creativity. What is needed to
were identified. Each process can be applied at prevent the increasing divergence from lead-
either the level of the individual's experience or
environment. In studying how individuals change ing to fragmentation, confusion and chaos
on their own compared with change in formalized and allow it to be the foundation for a more
treatments, four stages of change have been iden- fertile future?
tified. Individuals changing within and without Heinz Werner's (1948) theory of devel-
therapy appear to apply three verbal processes of opment may serve as a guide in this regard.
change in the contemplation and determination Development, as opposed to other forms of
stages and then apply two behavioral processes change, such as regression or chaos, is char-
in the action and maintenance stages. Rather than acterized by a combination of increasing dif-
being theoretically incompatible, the verbal pro- ferentiation and hierarchic integration. The
cesses are most important in preparing clients for
action, while the behavioral processes become mostincreasing production of new forms of psy-
important once clients have committed themselves chotherapy may indeed be an expression of
to act. the increasing differentiation of a growing
discipline like psychotherapy. Increasing
Psychotherapy appears to be approaching differentiation alone, however, can become
a crisis or a new wave of creativity. The po- like a cancer of uncontrolled growth that
tential for crisis comes in part from the un- threatens to destroy the very body of knowl-
precedented pace at which new therapies are edge in which it is growing. Unless increasing
being placed on the market (Prochaska, 1979). differentiation is matched by more effective
In 1975 Parloff reported that there were 130 forms of integration, then crisis rather than
therapies on the therapeutic marketplace (or creativity will be the result. In Guilford's
jungleplace as he more aptly described it). (1956) terms an increase in divergent thinking
By 1979 Time magazine was reporting that needs to be followed by higher levels of con-
there were over 200 therapies, and that the vergent thinking.
confusion of over-choice was adding to the What have been some of the professional
depression of psychiatry. responses to the increasing divergence in
Divergence has dominated the past decade psychotherapy? Psychiatry's depression over
of development within the field of psycho- the increased confusion is being treated in
therapy (Prochaska, 1979). Yet divergent part by an increased reliance on chemother-
apy. The emphasis on medication has the ad-
1 This work was partially supported by Grant CA27821
vantage of reaffirming psychiatry's medical
from the National Cancer Institute. identity and of relying on treatments that have
* Requests for reprints should be sent to James O. perhaps the most consistent empirical support
Prochaska, Dept. of Psychology, University of Rhode {Time, 1979; Luborsky, 1975).
Island, Kingston, RI 02881. Clinical social workers have mounted a se-
276
TRANSTHEORETICAL THERAPY 277

rious move to recognize ego psychology as emerging in which theorists and therapists
the system of greatest convergence within from different systems are searching for
professional social work (Freed, 1977). The common principles of change. Perhaps this
fragmentation and confusion from excessive is a move toward a higher level of convergence
divergence could thus be counteracted by a to balance out and integrate the divergence
commitment to a common theoretical foun- of the past two decades.
dation for training clinical social workers. Besides Goldfried's (1980) attempts to
Since no single system of psychotherapy ap- identify general principles of change, such
pears to have an empirical advantage over as direct feedback and new corrective expe-
any other (Luborsky et al., 1975), the argu- riences, there are others working toward an
ment can be made for creating a common integration across therapy systems. Bandura
professional identity through having a com- (1976), for example, has provided a com-
mon theoretical language and technical ex- prehensive model of change in which effective
pertise in one particularly valued system of therapy is seen as producing a cognitive re-
therapy. structuring in the individual's sense of self-
Clinical psychology over the past decade efficacy. Other integrative models include
has become characterized by an increasing those of Frank (1976), who has attempted to
percentage of therapists who label themselves identify the nonspecific processes of change
eclectics (Garfield & Kurtz, 1974). According that are active in any effective therapy;
to Prochaska (1979), true eclectics adopt a Wachtel (1977), who has provided a provoc-
relativistic intellectual perspective. Diversity ative integration of behavioral and psy-
and uncertainty in therapy are not temporary. choanalytical approaches; and Gurman
The very nature of knowledge is that it is (1978), who has attempted to identify the
contextual and relative. Given the pluralistic points of convergence as well as divergence
qualities of potential patients, their therapy of behavioral, psychoanalytical, and systems
needs to be pluralistic with a variety of valid approaches to marital therapy.
alternatives. The validity of any particular Developing within the Zeitgeist of a search
system of therapy is assumed to be relative for a synthesis, transtheoretical therapy is
to some particular criterion. For some eclec- moving toward a more comprehensive model
tics the form of therapy is relative to the pa- of change. Transtheoretical therapy emerged
tient's particular problems, personality, or from a comparative analysis of 18 leading
value system. For other eclectics the validity therapy systems (Prochaska, 1979). The
of any therapy is relative to the therapist's original model was composed of the following
personality or values. variables:
Increasing eclecticism is criticized by some
clinical psychologists as muddying the ther- 1. preconditions for therapy
apeutic waters because of a failure to provide 2. processes of change
any model of humanity (Frank, 1974). The 3. content to be changed
advantage of adopting a particular theoretical 4. therapeutic relationship
persuasion is that it provides a model of the
person that can guide both systematic research One of the most critical preconditions for
and systematic practice. therapy to proceed is that the client bring
Those who have adopted a particular the- positive expectations to treatment. If the client
oretical persuasion may be facing what has negative expectations and believes that
Goldfried (1980) has called a Kuhnian cri- therapy is not likely to be of help, then the
sis. Goldfried, who has been a proponent of client is less likely to be willing to spend the
the behavioral system of therapy, demon- time, money and/or effort to allow therapy
strates the increasing dissatisfactions within to progress. Similarly, if the client's expec-
particular camps. Increasingly, representa- tations about how therapy will progress are
tives of major therapy-systems are willing to not met, then the client is most likely to ter-
look beyond their own system for more ef- minate therapy prematurely. Unfortunately,
fective approaches to treatment. What Gold- clients often decide to drop out of therapy
fried suggests is that there is a Zeitgeist too soon, as confirmed by the consistent find-
278 JAMES O, PROCHASKA & CARLO C. DICLEMENTE

