Prochaska J. O., DiClemente C. C. and Norcross, J. C. (1992), In Search of How People Change

8/6/2019 Prochaska J. O., DiClemente C. C. and Norcross, J. C. (1992), In Search of How People Change

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In Search of How People ChangeApplications to Addictive Behaviors

James O. ProchaskaCarlo C. DiClementeJohn C. Norcross

Cancer Prevention Research Consortium,University of Rhode IslandUniversity of HoustonUniversity ofScranton

How people intentionally change addictive behaviors withand without treatment is not well understood by behavioralscientists. This article summarizes research on self-ini-tiated and professionally facilitated change of addictivebehaviors using the key transtheoretical constructs ofstages and processes of change. Modification of addictivebehaviors involves progression through five stages pre-contemplation, contemplation, preparation, action, andmaintenance and individuals typically recycle throughthese stages several times before termination of the ad-diction. Multiple studies provide strong support for thesestages as well as for a finite and common set of changeprocesses used to progress through the stages. Researchto date supports a transtheoretical model of change thatsystematically integrates the stages with processes ofchange from diverse theories of psychotherapy.Hundreds of psychotherapy outcome studies have dem-onstrated that people successfully change with the helpof professional treatment (Lambert, Shapiro, & Bergin,1986; Sm ith, Glass, & Miller, 1980). These outc om e stud-ies have taught us relatively little, however, about howpeople change with psychotherapy (Rice & Greenberg,1984). Numerous s tudies also have demonstrated thatmany people can modify problem behaviors without thebenefit of formal psychotherapy (M arlatt, Baer, Donovan,& Divlah an, 1988; Schachter, 1982; Shap iro et al., 1984;Veroff, Douvan, & Kulka, 1981a, 1981b). These studieshave taught us relatively little, however, about ho w peoplechange on their own.Similar results are found in the literature on addic-tive behaviors. Certain treatment methods consistentlydem onstrate successful outcomes for alcoholism and otheraddictive behaviors (Miller & Hester, 1980, 1986). Self-change has been documen ted to occur with alcohol abuse,smoking, obesity, and opiate use (Cohen et al., 1989; Or-ford, 1985; Roizen, Cah aland, & Shan ks, 1978; Schachter,1982; Tuchfeld, 1981). Self-change of addictive behaviorsis often misnamed "spontaneous remission," but suchchange involves external influence and individual com-m itm ent (Orford, 1985; Tuchfeld, 1981). These studiesdemonstrate that intentional modification of addictivebehaviors occurs both with and without expert assistance.Moreover, these change s involve a process that is not wellunderstood.

Over the past 12 years, our research program hasbeen dedicated to solving the puzzle of how people in-tentionally change their behavior with and without psy-chotherapy. We have been searching for the structure ofchange that underlies both self-mediated and treatment-facilitated modification of addictive and other problembehaviors. Wehave concentrated on the phenomenon ofintentional change as opposed to societal, developm ental,or imposed change. Our basic question can be framed asfollows: Because successful change of complex addictio nscan be demons trated in both psychotherapy and self-change, are there basic, comm on principles that can revealthe s tructure of change occurring with and without psy-chotherapy?This article provides a comprehensive summary ofthe research on the basic constructs of a mod el that h elpsus understand self-initiated and professionally assistedchanges of addictive behaviors. The key transtheoreticalconcepts of the stages and processes of change are ex-amined, and their applications to a variety of addictivebehaviors and populations are reviewed. This transtheo-retical model offers an integrative perspective on thestructure of intentional change.Stages of ChangeOne objective of treatment outcome research in the ad-dictions is to establish the efficacy of interventions. How-ever, study after study demonstrates that not all clientssuffering from an addictive disorder improve: Some dropout of treatment, and others relapse following brief im-proveme nt (Kanfer, 1986; Marlatt & Gordon, 1985). In-adequate motivation, resistance to therapy, defensiveness,and inability to relate are client variables frequently in-voked to account for the imperfect o utcome s of the changeenterprise. Inadequate techniques, theory, and relationshipskills on the part of the therapist are intervention variablesfrequently blamed for lack of therapeutic success.In our earliest research we found it necessary to ask

Bernadette Gray-Little served as action editor for this article.This research was supported in part by Grants CA27821 andCA50087 from the National Cancer Institute.Correspondence concerning this article should be addressed toJames Q Prochaska, Cancer Prevention Research Co nsortium, Universityof Rhode Island, K ingston, RI 02881.

1102 September 1992 American PsychologistCopyright 1992 by the American Psychological Association, Inc. 0OO3-066X/92/$2 00


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when changes occur, in o rder to explain th e relative con-tributions of client and intervention variables and to un-derstand the underlying structure of behavior change(DiClemente & Prochaska, 1982; Prochaska & D i-Clemente, 1983). Individuals modifying addictive behav-iors move through a series of stages from precontempla-tion to maintenance. A linear schema of the stages wasdiscovered in research with smokers attempting to quiton their own and with smokers in professional treatm entprograms (DiClemente & Prochaska, 1982). People wereperceived as progressing linearly from precontem plationto contemplation, then from preparation to action, andfinally into m aintenance. Precursors of this stage modelcan be found in the writings of Horn and Waingrow (1966),Cashdan (1973), and Egan (1975). Variations of and al-ternatives to ou r stage model can be found in mo re recentwritings of Beitman (1986); Brownell, Marlatt, Lichten-stein, and Wilson (1986); Dryden (1986); and Marlatt andGordon (1985).Several lines of research support the stages of changeconstruct (Prochaska & DiClemente, 1992). Stages ofchange have been assessed in outpatient therapy clientsas well as self-changers (DiClemente & Hughes, 1990;DiClemente & Prochaska, 1985; DiClemente, Prochaska,& Gilbertini, 1985; Lam, McM ahon, Priddy, & Gehred-Schultz, 1988; McConnaughy, DiClemente, Prochaska,& Velicer, 1989). Clusters of individuals have been foundin each of the stages of change, whether the individualswere presenting for psychotherapy or attempting tochange on their own. Stages of change have been ascer-tained by two different self-report methods: a discretecategorical measure, which assesses the stagefroma seriesof mutually exclusive questions (DiClemente et al., 1991),and a continuous measure, which yields separate scalesfor precontemplation, contemplation, action, andmaintenance (McConnaughy et al., 1989; McConnaughy,Prochaska, & Velicer, 1983).In our original research we had identifiedfivestages(Prochaska & DiClemente, 1982). But in principal com-ponent analyses of the continuous measure of stages, weconsistently found only four scales (McConnaughy et al.,1983, 1989). We misinterpreted these data to mean thatthere were only four stages. For seven years we workedwith a four-stage mode l, omitting the stage between con-templation and action (Prochaska & D iClemente, 1983,1985, 1986). We now realize that in the sam e studies onthe continuous measures, cluster analyses had identifiedgroups of individuals who were in the preparation stage(McConnaughy et al., 1983, 1989). They scored high onboth the contemplation and action scales. Unfortunatelywe paid more attention to principle component analysesrather than the cluster analyses and ignored the prepa-ration stage. Recent research has supported the impor-tance of assessing preparation as a fifth stage of change(DiClemente etal., 1991; Prochaska &Diclemente, 1992).Following are brief descriptions of each of thefivestages.Precontemplation is the stage at which there is nointention to change behavior in the foreseeable future.Many individuals in this stage are unaware or underaware

