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    Systems of Psychotherapy A Transtheoretical Analysis Ninth Edition James O. Prochaska University of Rhode Island John C. Norcross University of Scranton Prochaska, J.0., & Norcross, J.C. (2018) Comparative conclusions: Toward a transthoretical therapy. In Systems of psychotherapy: A transtheoretical framework, th Edition (pp. 414-440), New Youk, NY: Oxford University Press, Moustakas Johnson Library Mi School of Prof. Psychology 26811 Orchard Lake Rd. Farmington Hills, MI 48334 Reproduced with Permission ee aa ‘material may be protected by Copyright law (Title 17 U.S. Code) OXFORD cuavren 17 The tantoretcl model belas wth 2 com- partve analy of the major systems of ps Ghotherpy, ae realized in this book, That “Sompartiveanalis deal demonstrates how noch pychotherapy stems agree a the pro ‘ees prodicing change while disagreeing on the content that acest be chanB85ped. Wecl- icine fegueniy gree on how to change but ‘ot on what change a the Integrative opr, the tantheoreia model seks the bet that each system oer [he you tead-and as we wrte—the preceding ‘haps we recogeized hat each psychotherapy System cota rat nigh the Maran conden. ‘ach system provides a coherent and com poling constriction for understanding huran fantion and dysfunction, once we Sect Is core stumptons. Most of the systems are inspringand we hope encourage deeper explo fatlon ofthe theory and ts methods. APN the sjtemsto these complex ease of Mrs. indicates how dire and et coasncinghy fch can explain and teat the same toublt inv Al ofthe systems pride prctal au Insights that cn be wel within an nigratie del of therapy: sch puyhotherpy este alio mnie shortcomings, however Mos are more rational than empiial In construction. None conss- ‘ily demonstrate contig esearch spe For ability to pedi hove people resyond in pchotherapy or superior aby 0 hap peo- Pie change a4 real of pychotheragy Even then sve encountered the apparently superiog Cfestvenss of select therapies, we 020 ds avesed tt euch clans were empeed by the limestgeto allegiance fe. Many systems focus on theories of personaly and pschopa- ‘thology (hat o change) rates than process of change (ow to change). Aad wi te excep ton ofthe interne therapies, none of the poptotheapy stems syshesze the pound Insights and slab methods foe diverse therapies into a more comprehensive modal of the denna of choosing the pe af >sycho- therapist we night become orth NP of SF thoherapit we might comma. What Farther Comparative Conclusions structure can we provide fe such dives, ot agente sep? For starters, we mst rele at he way stricture and iterate psychotherapy cannot at this te depend entry on aceite research \Noslnge sytem of paychotherapy has cornered he market an ecienes Assen rougbout thlsbook research as revealed onifew robust Aliffrence in cuore aenorg the eased ‘mabsteam therapies “Met-aaljtc research how charity for all treatoents and malice ‘rats pone (Londen, 1888p. 7). Noe can & rely rational nalts ofthe theoretical morass protide a definkve answer At thls poi inthe Alevelopment of cinclknowedgs, the manner in which we intgate psjchotherapy stems Is lage imposition of our own ntelecaal and shal development. Tn this chape, we introduce two perspec te or understanding he intelecteal a teal development of an iterative theory. We {hen review the core dimensions of the tan theocetcal moddl—the process, sages, and levels of change and apply thom tothe ps tems of payhotherapy covered inthis book The teanstheoretical relationship the effecienes of ttanathcoretical therapy, and cine of are Mdzessed. Fly we feature a transtheoetial snl of Mis Cand eprt onthe outcome af he poychotherpy: Developmental Perspectives Perrys Mode Liven the plaraisic natre of knowlege, ded leated Individuals wil structure knowledge scoring to their cognitive development Let ot ply Wil Per’ (1970) model of nal {alan etal growth othe diese theories of pehotheepy. ‘Based on longtdinlrescrch on the itel- lecul and ethical development of undergrad ates, Perry (1970) devived a stage theory. He ‘dented nine sages each representing a qual Itiey erent mode of thinking sbout the aire of knowlege. As several of Perry stages te primal tanstlonh e wil derbe ony the four stages that represent the most omirast- ing teucures dha students pore on kn edge These four stages ofinlectal and tial ‘evelopment can be summarized elle Dole + Multpliie > Reaviaic > commited Dui Inthe dulisie stage, the world is sen in polar terms righting, th ero, good bd. Dual students are ky to expec hat In this chapter the authors as authori wll ‘evel which singe theory of thrpy Is one Dualit stents vew themselves a recep eleseagety ng orc the truth, Daas therpiss ble they have had the tah evel to thm, Dale ae the te balevers wh think that paula therapy 5 temisconel anal ters en ers Reseach ‘riences ofileinteret bse he toe ye ‘ofpychothepy i aendy sumed lo be KDW, ‘nd seach woud only document the abies ‘Dalit thera abe fund ay 8 tem of psychotherapy True elievngpoyehoan sipt,bensirints or humanist are thereat fot ofthe