ings that between 35% and 60% of clients in the importance of developing a warm, trusting
community mental-health clinics terminate relationship if therapy is to progress (Haspel,
their treatment by the third session of therapy 1980).
(Haspel, 1980). Reviews of drop-out research
indicate that problems with expectations are PROCESSES OF CHANGE
indeed one of the most important reasons for
therapy not proceeding. Once therapy is proceeding, what are the
Some critics of therapy have suggested that critical processes of change that allow clients
clients' expectations are the main variables and therapists to attain their goals? Are there
that produce change: the more therapy induces over 200 unique processes of change for each
positive expectations for change, the more of the forms of therapy currently being prac-
successful therapy is. Unfortunately, the ef- ticed? Instead of finding separate change
fects of therapy and the process of client- processes unique to each system of therapy,
change are not so simple. The research results a comparative analysis of 18 leading systems
concerning the effects of expectations-on- of therapy suggested that there arefivecentral
outcome once clients are proceeding through processes of change (Prochaska, 1979). The
therapy are mixed. About half the studies fail five processes can be applied at either an ex-
to find any significant effect of expectations- periential or an environmental level in order
on-outcome, while the remainder find a mod- to produce change. Table 1 presents an over-
est effect at best (Dupont, 1975; Wilkins, view of the basic processes of change and
1971). Thus, positive expectancies appear to their application at each of the two levels of
be a precondition for therapy to proceed but intervention.
do not appear to be the critical process that The 18 therapy systems did differ in terms
produces change once therapy is in progress, of which of the processes were emphasized
There also appears to be general agreement and in terms of whether the processes were
among therapists, but less conclusive support, applied more experientially or more environ-
that motivation for change is a key precon- mentally. There tended to be more agreement
dition for therapy. In our model we also as- however, on the importance of particular
sume that a warm, trusting relationship is a processes in producing change than one might
precondition not only for therapy but for any expect from the surface differences between
of the helping professions. If clients feel that major systems of therapy,
the professional does not care about them or Consciousness raising was the most fre-
if they do not trust the professional to ade- quently applied process of change with 16 of
quately care for their needs, then clients are the 18 systems of therapy utilizing this classic
obviously more likely to terminate the helping approach (Prochaska, 1979). Beginning with
relationship rather quickly. The research on Freud's assumption that the basic therapeutic
drop-outs from therapy does indeed support process is to make the unconscious conscious,

TABLE 1. Change Processes at Experiential (A) and Environmental (B) Levels.