of their problems. As G. K. Chesterton once said, "Itisn't that they can't see the solution. It is that they can 'tsee the problem." Families, friends, neighbors, or em-ployees, however, are often well aware that the precon-templators have problems. When precontemplators pre-sent for psychotherapy, they often do so because of pres-sure from others. Usually they feel coerced in to changingthe addictive behavior by a spouse who threatens to leave,an employer who threatens to dismiss them, parents whothreaten to disown them , or courts who threaten to punishthem . They may even demonstrate change as long as thepressure is on. Once the pressure is off, however, theyoften quickly re turn to their old ways.In our studies using the discrete categorization m ea-surement of stages of change, we ask whether the indi-vidual is seriously intending to change the problem be-havior in the near future, typically within the next sixmon ths. If not, he or she is classified as a precontemplator.Even precontemplators canwish to change, but this seemsto be qu ite different from intending or seriously consid-ering change in the next six months. Items that are usedto identify precontemplation on the continuous stage ofchange measure include "A s far as I'm concerned, I don'thave any problems that need changing" and "I guess Ihave faults, but there's nothing that I really need tochang e." Resistance to recognizing or modifying a p rob-lem is the hallmark of precontemplation.Contemplation is the stage in which people are awarethat a problem exists and are seriously thinking aboutovercoming it but have not yet made a commitment totake action. People can remain stuck in the contemplationstage for long periods. In one study of self-changers, wefollowed a group of 200 smokers in the contemplationstage for two years. The modal response of this group w asto remain in the contemplation stage for the entire twoyears of the project without ever moving to significantaction (DiClemente & Prochaska, 1985; Prochaska &DiClemente, 1984).The essence of the contemplation stage is commu-nicated in an incident related by Benjamin (1987). Hewas walking home one evening when a stranger ap-proached him and inquired about the whereabouts of acertain street. Benjamin pointed it out to the strangerand provided specific instructions. After readily under-standing and accepting the instructions, the stranger beganto walk in the opposite direction. Benjamin said, "Youare headed in the wrong direction ." The stranger replied,"Yes, I know. I am not q uite ready yet." This is contem-plation: knowing where you want to go but not quiteready yet.Another im portan t aspect of the contemplation stageis the weighing of the pros and cons of the problem andthe solution to the problem. Contemplators appear tostruggle with their positive evaluations of the addictivebehavior and the am oun t of effort, energy, and loss it willcost to overcome the problem (DiClemente, 1991; Pro-chaska & DiClemente, 1992; Velicer, DiClemente, Pro-chaska, & Brandenburg, 1985). On discrete measures,individuals who state th at they a re seriously considering

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changing the addictive behavior in the next six monthsare classified as contemplators. On the continuous mea-sure these individuals would be endorsing such items as"I have a problem and I really think I should work onit" and "I 've been thinking that I might want to changesomething about myself." Serious consideration of prob-lem resolution is the central element of c ontemplation.Preparation is a stage that combines intention andbehavioral criteria . Individuals in this stage are intendingto take action in the next month and have unsuccessfullytaken action in the past year. As a grou p, individuals whoare prepared for action report some small behavioralchanges, such as sm oking five cigarettes less or delayingtheir first cigarette of the day for 30 minutes longer thanprecontemplators or contemplators (DiClemente et al. ,1991). Although they have made som e reductions in theirproblem behaviors, individuals in the preparation stagehave not yet reached a criterion for effective action, suchas abstinence from smoking, alcohol abuse, or heroin use.They are intending, however, to take such action in thevery near future. On the continuous measure they score

high on both the contem plation and action scales . Someinvestigators prefer to conceptualize the preparation stageas the early stirrings of the action stage. We originallycalled it decision making.Action is the stage in which individuals m odify theirbehavior, experiences, or environment in order to over-come their problems. Action involves the most overt be-havioral changes and requires considerable com mitm entof tim e and energy. Modifications of the addictive behav-ior made in the action stage tend to be most visible andreceive the greatest external recognition. People, includingprofessionals, often erroneously equate action withchange. As a consequence, they overlook the requisitework that prepares changers for action and the im portan tefforts necessary to maintain the changes following action.Individuals are classified in the action stage if theyhave successfully altered th e addictive behavior for a pe-riod of from one day to six m ont hs. Successfully alteringthe addictive behavior means reaching a particular cri-terion, such as abstinence. With smoking, for example,cutting down by 50% and changing to lower tar and nic-otine cigarettes are behavior changes that can better pre-pare pe ople for action b ut d o no t satisfy the field's criteriafor successful action. On the continuous measure, indi-viduals in the action stage endorse statements such as "Iam really working hard to cha nge" and "A nyone can talkabout changing; I am actually doing something about it ."

They score high on the action scale and lower on theother scales. Modification of the target behavior to anacceptable criterion and significant overt efforts to changeare the hallmarks of action.Maintenance is the stage in which people work toprevent relapse and consolidate the gains attained duringaction. Traditionally, maintenance was viewed as a staticstage. However, maintenance is a continuation, not anabsence, of change. F or addictive behaviors this stage ex-tends from six months to an indeterminate period pastthe initial action. For some behaviors maintenance can