structure ofthe theories, ut ther ‘ofthe sactr ofther o intllet Matipis ‘As sens develop, they come to accept the @ersiy and upcertigy in an aren sch a5 prjchotherspy A fit he versity See 35 Tate confusion that comes rom poorly (qalifed sutheries “Psychotherapist dant “Epo wha the ell they deg” may beacon ‘om complain of thee tadent- Late, erty nt uncertain re seen a eptiate ba on 38 {emporsryin the development four kao “Tse lilt terpist hike that ame point in the fre patel theory of therapy fl be proved cree. Malpas ae the te Detiors who ae convinced tht investing thir cherie in one therapy wl py off nthe fae en ts eventually proven to be cote Relatives Stadents in the relativistic stage of etlee- ‘ual development view knowledge ae dicon- ‘ected frm the eonenp of tat and cariily. Diversgy and uncer are ot temporary: the very ature of knowledge is thai Is con testal and reative. The th about therpy fe that is pluraic, with «variety of val alternatives. Relist ae the ru eects (or Inveraonis). a6 ‘The val of psychotherapy systems is re ative to pra ues, Some eect ee the ov tery a5 reve to patents specific lores or synptons theywoeld elect the est {rennet for sy depresion or balimia. Other Therpissee the uty of therapy stems 0 eae tothe patent personaly, whereas ot tv acume that the Yale of any therapy sel {iewtbe traps perso: Other eaten se the treatment fcc sree tothe nes so tha they match heap 0 valet for pefirences. {ven the svt naire of knowledge theeletie thinks tat no sage pyehothenpy theory wl eer be fund tobe the best othe mos eoret, Sone develping pyehoterpiss Fn thi reltvim tobe tremendously son fertng Te od gullies af ghtwrong and truefae ae los andthe therapist ca face a Senatingespeience of being lot and aloe ina hated fp Sich eps ‘re ual jaded to have slow teerance obi though more accurately they havea Tow tolerance for tel. The emuing existe. tial anguish can precip reteat tothe more cute tages of dal o tipi. Although the elt of cect i 2 sespetable scholar potion one problem that the poychothespat st function ss an acti. potonl acho Sekingtopesrpive match paychotherapies with does personales oF ‘ales contest ake time, Bat what oes the ett therapist do when confoted veh pric pti? The esearch evidences tot ava inforativ on which therapes work test with which types of problems at patent far now the elect equ left wih dec Slons onthe bai of patient ales and linia “apesience, mach of whi ny wal Bet Bat Se ofc ‘Given the knowledge explosion, does anyone sesouly ble tht any pectisooer wll a ter all the stable theories and techniques of payhotherapy? Maay therapists who each the Flags ofntltl relativism begin to compre fend the nee of personal commitment Commie “he derma forthe ethical psychotherapist 6 sing ltl nterty whle commit- tng to personal appeoach without the scerty system of aychotheapy fresh evidence inal stations. Reiring thatthe mpi evidence isnt avas deter pia and tha there iste cansenss on doing Pchotheray, the clnan commits oa theo Fev yee bated on an ela position a postion of vals. The ethical therapist mows beyond the realm ofknowing othe elm of inghyafierming, "This the appoachto human fy the Tw lve tae vad aid T commit ‘ayel to validating” A hcl commitment ‘ngs witha passion to master the partclar therapy to mprone and orate “The tial heap eno a dogmatic abio- last The commitment ows ou an undeni Ve eatinsm and ental hamaity hat ers from the swaenee that other therapy systems tay be equal valid fr other individuals The Commitedtherpit fers cnt to other teat ‘nents when tr patent thatthe elias snot ogressng or ot ort ote therapist ‘ral appoch, By contrast the dais he Tpit il work to convert the cent ia the mame tra, ightousnesy and all das go, Committed therapists frm 2 community of ded professionals who eelze that, at {his pot in our ftellectal developmen, the {gestions we share are more important han the vets we give That they are centrally co ened wih questions of what the Dest 9 0 Conduct pychotherpy; wba the most valu He eatient for aur dents or clleages ee for seats and how ean we help our eens Ita ete i, Ae inet rasts, We ow we cannot provide absolut answers 0 fh questions. We alae the fact that ollngues {ecommaed vo sctunengleraaves that we ‘ures ave not hose, Werners Model Wemer® (1948) Werner & Kaplan, 1963) organic deveopmncatal theory also proves instructive for oneepualiing psycho Terps development of a mature inlese tive stance (Kaplan eal, 1983; Rebecca ct ale 1976 Inthe ft of hee deelopmental sages In leaning new information, one percelves 0 experiences global whole, with no cer di ‘intone among component parts Alsystemso paychutherapy are unereally grouped into the fntchall cxepory of “therapy” Unophistiaed ‘Compartive Conclusions luypersins and untrained undergrads Err ree vem ae Tn he second stage ae perceives or expe rinse diferentiton ofthe whole toto pats, wih x more pec and dtnet understand {ng of emponent within the whole, Obie cmparsons and prec contrasts among py ‘hotherpy systems te prized. However, one 20 longer enoys a pespetive onthe le and comeguenty loss the big pletwe. