Journal of Psychotherapy Integration, Vol. 9, No.

1,1999

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

James O. Prochaska1 and Janice M. Prochaska2,3

People don't change because they can't, don't want to, don't know how, or don't know what to change. The transtheoretical model provides an integrative model for understanding reasons for not changing, as well as readiness to change. Stages and levels of change guide therapists in their work in helping clients change. Clients in the precontemplative stage typically cannot change without special help. Those in the contemplation stage are not sure they want to change. Those in the preparation stage are afraid they do not know how to successfully change. The levels of change help guide therapists and clients on what to change.
KEY WORDS: transtheoretical model; resistance to change; noncompliance.

INTRODUCTION As a 10 year-old, Jim explored an atlas and discovered that South America could fit against Africa like two pieces of a puzzle. Similarly, North America could fit against Europe as if they were once united. He thought that the continents must have moved apart at some time in the past. But that didn't make sense; continents don't move. If there is anything stable in this world, it is massive continents that provide humans with a firm foundation. The complementary shapes of continents must have been just a strange coincidence, Jim concluded. It wasn't until he took a geology course in college that he learned about the phenomena of continental drift. So continents can move, often imperceptibly, sometimes disruptively.
Psychology Department and Director of the Cancer Prevention Research Center, University of Rhode Island, Kingston, Rhode Island. 2 Pro-Change Behavior Systems, W. Kingston, Rhode Island. 3 Correspondence should be directed to Janice M. Prochaska, Pro-Change Behavior Systems, P. O. Box 755, W. Kingston, Rhode Island 02892.
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Just as we seldom see continents move, so too do we seldom observe people changing. Change is a process that occurs over an extended period of time, often imperceptibly, sometimes disruptively. People can be changing even when they appear to be standing still. Others can appear to be moving even when they are running in place. WHY DON'T PEOPLE CHANGE? (a) They can't. (b) They don't want to. (c) They don't know how to. (d) They don't know what to change. (e) All of the above. Let us examine each of these alternatives to better understand why people don't change. Can't Change Under what conditions are people unable to change? We cannot change those conditions of ourselves that cannot be brought under voluntary control. We cannot intentionally change the aspects of ourselves that are fixed, closed, and are determined entirely by forces outside of our control. Our genetic makeup, our time in history, our biochemistry, and the social status of our families of origin are givens that were determined for us not by us. They are relatively static variables that are not usually open to intentional change. Changes that we are referring to are intentional changes in which individuals apply psychological processes to improve their own psychological functioning, including overt behaviors, covert experiences, and broader patterns of personality. We can prevent pedophiliacs from abusing children by imprisoning them and converting them into convicts. But such change is necessarily coercive and not volitional. It involves the rise of legal or political processes to modify behavior. People also cannot change aspects of themselves that are not conscious. Alcoholism is commonly called a disease of denial since many troubled drinkers are not aware that alcohol is damaging or destroying their lives. People cannot change if they believe they cannot change. As an old saying goes, "If you believe you can't change, you're right!" People can become demoralized about their abilities to change and can conclude that they don't have the willpower or inner strength to change. Why don't more physicians try to help their patients change healthrelated behaviors like smoking, which put them at high risk for death and disease? Orleans and her colleagues (1985) found that the number one barrier to a physician's practicing preventive medicine is that 65% of physi-