be considered to last a lifetime. Being able to rema in freeof the addictive behavior and being able to consistentlyengage in a new incompatible behavior for more than sixmonths are the criteria for considering someone to be inthe maintena nce stage. On th e continuous measure, rep-resentative maintenance items are "I may need a boostright now to help me maintain the changes I've alreadymade" and "I 'm here to prevent myself from having arelapse of my problem." Stabilizing behavior change andavoiding relapse are the hallma rks of main tenance.Spiral Pattern of ChangeAs is now well-known, m ost people taking action to mo d-ify addic tions do no t successfully ma inta in their gains ontheir first attem pt. W ith smo king, for exam ple, successfulself-changers make an average of from three to four actionattempts before they become long-term maintainers(Schachter, 1982). Ma ny N ew Yea r's resolvers report fiveor more years of consecutive pledges before maintainingthe behavioral goal for at least six months (Norcross &Vangarelli, 1989). Relapse and recycling throug h th e stagesoccur quite frequently as individuals attempt to modifyor cease addictive behaviors. Variations of the stage modelare being used increasingly by beh avior change specialiststo investigate the dynamics of relapse (e.g., Brownell etal., 1986; Donovan & Marlatt, 1988).Because relapse is the rule rath er than the ex ceptionwith addictions, we found that we needed to modify ouroriginal stage model. Initially we conceptualized changeas a linear progression through the stages; people weresupposed to progress simply and discretely through eachstep. Linear progression is a possible but relatively rarephenomenon with addictive behaviors .Figure 1 presents a spiral pattern that illustrates howmost people actually move through the stages of change.In this spiral pattern, people can progress from contem-plation to preparation to action to maintenance, but mostindividuals will relapse. During relapse, individuals re-gress to an earlier stage. Some relapsers feel like failuresembarrassed, ashamed, and guilty. These individuals be-come demoralized and resis t thinking about behavior

Figure 1A Spiral Model of the S tages of ChangeTERMINATION

PRECONTEMPLATION (CONTE MPLA TION PREPARATIO|

PRECONTEMPLATION CONTEMPLATION PREPAHATIOI

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change. As a result, they return to the precontemplationstage and can remain there for various periods of time.Approximately 15% of smokers who relapsed in our self-change research regressed back to the precontemplationstage (Prochaska & DiClemente, 1986).Fortunately, this research indicates that the vast ma-jority of relapsers85% of smokers, for examplerecycleback to the contemplation or preparation stages (Pro-chaska & DiClemente, 1984). They begin to considerplans for their next action attempt while trying to learnfrom their recent efforts. To take another example, fully60% of unsuccessful New Year's resolvers make the samepledge the next year (Norcross, Ratzin, & Payne, 1989;Norcross & Vangarelli, 1989). The spiral model suggeststhat most relapsers do not revolve endlessly in circles andthat they do not regress all the way back to where theybegan. Instead, each time relapsers recycle through thestages, they potentially learn from their mistakes and cantry something different the next time around (DiClementeetal., 1991).On any one trial, successful behavior change is lim-

ited in the absolute numbers of individuals who are ableto achieve maintenance (Cohen et al., 1989; Schachter,1982). Nevertheless, in a cohort of individuals, the numberof successes continues to increase gradually over time.However, a large number of individuals remain in con-templation and precontemplation stages. Ordinarily, themore action taken, the better the prognosis. Much moreresearch is needed to better distinguish those who benefit

Figure 2Percentage Abstinent Over 18 Months for Smokers inPrecontemplation (PC), Contemplation (C), andPreparation (P/A) Stages Before Treatment (N = 570)

Pretest 1 6 12ASSESSMENT PERIODS

from recycling from those who end up spinning theirwheels.

Additional investigations will also be required to ex-plain the idiosyncratic patterns of movement through thestages of change. Although some transitions, such as fromcontemplation to preparation, are much more likely thanothers, some people may move from one stage to anyother stage at any time. Each stage represents a period oftime as well as a set of tasks needed for movement to thenext stage. Although the time an individual spends ineach stage may vary, the tasks to be accomplished areassumed to be invariant.Treatment ImplicationsProfessionals frequently design excellent action-orientedtreatment and self-help programs but then are disap-pointed when only a small percentage of addicted peopleregister, or when large numbers drop out of the programafter registering. To illustrate, in a major health mainte-nance organization (HMO) on the West Coast, over 70%of the eligible smokers said they would take advantage ofa professionally developed self-help program if one wasoffered (Orleans et al., 1988). A sophisticated action-ori-ented program was developed and offered with great pub-licity. A total of 4% of the smokers signed up. As anotherillustration, Schmid, Jeffrey, and Hellerstedt (1989) com-pared four different recruitment strategies for home-basedintervention programs for smoking cessation and weightcontrol. The recruitment rates ranged from 1% to 5% ofthose eligible for smoking cessation programs and from3% to 12% for those eligible for weight control programs.

The vast majority of addicted people are not in theaction stage. Aggregating across studies and populations(Abrams, Follick, & Biener, 1988; Gottleib, Galavotti,McCuan, & McAlister, 1990; Pallonen, Fava, Salonen, &Prochaska, in press), 10%-15% of smokers are preparedfor action, approximately 30%-40% are in the contem-plation stage, and 50%-60% are in the precontemplationstage. If these data hold for other populations and prob-lems, then professionals approaching communities andworksites with only action-oriented programs are likelyto underserve, misserve, or not serve the majority of theirtarget population.

Moving from recruitment rates to treatment out-comes, we have found that the amount of progress clientsmake following intervention tends to be a function oftheir pretreatment stage of change (e.g., Prochaska &DiClemente, 1992; Prochaska, Norcross, Fowler, Follick,& Abrams, 1992). Figure 2 presents the percentage of570 smokers who were not smoking at four follow-upsover an 18-month period as a function of the stage ofchange before random assignment to four home-basedself-help programs. Figure 2 indicates that the amountof success smokers reported after treatment was directlyrelated to the stage they were in before treatment (Pro-chaska & DiClemente, 1992). To treat all of these smokersas if they were the same would be naive. And yet, that iswhat we traditionally have done in many of our treatmentprograms.



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If clients progress from one stage to the next duringthefirstmonth of treatment, they can double their chancesof taking action during the initial six months of the pro-gram. Of the precontemplators who were still in precon-templation at one month follow-up, only 3% took actionby six months. For the precontemplators who progressedto contemplation at one month, 7% took action by sixmonths. Similarly, of the contemplators who remainedin contemplation at one month, only 20% took action bysix months. At one month, 41% of the contemplatorswho progressed to the preparation stage attempted to quitby six months. These data demonstrate that treatmentprograms designed to help people progress just one stagein a month can double the chances of participants takingaction on their own in the near future (Prochaska &DiClemente, 1992).

Mismatching Stage and TreatmentA person's stage of change provides proscriptive as wellas prescriptive information on treatments of choice. Ac-tion-oriented therapies may be quite effective with indi-viduals who are in the preparation or action stages. Thesesame programs may be ineffective or detrimental, how-ever, with individuals in precontemplation or contem-plation stages.