Action or Behavioral
Verbal Therapies Therapies

Consciousness Raising Conditional Stimuli


A. Feedback A. Counter-conditioning
B. Education B. Stimulus Control

Catharsis
A. Corrective Emotional Experiences
B. Dramatic Relief

Choosing Contingency Control


A. Sell-liberation A. Re-evaluation
B. Social Liberation B. Contingency Management
TRANSTHEORETICAL THERAPY 279

all of the systems that London (1964) labels their very defenses against change.
the "verbal psychotherapies" begin by Catharsis has one of the longest traditions
working to raise the individual's level of as a process of therapeutic change. It is well
awareness. It is fitting that verbal therapies known that the ancient Greeks, for example,
work with consciousness, since traditionally believed that the evoking of blocked emotions
consciousness has been assumed to be a hu- was one of the best means of providing per-
man characteristic that emerged with the sonal relief and improvement. Traditionally,
evolution of language. catharsis has been based on a hydraulic model
With the availability of language and con- of emotions in which unacceptable affects
sciousness, humans no longer need to respond such as anger, guilt, or anxiety are blocked
reflexively to the energy in a stimulus—such from direct expression. The damming off of
as, the mechanical energy from a hand hitting such emotions results in pressure from affects
against our back, which causes us to react to be released in some manner, no matter
with movement. Instead we can respond to how indirectly, such as anger being expressed
the information contained in the stimuli— through headaches. If emotions can be re-
such as, whether that hand touching us is a leased more directly in therapy, then their
pat on the back from a friend, a mugger grab- reservoir of energy is discharged and the per-
bing us, or a spouse playfully hitting us. In son is freed from a source of symptoms.
order to respond effectively, we must have Most often this therapeutic process has been
adequate information to guide us in making at the level of individual experience in which
a response that is appropriate to the stimulus. the stimuli that elicit cathartic reactions come
Therapies that apply consciousness raising from within the individual. This form of ca-
are increasing the information available to tharsis is called corrective emotional expe-
individuals so that they can make the most riences. The belief that cathartic reactions
effective responses to the stimuli impinging can be evoked by observing emotional scenes
on them. When the therapist is working at in the environment dates back at least to Ar-
the experiential level, the information given istotle's writings on theater and music, so we
a client is contained in the stimulation gen- call this source of catharsis dramatic relief.
erated by the client's own actions and ex- The role of choice in producing individual
periences. This experiential approach is la- change has been in the background of many
beled feedback. When the information given systems of psychotherapy. The concept of
in therapy is contained in stimulation gen- choosing has lacked respectability in the
erated by environmental events, we call this highly deterministic world view of most sci-
education. entists. Many theorists of therapy did not want
One of the most important sources for to give their critics more reason to call ther-
feedback is the information regarding the apists tender-minded by openly discussing
cognitive processes and structures that in- the issues of freedom and choice. Conse-
dividuals use to avoid threatening information quently, many therapy systems seem to as-
about themselves or their environment. These sume that clients will choose to change as a
defensive processes and structures are like result of therapy, but the systems do not ar-
blinders, such as the rose-colored glasses that ticulate the means by which clients come to
some people use to selectively attend to only use the process of choosing.
the positive information about themselves and Because there has been so little open con-
society and disattend to negative input. Such sideration of choosing as a fundamental
cognitive blinders can prevent individuals change process, it is most difficult to suggest
from being able to change effectively without what choice is a function of. Some theorists
feedback or education from an outside party. suggest that choice is irreducible since to re-
The rather consistent agreement across verbal duce choice to other events is to suggest the
therapies of the importance of defense mech- paradox that such events determine our
anisms in maintaining psychopathology (Pro- choices. Human action is seen as freely chosen
chaska, 1979) suggests that a minimal re- and to say that anything else determines our
quirement for an effective psychotherapist is choice is to show bad faith in ourselves as
the ability to help clients become aware of free beings. There are few therapists, how
280 JAMES O. PROCHASKA & CARLO C. DICLEMENTE