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cians believe that people can't change. These beliefs continue in spite of the frequent finding that even brief interventions by physicians can double the number of patients who quit smoking (Kotte, Battista, DeFriese, & Brekke, 1988). If people believe that their particular problem behaviors are under biological control, they may conclude that they cannot control such behaviors. Believing that alcoholism is due to one's genetic makeup, obesity is due to one's fat cells, smoking is due to nicotine addiction, depression is due to one's neurochemistry, can lead to people concluding that their own behavior is not under their control. To the extent that some problems, such as schizophrenia, may be primarily genetic and/or biochemical in origin, then people are not going to be able to overcome their problems just by applying psychological processes. Just as people can place or displace the entire responsibility for their behavior onto internal biological processes, so too can people project all of the controls onto external forces, such as family, society, or destiny. If people believe that their particular problems are under social control, then they may conclude that they are not powerful enough to control social forces that are causing their problems. To the extent that some problems, such as poverty, may be primarily social in origin, then people are not going to be able to overcome their problems just by applying psychological processes. One of the intriguing issues for the field of psychopathology and psychotherapy is the relative strengths of biological controls, social controls, and self-controls. While this issue is beyond the scope of this paper, we believe that people cannot change as long as they believe that self-control is too weak to change psychological phenomenon that are partially under the control of biology or society. Don't Want to Change Even if people believe in their power to change, there are conditions under which they may not want to change. People do not want to change when they perceive the benefits of problem behaviors as outweighing the cons of those behaviors. Similarly, people usually do not want to change when the benefits of changing only equal the costs of changing. We hear people saying, "I know my behavior may kill me someday, but I really enjoy my habit and it helps me deal with stress." People are less likely to want to change when they would have to trade immediate benefits, like pleasure and reduction of stress, in order to reduce the risks of longterm consequences, like death and disease. We can understand people not

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wanting to make these changes from a psychoanalytic perspective, which views the pleasure principle as primary to and more powerful than the reality principle. We can also understand this condition from a behavioral perspective in which immediate consequences have much more control over behavior than do delayed consequences (Prochaska & Norcross, 1998). Individuals are also likely to not want to change when they perceive other people as trying to pressure them or coerce them into changing. The desire to be in control of ourselves and our environment can cause us to resist changes that might otherwise be to our advantage Even wild mice seem to have motivation to be in control. Calhoun (1975) brought Norwegian mice from the wild but open environment into controlled laboratory conditions. When allowed to control their environment, the mice would consistently switch on a dim light in preference to a bright light or no light. When the experimenter turned on the dim light, however, the mice would switch on one of the other lights. Similarly, when the mice were able to switch on a revolving wheel, they would do so and run for hours, apparently to stay active and healthy. When the experimenter switched on the revolving wheel, however, the mice would switch it off. The wild mice seemed intent on being in control even when forced to live in the dark or live passive and unhealthy lives. Husbands who are forced into therapy by their wives, adolescents who are brought to therapy by their parents, and offenders who are sent to therapy by judges may not want to change even if remaining in control is self-defeating.

Don't Know How to Change People may want to change but they may not know how to change. Even with the best therapies available, the majority of alcoholics, drug addicts, obese individuals and smokers will return to their addictions within a year or two after treatment (Hunt & Matarazzo, 1973). Many obsessives have tried to overcome their compulsive rituals but they, too, tend to relapse back to old patterns. Many people enter therapy believing they can change and that's why they are there. They want to change and that's why they are there. But they don't know how to change and that's why they are there. A 52-yearold man returned to therapy because of a recent onset of impotency. He knew he could change. With the help of therapy and Alcoholics Anonymous he was celebrating nine years of sobriety. He certainly wanted to change. His sexuality and his love relationships were essential aspects of his sense of self. But as smart as he was and as successful as he had been with his alcoholism, he just could not find the solution to control his erections.

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This strong-willed individual was frustrated to find that the willpower he had used to control his drinking was not successful with sex. If anything, trying to will an erection was only making matters worse. He felt impotent, lacking the power to change. He was pleased to discover that he was just lacking knowledge about how to overcome this particular problem. Within a week he was functioning fine. Unfortunately, all too many people enter therapy believing that therapists have the knowledge to help them change chronic problems quickly. Acute problems, like this fellow's recent onset of impotence, can be reversed quickly. But, as we shall see, chronic problems take much longer to change. On the average, clients remain in therapy for a median of three sessions. As a result, they don't give therapy or therapists much chance to help them change. If people don't know how to change, including how long it takes to change, then they are not likely to recover from chronic behavioral problems. Don't Know What to Change Many individuals enter therapy not knowing what to change. They are confused about the causes and cures of their problems. Alcohol-troubled people, for example, can be confused about the causes and controls of their dysfunctional drinking, and may not know what to change in order to recover from alcohol abuse. If they consult a behavior therapist, they may be encouraged to analyze the immediate antecedents and consequences of their problem drinking. These situational stimuli are seen as the key causes or controls of behavior and will need to be changed if problem drinking is to be modified. Cognitive therapists, on the other hand, would encourage these same clients to analyze key cognitions or beliefs related to their drinking. For cognitive therapists, it is not the events preceding or following drinking that are critical but how people process or think about these events. Consulting an interpersonal therapist will lead clients to think about their interpersonal patterns and conflicts that are assumed to be the basis of most psychopathology. Most emotional, behavioral, and personality disorders are believed to be the result of unresolved interpersonal conflicts, such as communication and control conflicts. A 33-year-old author was driven to therapy by his wife who was preoccupied with his dysfunctional drinking. He was extremely sensitive to being controlled by others, especially women. Could he gain lasting control over his alcoholism without resolving his chronic conflicts over being controlled? Family therapists who focus on famines of origin would encourage clients to understand their early family rules and relationships more than