An intensive action- and maintenance-orientedsmoking cessation program for cardiac patients was highlysuccessful for those patients in action and ready for action.This same program failed, however, with smokers in theprecontemplation and contemplation stages (Ockene,Ockene, & Kristellar, 1988). Patients in this special careprogram received personal counseling in the hospital andmonthly telephone counseling calls for six months fol-lowing hospitalization. Of the patients who began theprogram in action or preparation stages, an impressive94% were not smoking at six-month follow-up. This per-centage is significantly higher than the 66% nonsmokingrate of the patients in similar stages who received regularcare for their smoking problem. The special care programhad no significant effects, however, with patients in theprecontemplation and contemplation stages. For patientsin these stages, regular care did as well or better.Independent of the treatment received, there wereclear relationships between pretreatment stage and out-come. Twenty-two percent of all precontemplators, 43%of the contemplators, and 76% of those in action or pre-pared for action at the start of the study were not smoking

six months later.A mismatched stage effect occurred with anothersmoking program. An HMO-based self-help smokingcessation program for pregnant women was successfulwith patients prepared for action but had negligible im-pact on those in the precontemplation stage. Of thewomen in the preparation stage who received a series ofseven self-help booklets through the mail, 38% were notsmoking at the end of pregnancy (which was approxi-mately 6 months posttreatment). This was triple the 12%success rate obtained for those who received regular care

of advice and fact sheets. For precontemplators, however,6% of those receiving special care and 6% receiving regularcare were not smoking at the end of pregnancy (Ershoff,Mullen, & Quinn, 1987). These two illustrative studiesportend the potential importance of matching treatmentsto the client's stage of change (DiClemente, 1991; Pro-chaska, 1991).

Stage Movements During TreatmentWhat progress do patients in formal treatment evidenceon the stages of change? In a cross-sectional study wecompared the stages of change scores of 365 individualspresenting for psychotherapy with 166 clients currentlyengaged in therapy (Prochaska & Costa, 1989). Patientsentering therapy could usually be characterized as pre-pared for action because their highest score was on thecontemplation scale and second highest was on the actionscale. The contemplation and action scores crossed overfor patients in the midst of treatment. Patients in themiddle of therapy could be characterized as being in theaction stage because their highest score was on the actionscale. Compared with patients beginning treatment, thosein the middle of therapy were significantly higher on theaction scale and significantly lower on the contemplationand precontemplation scales.

We interpreted these cross-sectional data as indi-cating that, over time, patients who remained in treatmentprogressed from being prepared for action into takingaction. That is, they shifted from thinking about theirproblems to doing things to overcome them. Loweredprecontemplation scores also indicated that, as engage-ment in therapy increased, patients reduced their defen-siveness and resistance. The vast majority of the 166 pa-tients who were in the action stage were participating inmore traditional insight-oriented psychotherapies. Theprogression from contemplation to action is postulatedto be essential for beneficial outcome, regardless ofwhether the treatment is action oriented or insight ori-ented (also see Wachtel, 1977,1987).This crossover pattern from contemplation to actionwas also found in a longitudinal study of a behavior ther-apy program for weight control (Prochaska, Norcross, et

al., 1992). Figure 3 presents the stages of change scoresat pre- and midtreatment. As a group, these subjects en-tering treatment could be characterized as prepared foraction. During the first half of treatment, members ofthis contingent progressed into the action stage, with theircontemplation scores decreasing significantly and theiraction scores increasing significantly.

The more clients progressed into action early intherapy, the more successful they were in losing weightby the end of treatment. The stages of change scores werethe second best predictors of outcome; they were betterpredictors than age, socioeconomic status, problem se-verity and duration, goals and expectations, self-efficacy,and social support. The only variables that outperformedthe stages of change as outcome predictors were the pro-cesses of change the clients used early in therapy.



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Figure 3A Longitudinal Com parison of Stages of ChangeScores for Clients Before (Week I) and M idwayThrough (Week 5) a B ehavioral Program for WeightReductionSTAGES OF CHANGE-WEIGHT3 53 3

2 9

27 -

CONTEMPLATION

ACT ION

MAINTENANCE

N=53

WEEKSProcesses of ChangeThe stages of change represent a tempo ral dimension thatallows us to unde rstand when particular shifts in attitudes,intentions, and behaviors occur. The processes of changeare a second major dimension of the transtheoreticalmodel that enable us to understand ho w these shifts o ccur.Change processes are covert and overt activities and ex-periences that individuals engage in when they attemptto modify problem behaviors. Each process is a broadcategory encompassing multiple techniques, methods,and interventions traditionally associated with disparatetheoretical orientations. These change processes can beused within therapy sessions, between therapy sessions,or without therapy sessions.The change processes were first identified theoreti-cally in a comparative analysis of the leading systems ofpsychotherapy (Prochask a, 1979). Th e processes were se-lected by examining recommended change techniquesacross different theories, which explains the term trans-theoretical. At least 10 subsequent principal com ponen tanalyses on the processes of change items, conducted onvarious response formats and diverse samples, haveyielded similar patterns (Norcross & Prochaska, 1986;Prochaska & DiClem ente, 1983; Prochaska & Norcross,1983; Procha ska, Velicer, DiC lem ente, & Fava, 1988). Ex-tensive validity and reliability data on the processes havebeen reported elsewhere (Prochaska et al., 1988). Theprocesses are typically assessed by me ans of a self-report

instrument but have also been reliably identified in tran-scriptions of psychotherapy sessions (O'Connell, 1989).Our research discovered that naive self-changers usedthe same change processes that have been at the core ofpsychotherapy systems (DiClemente & Prochaska, 1982,1985; Prochaska & DiClemente, 1984). Although dis-parate theories will emphasize certain change processes,the bre adth of processes we have identified ap pear to ca p-ture basic change activities used by self-changers, psy-chotherapy clients, and mental health professionals.The processes of change represent an intermediatelevel of abstraction between metatheoretical assumptionsand specific techniques spawned by those theories. Gold-fried (1980, 1982), in his influential call for a ra ppro ach -men t among the therapies , independently recom mendedchange princip les or processes as the m ost fruitful levelfor psychotherapy integration. Subsequent research onproposed therapeutic commonalities (Grencavage &Norcross, 1990) and agreement on treatment recom-mendations (Giunta, Saltzman, & Norcross, 1991) hassupported Goldfried's view of change processes as thecontent area or level of abstraction most amenable totheoretical convergence. Although there are 25 0-4 00 dif-ferent psychological therapies (Herink, 1980; Karasu,1986) based on divergent theoretical assumptions, we havebeen a ble to identify only 12 different p rocesses of chang ebased on principal components analysis. Similarly, al-though self-changers use over 130 techniques to quitsmoking, these techniques can be summarized by a muchsmaller set of change processes (Prochaska et al., 1988).