ever, who accept such a radical view of human to choose in the face of inadequate information
freedom for their clients, since they usually as to whether the child will be healthy or not,
believe that there are many conditions that whether we will be adequate parents or not,
limit their clients' choosing. whether our lives will be enriched or dimin-
From a behavioral point of view, choice ished by the responsibility of child rearing,
would be in part a function of the number of etc. (Prochaska & Coyle, 1979). Choosing
alternative responses available to an individ- in the face of inadequate or unavailable in-
ual. If there is only one response available, formation is a much more difficult type of
there is no choice. From a more humanistic choice than the choice that follows from pro-
point of view, the number of responses avail- cessing accurate information. This type of
able can be increased by becoming more con- choice shall be referred to as commitment.
scious of alternatives that previously were As an additional example, choosing to become
not considered. Thus, for a variety of therapy an expert in one particular system of therapy
systems an increase in choice is thought to is a commitment rather than a decision since
result from the increase in consciousness that there is not adequate information available
would occur in therapy. as to the superiority of one system over an-
Traditionally, the freedom to choose has other.
been seen as a uniquely human response that At an experiential level, an increase in
is made possible by the development of the choosing involves the individual in becoming
consciousness that accompanies the acqui- aware of new alternatives, including the con-
sition of language. Responsibility is the bur- scious creation of new alternatives for living.
den that accompanies the awareness of This process also involves experiencing anx-
knowing that we are the ones able to respond, iety in being responsible for choosing an al-
to speak for ourselves. Since choice and re- ternative. We call this experiential level of
sponsibility are made possible by the emer- increased choosing a move toward self-lib-
gence of language, it seems only natural that eration. When changes in the environment
the therapeutic process of becoming freer to lead to more alternatives open to individuals,
choose how to respond has been a verbal pro- such as more jobs open to gay people, we
cess. call this a move toward social liberation.
The easiest choices in therapy follow from Therapists involved in such social changes
accurate information-processing that includes are usually called advocates.
an awareness of the consequences that will At the opposite extreme from changing
follow from particular alternatives. If a through choosing is a process in which we
woman was informed, for example, that birth- change by making critical changes in the
control pills eventually cause cancer in all conditional stimuli that control our responses.
women, then her best alternative is to follow Changes in conditional stimuli are necessi-
the implied directive from the information tated when the individual's behavior is either
she has just processed, i.e., avoid birth-con- elicited by classically conditioned stimuli
trol pills. Such choices that follow directly (CSs) or when stimuli are discriminable (SDs)
from accurate-information processing shall occasions for individuals to emit responses
be referred to as decisions. that are instrumentally conditioned. When
The actual situation with the pill, however, troublesome responses are conditioned to such
as with so many aspects of life, is that we stimuli, then being conscious of the stimuli
aren't aware of just what are the consequences will not produce change, nor can conditioning
of choices, such as to take the pill. In these be overcome just through the process of
situations there are no clear, external guide- choosing to change.
lines to become aware of, and we are faced Again, either we can change the way we
with the possibility of choosing an alternative experience or respond to particular stimuli
that might be a terrible mistake. Our ability or we can change the environment to minimize
to choose is a function of our ability to accept the probability of the stimuli occurring.
the anxiety that is inherent in taking respon- Changing our responses to the stimuli is re-
sibility for our future. Choosing whether to ferred to in our model as counter-condition-
have a child or not is an example of having ing, while changing the environment involves
TRANSTHEORETICAL THERAPY 281

stimulus control procedures. and not about him: we don't know whether
It is almost axiomatic for many behavior she is waiting for someone else to ask her
therapists that behavior is under the control out, whether she doesn't like dark hair,
of the consequences the behavior leads to. whether she is afraid of men or whether she
As most of us have learned, if a desired re- doesn't know him well enough; we don't know
inforcement is made contingent on a particular what her saying no says about him. After
response, then the probability is increased reevaluating how he would interpret being
that we will make that response. Whereas, if turned down for a date, the man began asking
particular punishments are made contingent women out, even though he was turned down
on particular responses, we are less likely to on his first request for a date.
emit those responses. By changing the con- The processes of consciousness raising,
tingencies that govern our behavior it is widely catharsis, and choosing represent the heart
assumed that we change our behavior, in- of the traditional verbal psychotherapies, in-
cluding troubled behavior. The extent to cluding both the psychoanalytic and the hu-
which particular consequences control be- manistic traditions. These major schools have
havior is a function of such variables as the focused primarily on the subjective aspects
immediacy, saliency and schedule of the of the individual, the processes occurring
consequences. From a more humanistic point within the skin of the organism. This per-
of view, the individual's valuing of particular spective of the individual sees greater poten-
consequences is also an important variable tial for inner-directed changes that can coun-
affecting contingency control. teract some of the external pressures from
If changes in an individual are made by the environment.
changing the contingencies that occur in the The processes dealing with conditional
environment, we call this contingency man- stimuli and contingencies have been the major
agement. For example, a profoundly retarded focus of the behavioral orientation to therapy,
youngster had been treated unsuccessfully which focuses on the more external environ-
with a wide range of approaches designed to mental forces that set very real limits on the
reduce her headbanging. After four years she individual potential for inner-directed change.
continued to hit herself at the rate of 3000 These are what the existentialists would call
times a day, a million times a year. By making the objective level of the organism.
a remote-controlled shock contingent upon Our integrative model suggests that to focus
each headbanging response, we were able to just on the subjective processes of con-
reduce her headbanging to zero within four sciousness, catharsis and choice is to act as
days of therapy (Prochaska et al., 1974). For if inner-directedness is the whole picture and
the past five years she has hit herself ap- to ignore the very real limits the environment
proximately 250 times compared with the 5 can place on individual change. On the other
million blows she might have delivered with- hand, the behavioral focus on the more ob-
out the contingency management of aversive jective, environmental processes selectively
consequences. ignores the potential for inner, subjective
Very seldom have behavior therapists con- change that individuals possess. An integra-
sidered the alternatives, but there are impor- tive approach sees a combination of the two
tant means by which individuals can change approaches as providing a more balanced view
their experience or response to anticipated that moves along the continuous dimensions
consequences without changing the conse- of inner to outer control, subjective to ob-
quences. Changing responses to consequences jective functioning, and self- to environmen-
without changing contingencies shall be called tally-induced changes. These continuous di-
reevaluation procedures. A very shy man mensions would appear to give a more
continued to desire a relationship with a complete picture of individuals by accepting
woman but avoided asking anyone out because both their potential for inner change while
of his anticipation that he might get turned recognizing the very real limits that environ-
down. After several intensive discussions, mental conditions and contingencies can place
he began to accept that when a woman turns on such change. Focusing therapeutically on
down a date, that is a statement about her change in the environmental conditions and
282 JAMES O. PROCHASKA & CARLO C. DICLEMENTE