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their current interpersonal patterns. Adult children of alcoholics, for example, can become alcoholics themselves with little awareness of how their current problems are ruled by unresolved conflicts with their families of origin. Psychoanalytic and psychodynamic therapists would help clients analyze intrapersonal conflicts that can be the basis of symptoms like dysfunctional drinking. Conflicts over unresolved oral dependency needs can be acted out through bouts with the bottle. Or an inadequate sense of self can lead to an inadequate lifestyle driven by drinking rather than ego needs, such as mastery and competency. No wonder many people can be confused about what to change, if five different types of therapists would attribute their problems to five different causes. And we haven't even discussed biologically or spiritually oriented therapists or other orientations from the more than 400 therapies that currently exist (Prochaska & Norcross, 1998). If professional therapists cannot agree on what needs to he changed in order to help people overcome problems like alcohol abuse, then how can we expect lay people to know what to change? A TRANSTHEORETICAL INTEGRATION OF WHY PEOPLE DON'T CHANGE Thus far, we have analyzed a rather eclectic set of reasons why people don't change, ranging from not being able to, not wanting to, not knowing how to, and not knowing what to change. We believe we can develop a more systematic understanding of why people don't change, by examining an integrative model of how people do change. The transtheoretical model has emerged from research on how people change on their own, as well as how they change with the help of therapy (Prochaska & DiClemente, 1983, 1984, 1986a,b; Prochaska & Norcross, 1983; Norcross & Prochaska, 1986; Norcross, Prochaska, & DiClemente, 1986). This model has been applied to understanding how people change health-related behaviors, such as alcohol abuse, obesity, smoking, and risky sexual behaviors (DiClemente & Hughes, 1990; Prochaska, Rossi, & Velicer, 1990; Prochaska & DiClemente, 1982; Prochaska, DiClemente, Velicer, Ginpil, & Norcross, 1985; Prochaska et al., 1994). It has also been based on research on how people change mental health problems, such as anxiety, depression, alcohol abuse, and a broad range of Diagnostic Statistical Manual (4th ed.) disorders (Prochaska & Norcross, 1983; McConnaughy, Prochaska, & Velicer, 1989; McConnaughy, DiClemente, Prochaska, & Velicer, 1989; Norcross & Prochaska, 1986; Norcross, Prochaska & DiClemente,