Table 1 presents the 10 processes receiving the m osttheoretical and em pirical sup port in our work, along withtheir definitions and representative examples of specificinterventions. A common and finite set of change pro-cesses has been repeatedly identified across such diverseproblem areas as smoking, psychological distress, andobesity (Prochaska & DiClemente, 1985). There arestriking similarities in the frequency with which thechange processes were used across these problem s. W henprocesses were ranked in terms of how frequently theywere used for each of these three problem behaviors, therankings were nearly identical. Helping relationships,consciousness raising, and self-liberation, for example,were the top three ranked processes across problems,whereas contingency management and stimulus controlwere the lowest ranked processes.

Significant differences occurred, however, in the ab-solute frequency of the use of change processes acrossproblems. Individuals relied more on helping relation-ships and consciousness raising for overcoming psycho-logical distress than they did for weight control andsmoking cessation. Overweight individuals relied moreon self-liberation and stimulus control than did distressedindividuals (Prochaska & DiClem ente, 1985).Processes as Predictors of ChangeThe processes have been potent predictors of change forboth therapy changers and self-changers. As indicatedearlier, in a behavioral weight control program, the pro-



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Table 1Titles, Definitions, and Representative Interventions of the Processes of ChangeProcess Definitions: InterventionsConsciousness raisingSelf-reevaluationSelf-liberation

CounterconditioningStimulus control

Reinforcement management

Helping relationshipsDramatic reliefEnvironmental reevaluationSocial liberation

Increasing information about self and problem: observations,confrontations, interpretations, bibliotherapyAssessing how one feels and thinks about oneself with respect toa problem: value clarification, imagery, corrective emotionalexperienceChoosing and commitment to act or belief in ability to change:decision-making therapy, New Year's resolutions, logotherapytechniques, commitment enhancing techniquesSubstituting alternatives for problem behaviors: relaxation,desensitization, assertion, positive self-statementsAvoiding or countering stimuli that elicit problem behaviors:restructuring one's environment (e.g., removing alcohol orfattening foods), avoiding high risk cues, fading techniquesRewarding one's self or being rewarded by others for makingchanges: contingency contracts, overt andcovert reinforcement,self-rewardBeing open and trusting about problems with someone who cares:

therapeutic alliance, social support, self-help groupsExperiencing andexpressing feelings about one's problems andsolutions: psychodrama, grieving losses, role playingAssessing how one's problem affects physical environment:empathy training, documentariesIncreasing alternatives for nonproblem behaviors available insociety: advocating for rights of repressed, empow ering, policyinterventions

cesses used early in treatment were the single best pre-dictors of outcome (Prochaska, Norcross, et al., 1992).For self-changers with smoking, the change processes werebetter predictors of progress across the stages of changethan were a set of 17 predictor variables, including de-mographics, problem history and severity, health history,withdrawal symptoms, and reasons for smoking (Pro-chaska, DiClemente, Velicer, Ginpil, & Norcross, 1985;Wilcox, Prochaska, Velicer, & DiClemente, 1985).The stages and processes of change combined witha decisional balance measure were able to predict with93 % accuracy which patients would drop out prematurelyfrom psychotherapy. At the beginning of therapy, pre-mature terminators were much more likely to be in theprecontemplation stage. They rated the cons of therapy

as higher than the pros, and they relied more on willpowerand stimulus control than did clients who continued intherapy or terminated appropriately (Medieros & Pro-chaska, 1992).Integrating the Processes and Stagesof ChangeThe prevailing Zeitgeist in psychotherapy is the integrationof leading systems of psychotherapy (Norcross & Gold-fried, 1992; Norcross, Alford, & DeMichele, 1992). Psy-chotherapy could be enhanced by the integration of the

profound insights of psychoanalysis, the powerful tech-niques of behaviorism, the experiential methods of cog-nitive therapies, and the liberating philosophy of existen-tialism. Although some psychotherapists insist that suchtheoretical integration is philosophically impossible, or-dinary people in the natural environment can be re-markably effective in finding practical means of synthe-sizing powerful change processes.The same is true in addiction treatment and re-search. There are multiple interventions but little inte-gration across theories (Miller & Hester, 1980). Onepromising approach to integration is to begin to matchparticular interventions to key client characteristics. TheInstitute of Medicine's (1989) report on prevention andtreatment of alcohol problems identifies the stages of

change as a key matching variable. A National CancerInstitute report of self-help interventions for smokers alsoused the stages as a framework for integrating a varietyof interventions (Glynn, Boyd, & Gruman, 1990). Thetranstheoretical model offers a promising approach to in-tegration by combining the stages and processes of change.A Cross-Sectional PerspectiveOne of the most important findings to emerge from ourself-change research is an integration between the pro-cesses and stages of change (DiClemente et al., 1991;



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A Longitudinal PerspectiveCross-sectional studies have inherent limitations for as-sessing behavior change, and we, therefore, undertookresearch on longitudinal patterns of change. Four majorpatte rns of behavior chang e were identified in a two-yearlongitudinal study of smokers (Prochaska, DiClemente,Velicer, Rossi, & Guadagnoli, 1992): (a) Stable patternsinvolved subjects who remained in the same stage for theentire two years; (b) progressive patterns involved linearmovement from one stage to the next; (c) regressive pat-terns involved movement to an earlier stage of change;and (d) recycling patterns involved two or more revolu-tions through the stages of change over the two-year pe-r iod. The stable pattern can be illustrated by the 27smokers who remained in the precontemplation stage atall five round s of data collection. Figure 4 presents theseprecontemplators ' s tandardized scores (M = 50, SD =10) for the 10 change processes being used at six-monthintervals over the two-year period. All 10 processes re-mained remarkably s table over the two-year period,demonstrating little increase or decrease over time.This figure graphically illustrates what individualsresistant to change were likely to be experiencing anddoing. Eight of 10 change processes, like self-reevaluationand self-liberation, were between 0.4 and 1.4 standarddeviations below the m ean (i.e., 50). In brief, these subjectswere doing very little to control or modify themselves ortheir problem behavior.This static pattern was in marked contrast to thepattern representing people who progressed from con-templation to maintenance over the two-year study. Sig-nificantly, many of the change processes did not simplyincrease linearly as individuals progressed from contem-plation to maintenance. Self-reevaluation, consciousnessraising, and dramatic reliefprocesses most associatedwith the contemplation stagedemonstrated s ignificantdecreases as self-changers moved th roug h the action stageinto maintenance. Conversely, self-liberation, stimuluscontrol, contingency control, and counterconditioningprocesses most associated with the action stageevi-denced dramatic increases as self-changers moved fromcontemplat ion to action. These change processes thenleveled off or decreased when maintenance was reached(Prochaska, DiClemente, et al., 1992).