contingencies can be seen as a more objective content determined by the client rather than
means of attempting to broaden or expand a favored theory of personality.
the current limits on inner-directed, subjective
processes of change. STAGES OF CHANGE

THEORY OF THERAPEUTIC CONTENT The concept of stages of change emerged


during an empirical investigation of the pro-
The processes of change are the contri- cesses that individuals use to change their
butions unique to a theory of therapy. The troubled behavior (DiClemente & Prochaska,
content that is to be changed in any particular 1982). If the transtheoretical model is indeed
therapy is largely a carryover from that sys- a comprehensive model of change, then it
tem's theory of personality and psychopath- should be able to account for the processes
ology. Many books supposedly focusing on that individuals use to change both within
therapy frequently confuse content and pro- and without therapy. In a retrospective study
cess and end up describing primarily the con- of smokers who successfully stopped smoking
tent of therapy with little explanation about on their own compared with smokers partic-
the processes of therapy. As a result, they ipating in two separate treatment programs,
really are books on theories of personality it became apparent that each group tended to
rather than theories of therapy. progress through a sequence of stages of
Those systems of therapy that do not contain change. In the pilot study, for example, sub-
theories of personality, like some of the be- jects were asked to rate the importance of
havioral therapies, are primarily process the- each process of change in their stopping
ories and have few predetermined concepts smoking. Their general response was that it
about what will be the content of therapy. depended on what stage in the course of
Other systems of therapy, such as Dasein- change we were talking about. In their own
analysis, which adopt change processes from language they referred to a series of stages
other systems of therapy, such as psycho- that they had passed through during their
analysis, are primarily concerned with therapy course of change.
content. Many systems of therapy differ pri- These subjects seem able to differentiate
marily in their content, or theory of person- four stages of change: 1) thinking about stop-
ality, while agreeing on the processes or the- ping smoking; 2) becoming determined to
ory of therapeutic change. stop; 3) actively modifying their habits and/
The transtheoretical model is much more or environment; and 4) maintaining their new
a process than content theory of therapy. That habit of not smoking. Figure 1 presents a
is, rather than assuming that all presenting schematic representation of these four stages
problems will eventually lead to conflicts over of change.
sex and aggression as the critical content of Figure 1 presents an ideal representation
therapy, the transtheoretical model assumes of the stages of change in which clients would
that the content of therapy will vary consid- progress linearly from one stage to the next.
erably from client to client. The client's par- In practice, however, we know that the tem-
ticular history, present environment and per- poral dimension is quite dynamic with clients
sonality will determine more of the focus of regressing at times as well as progressing at
therapy than will the therapist's theory. The other times. A wife who becomes determined
client can initially serve as the expert on the to leave an unhappy marriage, for example,
content to be changed while the therapist may find that when she acts by separating
serves as the expert on the processes that can from her husband, she is not yet ready to pay
produce change. Obviously the therapist can the price that comes with divorce. She may
and does influence the content of therapy in quickly regress to continued contemplation
the very course of producing change; for ex-
ample, by providing clients with feedback CONTEMPLATION
about experiential content that previously had
been outside of their awareness. But the
Figure 1. A linear schema of the stages of
transtheoretical therapist begins with the change.
TRANSTHEORETICAL THERAPY 283