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1986; Prochaska, Rossi, & Wilcox, 1991; Beitman, Beck, Carter, Davidson, & Maddock, 1994). Our first discovery was that people change by progressing through a series of stages. The stages we have identified are Precontemplation, Contemplation, Preparation, Action, and Maintenance (Prochaska & DiClemente, 1983; DiClemente, Prochaska, Velicer, Fairhurst, Rossi, & Velasquez, 1991). Precontemplation Stage Precontemplation is a stage in which people are not intending to change their behavior in the foreseeable future. People can be in the precontemplation stage because they are unaware that their behaviors are problems. A lack of awareness can be due to ignorance: they don't know that smoking can kill them, that their diets can destroy them, or that their sexual behaviors may infect them with deadly diseases. People can also be unaware that they have problems because of defensiveness. We have already discussed alcoholism as a disease of denial in which people can defend their drinking even though it is damaging or destroying their lives. Paranoid and psychopathic personalities often perceive others as needing to be changed, but not themselves. On the Stages of Change Questionnaire, precontemplators entering therapy are likely to agree with an item like "I'm not the one with problems and don't really need to be here." Precontemplators can also be demoralized about their abilities to change. They may have truly tried to change but failed. They don't believe they can change so they don't even want to think about it. It is clear that many people in the precontemplation stage cannot change. At least they cannot change without outside help. Ignorance, defensiveness, and demoralization are major barriers to being able to change. Some of these barriers can be particularly self-defeating because they can make precontemplators resistant to outside help that can facilitate change. Precontemplators often present for therapy because they are pressured by spouses, parents, employees, schools, or courts. Needless to say, they are at high risk for dropping out (Brogan, Prochaska, & Prochaska, 1999), even though they may need therapy more than people in any other stage of change. We tried to predict who would terminate therapy prematurely. Using the best predictors in the therapy outcome literature, such as the nature, severity, and intensity of the problem, socioeconomic status, age, and gender, we were unable to predict who would terminate prematurely. Using

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stage-related measures, we were able to correctly predict 93% of the therapy dropouts. The premature terminators clearly had stage profiles of precontemplators (Brogan et al., 1999). As therapists, we cannot help people change, if we do not enable them to be in therapy. Not only are many precontemplators not able to change, most do not want to change. As a group, they evaluate the pros of their problem behaviors as clearly outweighing the cons. For example, while most people in our society tend to judge the hazards of smoking as clearly outweighing the benefits, smokers in the precontemplation stage report the opposite pattern (Velicer, DiClemente, Prochaska, & Brandenburg, 1985). They judge the benefits as clearly outweighing the cons. Their imbalance could also emerge in pare from demoralization with cognitive dissonance, leading people to value behaviors they are stuck with. Finally, the imbalance could derive from defensiveness, with people rationalizing behavior that places them at greatly increased risk for disease and death. On the other hand, there are some well-informed precontemplators who believe they could change but do not want to because in their rational judgement the benefits of their behavior clearly outweigh the costs (Prochaska, Norcross, & DiClemente, 1994).

Contemplation Stage Contemplation is a stage in which people are intending to change problems in the foreseeable future, usually within six months. They have significantly higher self-efficacy or confidence than precontemplators that they can change (DiClemente et al., 1991). While contemplators are intending to change and are confident they can change, many do not change. For example, a sample of 800 smokers who were in the contemplation stage indicated that they were seriously intending to quit smoking in the next six months. Yet, following participation in a state-of-the-art, self-help program, the majority did not even try to quit for one day (Prochaska, DiClemente, Velicer, & Rossi, 1990). Why don't contemplators change? As a group, contemplators evaluate the pros of their problem as just about equal to the cons. So, while they are aware of, or admit more to the negatives of their behavior than do precontemplators, contemplators are very ambivalent about changing. They doubt that the benefits of changing will clearly outweigh the costs. And, the rule of thumb for the contemplation stage is when in doubt, don't change. Given the intense ambivalence that can characterize contemplation, people in this stage often end up not wanting to change. At least they don't want to change enough to risk taking action and to risk giving up the

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

Preparation Stage Preparation is a stage in which people are intending to take action in the near future, usually within a month. As the name of the stage indicates, they see themselves as more prepared for action. They are more confident than contemplators that they can control their problem behavior. The pros of changing clearly outweigh the cons. They have a concrete plan to change and may be taking small steps to reduce their problem behaviors (DiClemente et al., 1991). And, in the next six months, the large majority of people in the preparation stage will take action to change. But, as with many problems, the vast majority of people who take action will fail. They will either quickly or eventually relapse back to their old patterns. Many of these people do not know how to change. In our research on how people change, we have discovered that one of the secrets of success is that people must use appropriate processes of change to progress through particular stages of change. To progress from precontemplation to contemplation involves the application of affective and cognitive processes, like dramatic relief and consciousness raising (DiClemente et al., 1991; Prochaska & DiClemente, 1983). Movement from contemplation to preparation involves the use of cognitive and evaluative processes like consciousness raising and self-reevaluation. Action Stage To progress to the action stage, people must apply more existential processes like self-liberation, more humanistic processes like helping relationships, and more behavioral processes like counterconditioning, stimulus control, and reinforcement management (Prochaska & DiClemente, 1983). In the action stage, people use these processes to overtly modify their problem behavior to at least some minimum criterion of success. The action stage is the busiest time involving the greatest use of particular processes of change. The action stage lasts longer than most people expect, usually about six months of concentrated effort before risks for relapse are greatly reduced. If people move from preparation to action and continue to rely on processes like consciousness raising and self-reevaluation, they are much