Progressive self-changers demonstrated an almostideal pattern of how change processes can be used mosteffectively over time. They seemed to increase the partic-ular cognitive processes most im porta nt for the contem-plation stage and then to increase more behavioral pro-cesses in the action and maintenance stages. Before over-idealizing the wisdom of self-changers, note that only 9of 180 contemplators found their way through this pro-gressive pattern without relapsing at least once.The longitudinal results of the 53 clients completinga behavior therapy program for weight control provideadditional support for an integration of the processes andstages of change (Prochaska, Norcross, et al., 1992). As

mentioned earlier, this group progressed from contem-plation to action during the 10-week therapy program.Figure 5 presents the six change processes that evidencedsignificant differences over the course of t reatment . Aspredicted by the transtheoretical model, clients reportedsignificantly greater use of four action-related changeprocesses: counterconditioning, stimulus control, inter-personal control, and contingency management. Theyalso increased their reliance on social liberation and de-creased their reliance on medications, wishful thinking,and m inimizing threats. In other words, these clients weresubstituting alternative responses for overeating; they wererestructuring their environm ents to include more s timulithat evoked moderate eating; they reduced stimuli thatprompted overeating; they modified relationships to en-courage healthful eating; and they paid more attentionto social alternatives that allow greater freedom to keepfrom overeating.Integrative ConclusionsOu r search for how people intentiona lly modify add ictivebehaviors encompassed thousan ds of research participantsat tempting to alter, with and without psychotherapy, amyriad of addictive behaviors, including cigarette smok-ing, alcohol abuse, and obesity. From this and relatedresearch, we have discovered robu st com mona lities in howpeople modify their behavior. From our perspective theunderlying structure of change is neither technique-ori-ented nor problem specific. The evidence supports atranstheoretical model entailing (a) a cyclical pattern ofmovement through specific stages of change, (b) a com-m on set of processes of change, and (c) a systematic in-tegration of the stages and processes of change.Probably the most obvious and direct implicationof our research is the need to assess the stage of a client'sreadiness for change and to tailor interventions accord-ingly. Although th is step may be intuitively take n by manyexperienced clinicians, we have found few references tosuch tailoring before our research (Beutler & Clarkin,1990, Norcross, 1991). A more explicit model would en-hance efficient, integrative, and prescriptive treatmentplans. Furthermore, this s tep of assessing stage and tai-loring processes is rarely taken in a conscious and mean-ingful manner by self-changers in the natural environ-ment. Vague notions of willpower, mysticism, and bio-technological revolutions dominate their perspectives onself-change (Mahoney & Tho reson, 1972).

We have determined that efficient self-change de-pends on doing the right things (processes) at the righttime (stages). We have observed two frequent mism atches.First, some self-changers appear to rely primarily onchange processes most indicated for the contemplationstageconsciousness raising, self-reevaluationwhilethey are moving into the action stage. They try to modifybehaviors by becoming more aware, a common criticismof classical psychoanalysis: Insight alone does not nec-essarily bring about behavior change. Second, other self-changers rely primarily on change processes most indi-1110 September 1992 American Psychologist


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Figure 4Use of Change Processes (T scores) for 23 Smokers Who Rema ined in the Precontemp lation Stage at Each ofFive Assessment Points Over Two Years6 4

6 26 05 85 65 4

OZ 5 0LJJI DO 48W

PRECONTEMPLATORS* - - - # CONSCIOUSNESS RAISING Q O HELPING RELATIONSHIPS

A - - - A S 6 L F LIBERATION & ENVIRONMENTAL REEVALUATION - - - DRAMATIC RELIEF O - < > SOCIAL LIBERATION

_ V - COUNTER CONDITIONING V V SELF REEVALUATION STIMULUS CONTROL D Q REINFORCEMENT MANAGEMENT

Process

4 64 44 24 03836 h34

3 4ROUND

cated for the action stagereinforcement management,stimulus control, counterconditioningwithout the req-uisite awareness, decision m aking, and readiness providedin the contemplation and p reparation stages. They try tomodify behavior without awareness, a common criticismof radical behaviorism: Overt action without insight islikely to lead to temporary change.

We have generated a number of tentative conclusionsfrom our research that require empirical confirmation.Successful change of the addictions involves a progressionthrough a series of stages. Most self-changers and psy-chotherapy patients will recycle several times through thestages before achieving long-term ma intenance . Accord-ingly, intervention programs and personnel expectingSeptember 1992 American Psychologist 1111


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Figure 5Change Processes That Significantly Increased orDecreased During a 10-Week Behavioral Program forWeight Red uction on a L ikert Scale Ranging From 1(Newer Use; to 5 CAImost Always Use; (N = 53 )4 r

WISHFUL THINKING

zLUZ>o

COUNTER-CONDITIONINGSELF-LIBERATION

REINFORCEMENTMANAGEMENTMINIMIZING THREATS

STIMULUS CONTROLINTERPERSONALCONTROL

MEDICATIONS

W E E K ) WEEK 5 WEEK 10

people to progress linearly through the stages are likelyto gather disappointing and discouraging results.With regard to the p rocesses of change, we have ten-tatively concluded that they are distinct and measurableboth for self- and therapy changers. Similar processes ap-pear to be used to modify diverse problems, and similarprocesses are used within, between, and without psycho-therapy sessions. Dynamic measures of the processes andstages of change outperform static variables, like demo-graphics and problem history, in predicting outcome.Com peting systems of psychotherapy have pro mul-gated apparently rival processes of change. However, os-tensibly contradictory processes can become comple-mentary when embedded in the s tages of change. Spe-cifically, change processes traditionally associated withthe experiential, cognitive, and psychoanalytic p ersuasionsare most useful during the precontemplation and con-templation stages. Change processes traditionally asso-ciated with the existential and behavioral traditions, bycontrast, are mo st useful during action and m aintenance .People changing addictive behaviors with and withouttherapy can b e remarka bly resourceful in finding practicalmeans of integrating the change processes, even if psy-chotherapy theorists have been historically unwilling orunable to do so. Attending to effective self-changers inthe natural environment and integrating effective changeprocesses in the consulting room may be two keys to un-locking the elusive structure of how people change.