about her options. Clients may also stall in SMOKE FREE L . F E


a particular stage; for example, obsessives SATISFIED L-SMOKEBS
tend to become bogged down in prolonged \ ^- ,.
contemplation of a problem. Our own inter- y' ^v
pretation of this tendency is that the obsessive / \
is hoping to transform a commitment into a / V.
SCTI0N
decision. That is, the obsessive prefers to EX.T,^_/ "ANT6NANCS ^ ^ ^ \
believe that if he or she keeps thinking enough ™ lii'MI ^^^^^ V
about an issue that eventually the information T <^ETERM,NATICN IWOJS^T"
will be found that points to the perfect solution \\ ^ ^ ^ ^ ^ ^ ^ / °QU' T°
to a complex problem. The obsessive per- \ SELAP3E ^/i
sonality does not like to admit that there are \ CONTEMPLATE™
. /T
serious limits to reason and that many personal J^K /
problems can only be resolved by commit- ^z ^ ^ ^-^^i^v. HESE
ments that go beyond reason. The fear of fac- ^{D3FyRTHE, cAILUfiE """' •"
ing the irrational can keep obsessives seeking f*0** &L,£° 'F/
for years for sufficient information, moving
from one book to another or one therapist to Figure 2. The revolving-door schema of smoking
another. cessation.
One of the important issues that we are make a serious commitment to stop smoking,
struggling with has to do with why some Present research suggests that this stage ranges
problems, such as vaginismus (Prochaska & from two hours to two months, with most
Lapsanski, Note 1), appear to allow clients individuals reporting the actual commitment
to progress linearly in therapy without a high as occurring in a rather brief period of time
risk of relapse while other problems, such as (Prochaska et al., in press),
smoking and obesity, involve such a high A commitment to quit brings individuals
risk of relapse (DiClemente & Prochaska, into the relatively smoke-free world of a non-
1982; Heckerman & Prochaska, 1978). In smoker as they begin to actively change their
order to do justice to data on changes in smoking habits. Data indicate that most self-
smoking, weight control, or alcohol abuse quitters stop cold turkey (DiClemente & Pro-
the stages of change need to be represented chaska, 1982; Hecht, Note 2), and use rel-
as cyclical rather than linear in sequence. For atively fewer processes of change to modify
addictive problems, such as smoking, a re- their smoking patterns than do quitters from
volving-door schema is a more accurate rep- formalized treatment programs (DiClemente
resentation of the sequence that smokers pass & Prochaska, 1982).
through in their efforts to become non-smok- Although individuals experience some of
ers. the satisfaction of a smoke-free life for varying
Figure 2 presents a diagram of the revolv- amounts of time, most of them cannot exit
ing-door schema of smoking cessation. The from the revolving door the first time around,
lower half of the figure represents the more They struggle to maintain their recent status
static world of immotive smokers—those who as a non-smoker, but they soon find them-
do not currently experience enough motivation selves relapsing back into a smoke-filled life,
to change their smoking habits. The center They want to exit while they are out in the
circle is the revolving-door world of smokers realm of non-smokers. Forces unknown to
in transition. Immotive smokers enter the them, however, seem to hold them back and
realm of experience when they have enough the momentum of the revolving door seems
motivation to begin to seriously contemplate to shove them back around into a smoke-filled
changing their smoking habits. Recent data life again. The forces determining relapse
indicate that smokers stay in the contempla- are unknown to researchers as well, though
tion stage from two weeks to twelve months popular hypotheses include strength of the
(Prochaska et al., in press). smoking-habit pattern, weakness of com-
If smokers continue to progress, they move mitment, environmental contingencies, or
into the determination stage in which they inadequacy of maintenance strategies or
284 JAMES O. PROCHASKA & CARLO C. DICLEMENTE