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more likely to fail. They are not matching the appropriate processes of change to the stage they are in. These people do not know how to change. Therapists who do not match appropriate processes to the client's stage of change do not know how to help people change. Behavior therapists, for example, who apply counterconditioning and stimulus control with precontemplators or contemplators are likely to generate resistance rather than progress. Similarly, psychodynamic therapists who want to continue to increase consciousness with clients who are prepared for action are likely to increase resistance to therapy. Table I summarizes the relationships that our research has found between the stages people are in and the processes of change they apply to progress to the next stage (DiClemente et al., 1991; Prochaska & DiClemente, 1983; Prochaska & DiClemente, 1984). Not only must people apply appropriate processes of change, they must apply them frequently enough and for long enough duration if they are to succeed. Too often we hear people saying they went to therapy and it didn't do them any good. But how frequently did they go to therapy? Research on dose-response relationships indicate that most people who stay for less than six sessions of therapy do not receive enough of a dose to have an effect (Howard, Kopta, Krause, & Orlinksy, 1986). People who stay in therapy for less than six months are not likely to receive the full benefit of therapy. We say to precontemplators who are at risk of dropping out of therapy before it begins, "Give us six sessions and we can make a significant difference; give us six months and we can make a substantial difference." By significant difference we mean we can help them progress at least one stage in six sessions. Our research on smokers indicates that people who progress one stage in one month are twice as likely to be not smoking at six months. With six months of therapy we usually can help people to be more effective action with greatly reduced risks of relapse. Increasingly more informed consumers want to know what procedures
Table I. Stages by Processes of Change
Stages of Change Precontemplation Processes Contemplation Preparation Action Maintenance

Consciousness-raising Dramatic relief Environmental reevaluation Self-reevaluation Self-Liberation Contingency management Helping relationship Counterconditioning Stimulus control

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we will apply with their particular problems. In some treatment programs potential participants will say that they have already tried what the therapists had to offer and it didn't work. Therapists can become demoralized about their abilities to help such people change. They can conclude that they need to refer such clients to a different type of therapy. That may be correct in some cases. But if a patient with major depression reported having tried and failed with antidepressants, that doesn't mean we would rule out the use of such medications. We would need to assess the amount, duration, and type of antidepressant used. If a patient used the medication for only a week and we know it takes at least 10 days to get an effect, we would conclude that the medication had not been given a fair trial. If a patient used only 50 mg a day and we knew 150 mg was an optimal average dose, we would conclude that the medication had not been given a fair trial. But how frequently and how long do people need to apply consciousness-raising and self-reevaluation processes before they are adequately prepared for action? How frequently and how long did they need to rely on self-liberation, helping relationships, and counterconditioning before they are relatively free from risks of relapse? Unfortunately, with most problems, we have little or no data on how much processes must be used in order to progress. The fact is, as scientists and as practitioners we know all too little about how to help people change. With smoking cessation we have gathered much more data about how frequently people apply particular processes of change to progress from one stage to the next. We are able to use computers to generate individual progress reports to give people feedback about which processes of change they are underutilizing, which processes they are overutilizing, and which processes they are applying appropriately. After 18 months of follow-up we are finding that such feedback is continuing to nearly triple the outcomes of the best self-help programs previously available (Prochaska et al., 1993). Without adequate data and without systematic feedback, many people are forced to rely on trial and error learning to discover how to change. We believe this is a major reason why relapse is the rule rather than the exception when it comes to changing chronic problems and patterns. We reframe relapse as an excellent opportunity to learn rather than being a reason to fail. In fact, people who take action and fail are twice as likely to succeed over the next six months than those who don't take action during the first month of intervention (Prochaska et al., 1993). The average person who eventually succeeds in getting free from smoking takes 3-4 serious action attempts distributed over 7-10 years before they make it to longterm maintenance.