REFERENCESAbra ms, D. B., Follicle, M. J., & Biener, L. (198 8, Novem ber). Individualversus group self-help smoking cessation at the workplace: Initial im-pact and 12-month outcomes. In T. Glynn (Chair), Four NationalCancer Institute-funded self-help smoking cessation trials: Interim re-sults and emerging patterns. Symposium conducted at the annualmeeting of the Association for the Advancement of Behavior Therapy,New York.Beitman, B. D. (1986). The structure of individual psychotherapy. New

York: Guilford Press.Benjamin, A. (1987). The helping interview. Boston: Houghton Mifflin.Beutler, L. E., & Clarkin, J. F. (1990). Systematic treatment selection.New York: Brunner/Mazel.Brownell, K. D., M arlatt, G. A., Lichtenstein, E., & Wilson G. T. (1986).Understanding and preventing relapse. American Psychologist, 41,765-782 .Cashdan, S. (1973). Interactional psychotherapy: Stages and strategiesin behavioral change. New York: Grune & Stratton.Cohen, S., Lichtenstein, E., Prochaska, J. Q, Rossi, J. S., Gritz, E. R.,Carr, C. R., Orleans, C. X, Schoenbach, V. J., Biener, L., Abrams,D., DiClemente, C. G, Curry, S., Marlatt, G. A., Cummings, K. M.,Em ont, S. L., Giovino, G., & Ossip-Klein, D . (1989). Debunking mythsabo ut self-quitting: Evidence from 10 prospective studies of personsquitting smoking by themselves. American Psychologist, 44, 1355' ,365.DiClemente, C. C. (1991). Motivational interviewing and the stages ofchange. In W. R. M iller & S. Rollnick (Eds.), Motivational interviewing:Preparing people or change (pp. 191 -202) . New York: Guilford Press.DiC leme nte, C. C , & Hughes, S. L. (1990). Stages of change profiles inalcoholism treatment. Journal of Substance Abuse, 2, 217-235 .DiClem ente, C. C , & Prochaska, J. O. (1982). Self-change and therapychange of smoking behavior: A comparison of processes of change incessation and maintenance. Addictive Behaviors, 7, 133-142.DiClem ente, C. C , & Prochaska, J. O. (1985). Processes and stages ofchange: Coping and competence in smoking behavior change. In S.Shiffman & T. A. Wills (Eds.), Coping and substance abuse (pp. 319-343). San Diego, CA: Academic Press.DiC leme nte, C. C , Procha ska, J. O., Fairhurst, S. K., Velicer, W. F.,Velasquez, M. M., & Rossi, J. S. (1991). The process of smokingcessation: An analysis of precontem plation, contem plation, and p rep-aration stages of change. Journal of Consulting and Clinical Psychology,59 , 295-304.DiClemente, C. C , Prochaska, J. Q , & Gilbertini, M. (1985). Self-efficacyand the stages of self-change of smoking. Cognitive Therapy and Re-search, 9, 181-200.Donovan, D. M., & Marlatt, G. A. (Eds.). (1988). Assessment of addictivebehaviors: Behavioral, cognitive, and physiological procedures. NewYork: Guilford Press.Dryden, W. (1986). Eclectic psychotherapies: A critique of leading ap-proaches. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy.New York: Brunner/Mazel.Egan, G. (1975). The skilled helper: A m odel for systematic helping andinterpersonal relating. Monterey, CA: Brooks/Cole.Ershoff, D. H., Mullen, P. D., & Quinn, V. (1987, December). Self-helpinterventions for smoking cessation with pregnant w omen. Paper pre-sented at the Self-Help Intervention Workshop of the National CancerInstitute, Rockville, MD.Giun ta, L. C , Saitzman, N., & Norcross, J. C. (1991). Whither inte-gration? An exploratory study of contention and convergence in theClinical Exchange. Journal oflntegrative and Eclectic Psychotherapy,10 , 117-129.Glynn, T. J., Boyd, G. M., & Grum an, J. C. (1990). Essential elementsof self-help/minimal intervention strategies for smoking cessation.Health Education Quarterly, 17, 329-345 .Goldfried, M. R. (1980). Toward the delineation of therapeutic changeprinciples. American Psychologist, 35, 991-999.Goldfried, M. R. (1982). Converging themes in psychotherapy. New York:Springer.Gottlieb, N . H., Galavotti, C, Mc Cuan , R. S., & McAlister, A. L. (1990).Specification of a social cognitive model pre dicting sm oking cessationin a Mexican-American population: A prospective study. CognitiveTherapy and Research, 14, 529-542 .



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Grencavage, L. M , & Norcross, J. C. (1990). Where are the com mon -alities among the therapeutic co mm on factors? Professional Psychol-ogy: Research and Practice, 21, 372-378.Herink, R. (Ed.). (1980). The psychotherapy handbook. New York: Me-ridian.Horn , D. & Waingrow, S. (1966). Som e dimensions of a m odel for smokingbehavior change. American Journal of Public Health, 56, 21-26.Institute of Medicine. (1989). Prevention and treatment of alcohol prob-lems: Research opportunities. Washington, DC: National AcademyPress.Kanfer, F. H. (1986). Implications of a self-regulation model of therapyfor treatment of addictive behaviors. In W. R. Miller & N. Heather(Eds.), Treating addictive behaviors: Processes of change (pp. 29-50) .New York: Plenum Press.Karasu, T. B. (1986). The specificity versus nonspecificity dilemma: To-ward identifying therapeutic change agents. American Journal of Psy-chiatry, 143, 687-695 .Lam , C. S., McMahon, B. T , Priddy, D. A., & Gehred-Schutlz, A. (1988).Deficit awareness and treatment performance among traum atic headinjury adults. Brain Injury, 2, HS-lAl.La mb ert, M. J., Shap iro, D . A., & Bergin, A. E. (1986). Th e effectivenessof psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbookof psychotherapy and behavior change (3rd ed.). New \brk : W iley.Mahoney, M . J., & Thoreson , C . E. (1972). Behavioral self-control: Powerto the person. Educational Researcher, I, 5 - 7 .Marlatt, G. A., Baer, J. S., Donovan, D. M ., & Divlahan, D. R . (1988).Addictive behavior: Etiology and treatment. Annual Review of Psy-chology, 39, 223-252 .Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention: A self-controlstrategy for the maintenance of behavior change. New York: GuilfordPress.McConnaughy, E . A., DiClemente, C. C , Prochaska, J. Q, & Velicer,W. F. (1989). Stages of change in psychotherapy: A follow-up report.Psychotherapy, 26, 494-503 .McC onnaugh y, E. A., Pro chaska, J. Q , & Velicer, W. F. (1983). Stagesof change in psychotherapy: Measurement and sample profiles. Psy-chotherapy, 20, 368-375 .Medieros, M., & Prochaska, J. O. (1992). Predicting premature termi-nation from psychotherapy. Manuscript submitted for publication.Miller, W. R., & Hester, R. R. (1980). Treating the problem drinker:Modern approaches. In W. R. Miller (Ed.), The addictive behaviors:Treatment of alcoholism, drug abuse, smoking and obesity (pp. 11-141). Oxford, England: Pergamon Press.Miller, W. R., & Hester, R. R. (1986). The effectiveness of alcoholismtreatment. In W. R. Miller & N. Heather (Eds.), Treating addictivebehaviors: Processes of change (pp. 121-174). New \brk: PlenumPress.Norcross, J. C. (1991). Prescriptive matching in psychotherapy: Psy-choanalysis for simple phobias? Psychotherapy, 28, 4 3 9 - 4 4 3 .Norcross, J. C , Alford, B. A., & DeMichele, J. T. (1992). The future ofpsychotherapy: Delphi data and concluding observations. Psycho-therapy, 29, 150-158.Norcross, J. C, & Goldfried, M . R. (Eds.). (1992). Handbook of psy-chotherapy integration. New York: Basic Books.Norcross, J. G , & Prochaska, J. O. (1986). Psychotherapist heal thyself:1. The psychological distress and self-change of psychologists, coun-selors, and laypersons. Psychotherapy, 23, 102-114.Norcross, J. C , Prochaska, J. Q , & DiClemente, C. C. (1991). Thestages and processes of behavior change: Two replications w ith weightcontrol. Manuscript submitted for publication.Norcross, J. C, Ratzin, A. C , & Payne, D. (1989). Ringing in the NewYear: The change processes and reported outcomes of resolutions.Addictive Behaviors, 14 , 205-212.Norc ross, J. C , & Vangarelli, D. J. (1989). Th e resolution solution: Lon-gitudinal examination of New Year's change attempts. Journal ofSubstance Abuse, I, 127-134.Ockene, J., Ockene, I., & Kristellar, J. (1988). The coronary arterysmoking intervention study. Worcester, MA: National Heart LungBlood Institute.O'Connell, D. (1989). An observational coding scheme for therapists'processes of change. Unpublished doctoral dissertation, University ofRhode Island, Kingston.

Orford, J. (1985). Excessive app etites: A psychological view of addictions.New York: Wiley.Orleans, C. T , Schoenback, V. J., Salmon, M . A., Wagner, E. A., Pearson,D . C , Fiedler, J., Quade, D ., Porter, C. Q., & Kaplan, B . A. (1988 ,November). Effectiveness of self-help quit smoking strategies. In T.Glynn (Chair), Four National Cancer Institute-funded self-help smok-ing cessation trials: Interim results and em erging patterns. Symposiumpresented at the annual meeting of the Association for the Advance-ment of Behavior Therapy, New York.Pallonen, U. E., Fava, J. L., Salonen, J. T, & Prochaska, J. O. (in press).Readiness for smoking change among middle-aged Finnish m en: Th eKUOPIO CVD risk factor trial. Addictive Behaviors.Prochaska, J. O. (1979). Systems of psychotherapy: A transtheoreticalanalysis. Homewood, IL: Dorsey Press.Prochaska, J. O. (1991). Prescribing to the stages and levels of change.Psychotherapy, 28, 463-468.Prochaska, J. O, & Costa, A. (1989). A cross-sectional comparision ofstages of change for pre-therapy and within-therapy clients. Unpub-lished manuscript, University of Rhode Island, Kingston.Prochaska, J. Q , & DiClemente, C . C. (1982). Transtheoretical therapy:Toward a more integrative model of change. Psychotherapy: Theory,Research and Practice, 20, 161-173.Prochaska, J. Q , & DiClem ente, C. C. (1983). Stages and processes ofself-change in smoking: Toward an integrative model of change. Journalof Consulting and Clinical Psychology, 5, 390-395 .Prochaska, J. Q , & DiClem ente, C. C. (1984). The transtheoretical ap-proach: Crossing traditional boundaries of change. Homewood, IL:Dorsey Press.Prochaska, J. O, & DiClemente, C. C. (1985). Common processes ofchange in smoking, weight control, and psychological distress. In S.Shiftman & T. Wills (Eds.), Coping and substance abuse (pp . 345-363). San Diego, CA: Academic Press.Prochaska, J. Q , & DiC lemente, C. C. (1986). Toward a comprehensivemodel of change. In W. R. Miller & N. Heather (Eds.), Treating ad-dictive behaviors: Processes of change (pp. 3-27). New \brk: PlenumPress.Prochaska, J. Q , & DiClem ente, C. C. (1992). Stages of change in themodification of problem behaviors. In M. Hersen, R. M. Eisler, & P.M. Miller (Eds.), Progress in behavior modification (pp. 184-214).Sycamore, IL: Sycamore Press.Prochaska, J. Q , DiC lemente, C. C , Velicer, W. F., Ginpil, S., & Norcross,J. C. (1985). Predicting change in smoking status for self-changers.

Addictive Behaviors, 10, 395-406.Procha ska, J. Q , D iClem ente, C. C , V elicer, W. F., Rossi, J. S., & Guad-agnoli, E. (1992). Patterns of change in smoking cessation: Betweenvariable comparisons. Manuscript submitted for publication.Prochaska, J. O , & N orcross, J. C. (1983). Psychotherapists' perspectiveson treating themselves and their clients for psychic distress. ProfessionalPsychology: Research and Practice, 14, 642-655 .Procha ska, J. O., Norcross, J. C , Fowler, J. L., Follick, M. J., & Abram s,D. B. (1992). Attendance and outcome in a work-site weight controlprogram: Processes and stages of change as process and predictorvariables. Addictive Behaviors, 17, 3 5 - 4 5 .Procha ska, J. O , Velicer, W. F., DiC leme nte, C . C , & Fava, J. S. (1988).Measuring processes of change: Applications to the cessation ofsmoking. Journal of Consulting and C linical Psychology, 56, 5 2 0 -528.Rice, L. N., & Greenberg, L. (Eds.). (1984). Patterns of change. NewYork: Guilford Press.Roizen, R., Cahaland, D., & Shanks, R. (1978). Spontaneous remissionamong untreated problem drinkers. In D. Randell (Ed.), Longitudinalresearch on drug use: Empirical findings and methodological issues.Washington, DC: Hemisphere.Schachter, S. (1982). Recidivism and self-cure of smoking and obesity.American Psychologist, 37, 436-444.Schm id, T. L., Jeffrey, R. W , & Hellerstedt, W. L. (1989). Direct mailrecruitm ent to hom e-based smoking and weight control programs: Acomparison of strengths. Preventive Medicine, 18, 503-517 .Shap iro, S., Skinner, E., Kessler, L., Van Korff, M., G erma n, P., Tischler,G., Leon, P., Bendh am, L., Cottier, L., & Regier, D. (1984). Utilizationof health and mental health services. Archives of G eneral Psychiatry,41, 971-978.



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Documents

Prochaska J. O., DiClemente C. C. and Norcross, J. C. (1992), In Search of How People Change