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In Search
of
How People Change
Applications to Addictive Behaviors
James
O.
Prochaska
Carlo
C.
DiClemente
John
C.
Norcross
Cancer Prevention Research Consortium,
University of Rhode Island
University of Houston
University ofScranton
How people intentionally change addictive behaviors with
and without treatment
is not
well
understood by behavioral
scientists. This article summarizes research
on
self-ini-
tiated
and
professionally facilitated change
of
addictive
behaviors using
the key
transtheoretical constructs
of
stages and processes of change. Modification of addictive
behaviors involves progression through five stages—pre-
contemplation, contemplation, preparation, action,
and
maintenance—and individuals typically recycle through
these stages several times before termination
of
the
ad-
diction. Multiple studies provide strong support for these
stages
as
well as
for a
finite
and
common
set
of change
processes used
to
progress through
the
stages. Research
to date supports
a
transtheoretical model
of
change that
systematically integrates
the
stages with processes
of
change from diverse theories of psychotherapy.
Hundreds
of
psychotherapy outcome studies have
dem-
onstrated that people successfully change with
the
help
of professional treatment (Lambert, Shapiro,
&
Bergin,
1986;
Smith, Glass, & Miller, 1980). These outcome stud-
ies have taught
us
relatively little, however, about
how
people change with psychotherapy (Rice
&
Greenberg,
1984).
Numerous studies also have demonstrated that
many people
can
modify problem behaviors without
the
benefit
of
formal psychotherapy (Marlatt, Baer, Donovan,
& Divlahan, 1988; Schachter, 1982; Shapiro
et al., 1984;
Veroff,
Douvan,
&
Kulka, 1981a, 1981b). These studies
have taught
us
relatively little, however, about how people
change
on
their
own.
Similar results
are
found
in the
literature
on
addic-
tive behaviors. Certain treatment methods consistently
demonstrate successful outcomes
for
alcoholism and other
addictive behaviors (Miller
&
Hester,
1980,
1986).
Self-
change has been documented
to
occur with alcohol abuse,
smoking, obesity,
and
opiate
use
(Cohen
et
al., 1989;
Or-
ford,
1985;
Roizen, Cahaland, & Shanks, 1978; Schachter,
1982;
Tuchfeld, 1981). Self-change of addictive behaviors
is often misnamed "spontaneous remission,"
but
such
change involves external influence
and
individual
com-
mitment (Orford, 1985; Tuchfeld, 1981). These studies
demonstrate that intentional modification
of
addictive
behaviors occurs both with
and
without expert assistance.
Moreover, these changes involve
a
process that is
not
well
understood.
Over
the
past
12
years,
our
research program
has
been 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
of
change that underlies both self-mediated
and
treatment-
facilitated modification
of
addictive
and
other problem
behaviors.
We
have concentrated
on the
phenomenon
of
intentional change as opposed
to
societal, developmental,
or imposed change.
Our
basic question
can be
framed
as
follows: Because successful change of complex addictions
can
be
demonstrated
in
both psychotherapy
and self-
change, are there basic, common principles that can reveal
the structure
of
change occurring with
and
without
psy-
chotherapy?
This article provides
a
comprehensive summary
of
the research
on the
basic constructs of a model that helps
us understand self-initiated
and
professionally assisted
changes
of
addictive behaviors.
The key
transtheoretical
concepts
of the
stages
and
processes
of
change
are ex-
amined,
and
their applications
to a
variety
of
addictive
behaviors
and
populations
are
reviewed. This transtheo-
retical model offers
an
integrative perspective
on the
structure
of
intentional change.
Stages
of
Change
One 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
clients
suffering from
an
addictive disorder improve: Some drop
out
of
treatment,
and
others relapse following brief
im-
provement (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 outcomes of the change
enterprise. Inadequate techniques, theory,
and
relationship
skills
on
the part of the therapist are intervention variables
frequently 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
and
CA50087 from
the
National Cancer Institute.
Correspondence concerning this article should
be
addressed
to
James
Q
Prochaska, Cancer Prevention Research Consortium, University
of Rhode Island, Kingston,
RI
02881.
1102September
1992 •
American Psychologist
Copyright
1992 by the
American Psychological Association,
Inc.
0OO3-066X/92/$2
00
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