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Maintenance Stage

Maintenance is the stage in which people are working to consolidate the gains they made during action in order to be free from risks for relapse. In the transtheoretical model, maintenance begins after six months of concerted action. Maintenance used to be thought of as a stable stage in which people do not have to work at changing. We now know that people continue to apply particular processes of change, such as counterconditioning and stimulus control to keep from relapsing (Prochaska & DiClemente, 1983). How long does maintenance last? For some problems, like obesity, it may be a lifetime. For other problems like alcoholism, smoking, and certain anxiety and mood disorders, people may be able to entirely terminate their problems and not have to do anything to prevent relapse. The criteria we use for termination is that people attain maximum self-efficacy or confidence and minimum temptation to engage in their problem behavior across all previously risky situations. Many smokers get to the point where they experience no desire to smoke, are fully confident that they will never smoke again, and report having to do nothing to keep from smoking. How long does it take to complete the maintenance stage? We used to think that for a smoker, 12 months of continuous abstinence meant they were home free. We now know that even after a year of never smoking, 37% of the people will relapse back to regular smoking over the course of their lifetimes. After five years of continuous abstinence the risks for relapse finally drop to 7% (U.S. Department of Health and Human Services, 1990). So, maintenance lasts for six months to 5 years after action is taken.
Integrating Stages and Reasons for Not Changing

To integrate the most common reasons why people don't change, we can use the stage model. Table II illustrates the most common reasons why people at different stages are most likely not to change. Precontemplators as a group cannot change and most also do not want to change. ContemplaTable II. Stage X Reasons Why People Don't Change Precontemplation -> Can't change Don't want to change Don't know how to change Don't know what to change Contemplation -> Preparation -> Action -> Maintenance ->

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

What To Change Depends on the Levels of Change The field of psychotherapy cannot agree on what to change in order to help people overcome their problems. As discussed earlier, causal attributions of clients and therapists about a single problem, like alcoholism, can range from immediate situations to maladaptive cognitions to current interpersonal conflicts to past families of origin issues to intrapersonal dynamics. Are clients left with a potpourri of causal attributions that can vary arbitrarily depending on the particular therapist they consult? Or can we integrate these alternative attributions into a framework that provides more systematic strategies for deciding what to change in order to alter the troubled parts of life? The transtheoretical model uses the levels of change as the dimension for organizing the content of therapy; that is, what we are trying to change in order to resolve problems. The stage dimension represents when particular types of changes can be accomplished. The processes dimension represents how particular changes can be accomplished. And the levels dimension represents which particular type of changes need to be accomplished. The levels dimension organizes the psychological causes and controls of problem behaviors on a hierarchy that ranges from most to least available to consciousness and from most to least contemporary in origin. The following five levels have received the most clinical and empirical support to date (Norcross, Prochaska, Guadagnoli, & DiClemente, 1989; Norcross, Prochaska, & Hambrecht, 1985): 1. 2. 3. 4. 5. Symptom/Situational Level. Maladaptive Cognitions. Interpersonal Conflicts. Family of Origin Conflicts. Intrapersonal Conflicts.

What is the key level of content for psychotherapy? The answer obviously depends on the therapist's preferred theory of personality and psychopathology and/or the client's implicit theory of problems. As an eclectic perspective, the transtheoretical approach appreciates the validity of each level of problems. How critical each level is can vary for different clients even when they are presenting the same type of problem (Prochaska & DiClemente, 1984).