skills. Even more unfortunate is the fact that many


But relapsers do not stop there. Many smokers never find their way to become free
smokers in transition move back into the of their habit. Some avoid the frustration of
contemplation stage again, as they prepare continued failure by leaving the revolving
for another frustrating trip around the re- door through Exit 3 and try to resume the life
volving door. However, some eventually exit of a satisfied smoker. Others continue to con-
from this frustrating circle of change. Figure template change, waiting for the right moment
2 presents the most common exits used to or the right method to come along to try again.
leave the revolving door. Exit 1 is the quickest Others decide they need a rest from struggling
way out. People who have been contemplating with the stresses of change. They tell them-
change decide that they do not really want to selves that someday in the future they will
change even though they have been thinking once again go back to struggling to succeed
about the hazards of the habit and the advan- in stopping smoking.
tages of not smoking. Or they decide that From our research with smokers it has be-
they cannot change. Most contemplators, come apparent that there are rather consistent
however, give it a whirl in trying to stop even stages that both precede and follow change.
if it is only a 24-hour spin without cigarettes. Precontemplation is the name given to the
Exit 2 is the truly successful way out of stage preceding change, while termination is
the smoking habit. The person who exits here the stage that completes maintenance. Indi-
no longer experiences a desire to smoke or, viduals in the precontemplation stage are those
at a minimum, experiences little, if any, dif- who are not aware of having a particular
ficulty in not smoking across all situations. problem even though others recognize them
Our one-year follow-up of recent quitters as having a problem. A wife of a troubled
(DiClemente & Prochaska, 1982) suggests drinker, for example, may recognize the
that some successful quitters have exited from drinking as a problem even though the drinker
the revolving door and consider themselves himself does not think of his drinking as a
to be confirmed non-smokers. They report problem. The precontemplator is either na-
that there are few, if any, situations that tempt ively uninformed about the consequences of
them to smoke again. The first three to six his/her behavior, such as the rare smoker who
months appears to be the most difficult and is not aware of the hazards of smoking, or
dangerous time for relapse. The next six- actively resists being informed about the
month period frequently requires active problem, such as the troubled drinker who
maintenance but is not as difficult. Self-quit- denies the extent or effects of his drinking.
ters vary considerably in the amount of Obviously, as long as a person remains in
maintenance problems they experience. Those the precontemplation stage, he/she is not
individuals who continue to experience dif- likely to change his/her behavior.
ficulty in keeping from smoking remain in a Following change some individuals exit
prolonged maintenance stage in which specific successfully by terminating the problem en-
strategies must be used to keep from relapsing. tirely. After a prolonged period of mainte-
Unfortunately, Exit 2 doesn't appear to nance, many non-smokers, for example, no
open up for most smokers prior to the second longer experience a desire to smoke and are
revolution of change. For successful former not in risk of relapsing. As long as the person
smokers it takes an average of three revolu- is still in the maintenance stage, the risk of
tions of change before they find their way to relapse is real and the person will at times
becoming fully free of the habit. Current data experience the anxiety or stress that can ac-
on long-term self-quitters also suggest that company efforts to maintain a change. Other
most self-stoppers remained in the mainte- individuals make progress in moving toward
nance stage from six to twelve months before their goals but relapse into their problem pat-
they no longer experienced any difficulty in terns. Some of these relapsers will re-enter
keeping from smoking (Prochaska et al., in the contemplation stage while others will
press). struggle to become precontemplators again
TRANSTHEORETICAL THERAPY 285

so that they no longer will have to think of since we found that it often took a corrective
their behavior as a problem to be changed. emotional experience to get clients to commit
In our laboratory we have developed a scale themselves to the arduous task of changing
of the stages of change with 150 outpatients their habit patterns.
at a large community mental health center The behavioral processes of contingency
(McConnaughy et al., in press). We are control and conditional stimuli, on the other
testing relationships between the client's stage hand, were seldom used until the individuals
of change upon entering therapy and the were ready to act upon their increased con-
course that therapy takes. Precontemplators, sciousness and commitment. These behavioral
for example, are expected to drop out of ther- processes frequently continued to be used well
apy at a much higher rate than other clients. into the maintenance stage.
Drop-outs who are not precontemplators are What our research and model on self-change
expected to either regress in their stage of and therapy change clearly suggests is that
change or show no progress. The further along verbal and behavioral processes of change
in the stages of change that clients are, the are not theoretically incompatible. In fact,
more readily they will be expected to progress both sets of processes appear to be vitally
on a particular problem during the course of important for individuals to complete the
therapy. Those who make the most progress course of change. The major difference is
in therapy will be expected, upon retesting, that the verbal processes are most important
to show the most progress on the stages of in preparing clients for action, while the be-
change scale. These are examples of the types havioral processes become more important
of practical hypotheses that can be generated once clients have committed themselves to
from the concept of stages of change. act.
Therapists who rely only upon verbal pro-
INTEGRATION OF STAGES AND PROCESSES cesses of change frequently make the implicit
OF CHANGE assumption that once clients are more fully
aware of themselves and their environment,
One of the most important findings to a n d o n c e t h e y a r e committed to act, then the
emerge from our research with self-changers clients can choose the appropriate processes
and therapy changers is that particular pro- f o r effective action. Our work with smoking
cesses of change tend to be used much more d o e s indeed support the notion that some
during particular stages of change. The initial populations, at least, are quite effective in
integration of processes and stages of change u s i n g contingency control, counter-condi-
is presented in Figure 3. tioning and stimulus control techniques
Figure 3 indicates that the verbal processes without the help of a therapist. The problem
of change—consciousness raising, catharsis i s t h a t s o m e clients may not be nearly as
and choosing—are most important during the skilled in applying counter-conditioning
first two stages of change. This is not to say procedures, for example, to a disruptive fear
that these processes are never used in later like vaginismus.
stages of change but rather that they are em- F r o m t h e perspective of our model we as-
phasized when the clients are contemplating sume that many traditional behavior therapists
change and determining if they are willing implicitly expected that their clients were
to pay the price to change. Catharsis is shown committed to change and were ready for ac-
as bridging contemplation and determination t i o n - A s therapists who have practiced be-
havior therapy, the problem has arisen all too
STAGES, CONTEMPLATION—-TE9-1,,T,"n-HI^T .•«-.TENANT often that some clients are not as committed
PROCESSES CCN3C=USNE5S OCSC O-, , GENC of TTCL to action as we are. These clients tend n
comply with our behavioral prescriptions,
CAI WARS TS CQND TIGNAL S7 [("ML i X J i JT '

such as doing regular relaxation exercises,


Figure 3. Initial integration of stages and processes even though the data might suggest that such
of change. exercises are the best action for lowering their
286 JAMES O. PROCHASKA & CARLO C. DICLEMENTE

level of anxiety. mation that is characteristic of defense


Our model would also suggest that when mechanisms which keep individuals from
clients are committed to action then behavior changing what society or significant others
therapies should outperform verbal therapies. judge to be problem behaviors.
Such may have been the case in Gordon Paul's Once change has occurred, what processes
(1966) classic study on college students in allow some individuals to successfully main-
public-speaking courses who volunteered for tain their gains until they eventually terminate
therapy for public-speaking anxiety. A more their problem, while others relapse? The
representative sample of clinic patients which search for the determinants of relapse is the
includes clients at various stages of change, focus of an increasing number of investiga-
including precontemplation and contempla- tors. From our research on smokers, the only
tion, would not necessarily favor the behav- variable that related to long-term success was
ioral approaches. Such was the case in Sloane the individual's level of self-efficacy at the
et al. 's (1975) already classic comparison of time of stopping smoking (DiClemente,
behavior therapy and psychotherapy. 1981). The individual's level of self-efficacy
What processes move individuals into be- at the time of quitting was the only predictor
ginning to think about their behaviors as of relapse within thefirstfivemonths of quit-
problems in the first place? What processes ting. The more effective the individual saw
move a person from precontemplation into himself/herself in dealing with internal and
the contemplation stage? Conversely, what external pressures to smoke the more likely
processes keep many individuals from think- that individual was to resist relapse. This
ing about particular behaviors as problems finding supports Bandura's (1977) contention
needing to be changed? Our initial data sug- that efficacy expectations are cognitions which
gest that many individuals begin to contem- intervene in terms of the individual's com-
plate changing particular aspects of their lives mitment to particular changes in the face of
because of developmental processes that move obstacles and difficulties.
them into a new stage in life. As Levinson These findings suggest that a successful
et al. (1978) suggest, for example, many men course of change involves not only a restruc-
find themselves quite satisfied with a partic- turing of the person's patterns of behavior
ular spouse during their twenties, but when but also a restructuring of key cognitions about
they enter the transition into the thirties they one's self. In the transtheoretical model such
begin to contemplate radical changes in their cognitive restructuring is seen as the result
marriages. Similarly, many smokers begin of the individual effectively applying the ap-
to contemplate stopping smoking seriously propriate processes of change during each of
as they approach age 40 and feel pressured the appropriate stages of change.
to face the finiteness of their lives. Another
group of individuals appear ready for change COOPERATION BETWEEN CLIENTS
not because of internal developmental changes AND THERAPISTS
but because their environment has changed.
Perhaps a spouse or child has reached a new From our research with self-changers and
developmental stage and asks or demands that changers in therapy, we are convinced that
they stop drinking or smoking. Or they may clients are as much agents of change as are
realize that their environment no longer rein- therapists. We have found, for example, that
forces their smoking like it once did but now individuals who stop smoking on their own
responds with subtle and not-so-subtle pun- can be as effective five months later in main-
ishments to their old habits. taining their non-smoking, as clients of ex-
While some individuals respond to envi- pensive and complex treatments. We have
ronmental pressures to change more openly, also found that clients in the complex treat-
many become defensive. We are currently ments selectively choose which of the par-
studying the defensive processes that smokers ticular techniques to use and which to ignore,
use to resist change in the face of increasing rather than blindly using all the techniques
social pressures to stop. We assume, then, that the experts suggest.
that it is the selective processing of infor- We believe that many therapists might be-
TRANSTHEORETICAL THERAPY 287

come more effective if they accepted that we can enhance the practice of transtheoretical
clients can be at least as much a source of therapy.
change as a source of resistance to change.
In fact, one of the more common sources of REFERENCE NOTES
resistance might well be when clients and
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of change. The more directive, action-oriented three cases of vaginismus: An easy success, a difficult
success and a failure. Unpublished manuscript, Uni-
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