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While therapists of different theoretical persuasions can present a case for attributing problems to at least five different levels, is it not the case that clients attribute problems to only one or two levels of causality? Research based on attribution theory, for example, suggest that the naive psychology of the public attributes behavior to either situational or dispositional causes (Jones & Nisbett, 1972). Similarly, locus of control research reports people attributing both functional and dysfunctional behavior to variables under either external or internal locus of control (Rotter, 1970). The problem is that attribution research and locus of control research limit their research to only two levels. These theories artificially dichotomize the causal world of clients. The fact is that people perceive their problems in much more complex and confusing ways than suggested by most theories of behavior, including theories of troubled behavior. In research with college students suffering from problems like depression, anxiety, and academic difficulties, we found that students did indeed attribute problems to the five levels emphasized in the transtheoretical model. In fact, the students discriminated not 5 but 10 different causes of personal problems. The students also discriminated between spiritual determinism, bad luck, biological deficiencies, chosen lifestyle, and insufficient effort as causes of personal problems. Table III lists the 10 levels that accounted for 67% of the variance of the Levels of Change Questionnaire. Two of the categories, spiritual determinism and bad luck, were used by only a small minority of the sample (Norcross et al., 1985). Similarly, clinical research suggests that only about 5% of clients construe their problems as primarily due to religious or spiritual causes (Bergin, 1983). Furthermore, people who experience their problems as spiritual in origin are much more likely to go to religious healers for help. On the other hand, people who attribute their problems to biological reasons are likely to seek help from an internist or health specialist rather than a psychotherapist. Where someone

Table III. The 10 Levels of Change and Reliability Coefficient Level Alpha Symptom and situational difficulties Maladaptive cognitions Interpersonal conflicts Family/systems conflicts Interpersonal conflicts Spiritual determinism Biological deficiencies Bad luck Chosen lifestyle Insufficient effort

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

.87 .89 .89 .91 .88 .92 .89 .87 .79 .87

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turns to change bad luck is an open question, though some fatalists seek guidance from astrologers or fortune-tellers. People who attribute their problems primarily to insufficient effort are likely to try harder and may succeed as self-changers before they seek a therapist. Those who perceive problems as a consequence of their chosen lifestyles are likely to cope with such stresses by accepting them as the problems that are inherent in a particular lifestyle. On the other hand, there are enough clients whose problems are that they want to go on living that way they have been living but want the consequences to different. Workaholics often want to go on working 70 or 80 hours a week without having their marriages or families being distressed. Clients like these tend to be seeking magic rather than therapeutic change, and this can be a reason they don't change. Most clients and most therapists are prepared to work at one or more of the five levels emphasized in the transtheoretical approach. This is not to say that people do not have genuine problems at the spiritual, biological, or luck levels of existence, but rather that psychotherapists would not be particularly well prepared to help them at these levels. Our professional responsibility and our ability to help people change tend to be limited to the psychological levels of change. Beyond that, we would refer clients to other professionals or helpers better prepared for problems at nonpsychological levels. From a levels perspective, then, people don't change if they don't know what to change. This includes having no idea what to change and having the wrong idea what to change, if people misattribute problems to incorrect causes they are not likely to change. Hypochondriacal clients who insist on attributing their symptoms to undiagnosed biological origins in the face of feedback from medical specialists that their problems are psychological in origin can be very resistant to psychotherapeutic interventions and are not likely to change. They are likely to go on seeking assessments from different medical specialists because they are convinced that they suffer from physical rather than psychological problems. People who misattribute problems at one level to causes at a different level are also not likely to change. People don't change interpersonally based problems by changing their immediate situations. Travel therapy is a common example of misattributing one's problems to immediate situations, moving to a new environment only to discover that one's problems were packed inside one's self. Conversely, people don't change if they spend years contemplating early childhood causes of problems that are controlled by more contemporary cognitions or situations. Masters and Johnson (1970) demonstrated how many sexual dysfunctions that were once attributed to distant unconscious

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intrapersonal conflicts could be readily reversed by modifying more immediate sexual situations and cognitions. People don't change in therapy very well if their attributions don't match their therapists' attributions or vise versa. If clients are convinced that their problems are interpersonal in origin and their therapists are trying to change intrapersonal conflicts, then resistance is likely to be the result. Similarly, if therapists are trying to solve situational problems that clients are convinced are rooted in unresolved family of origin issues, then resistance is likely to result. It is like the woman who told her student therapist that trying to solve her obsession with desensitization was like trying to cure cancer with an aspirin. In the face of a lack of consensus about the causes of most common clinical conditions, how can therapists proceed most systematically and effectively? There are three strategies that are used most often in the transtheoretical approach (Prochaska & DiClemente, 1984). The first is the key level strategy. In this strategy clinical assessments are used to determine if there is a key level that is causing or controlling the client's particular problems. If the available clinical evidence points to the problem as interpersonal in origin, the therapeutic efforts are likely to be more effective when focused on resolving interpersonal conflicts. The key level strategy can proceed most smoothly if the client concurs or can be convinced that the problems are indeed interpersonal in origin. All too often, the clinical data are complex and confusing, and no one key level emerges as the cause of a particular condition. The second alternative is the shifting level strategy. In this strategy we intervene at the highest level that the clinical data can justify, such as the symptom/situational or the cognitive levels. We prefer to intervene at these higher levels because change tends to occur more quickly at these more conscious and contemporary levels. The further down the hierarchy we focus, the further removed from awareness are the determinants of the problem likely to be. The less awareness there is about what needs to be changed, the earlier the stage the person will be in. People can be prepared to take action at the symptom and situational level, for example, while having no intentions to change their relationships to their families of origin. We predict from the transtheoretical model that the deeper the level that needs to be changed, the longer and more complex therapy is likely to be. Given that average clients give us all too little time to make an impact, we are better off to begin at the levels that are most easily changed. If the problem can be resolved at the highest levels, then therapy can be terminated most efficiently and can best match most clients' preference for briefer therapies. Unfortunately, all too many problems cannot be resolved just by focus-

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ing on situational or cognitive variables. If insufficient progress is made at these levels, then an alternative is to shift to the next deeper level, such as the interpersonal level. Therapy can proceed more systematically shifting from one level to the next until enough change has been accomplished. The third alternative is the maximum impact strategy, which is used with problems that are clearly caused or controlled by variables at multiple levels of change. With multilevel problems, change processes are applied in a manner designed to facilitate progress at each relevant level of change. Consciousness-raising, for example, can be used to help clients become more aware of the immediate antecedents and consequences of their problem behaviors; the cognitions used to process these antecedents and consequences; the interpersonal conflicts that are part of the problem; the family of origin issues that originally produced the problem, and the intrapersonal dynamics that may have caused the problem to become integrated as a pare of one's identity or sense of self. The maximum impact strategy has the potential to help clients process change at each level of their existence. By being aware of change occurring at each level, they can develop a deeper sense of themselves and the complexities of their problems. By making changes at each level, they are less likely to relapse when faced with disturbing situations, distressing cognitions, interpersonal conflicts, dysfunctional family patterns, or the deeper dynamics of themselves. We need to remember, however, that the further removed from consciousness and the further back in time are the determinants of a problem, the greater resistance there will be to trying to change those determinants. One of the reasons for greater resistance is that deeper attributions tend to be more threatening to self-esteem than are higher level attributions. It is more threatening, for example, to believe that sexual dysfunctions are due to hostility toward one's spouse or one's parents than to believe that sexual situations elicit performance anxiety. One of the rules of the transtheoretical approach is to use the least threatening attributions that can be justified, since our clinical formulations have the potential for producing resistance as well as the power to facilitate change.

PEOPLE CAN CHANGE Let us conclude with some of the conditions under which people can change. People can change: 1. When they progress one stage at a time rather than before they are prepared.

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2. When they apply processes that are appropriate to their current stage of conditions under which trying to leap to action change. 3. When they are in a therapy that matches their stage of change rather than trying to match the therapy's preferred stage of change. 4. When they learn from their relapses rather than becoming demoralized. 5. When they understand the complexities of change rather than reducing it all to one process, such as consciousness-raising, counterconditioning, willpower, or a therapeutic relationship. 6. When they work at the highest levels that are appropriate to their problems. 7. When they shift to deeper levels when further progress is needed. 8. When they understand their inability to change as often due to misattribution to levels of change that are not appropriate to their problem. 9. When they understand resistance to change is often due to mismatches between the clients' and therapists' stages and/or levels of change. 10. When they have better roadmaps and models to help guide them through the stages and levels of change.

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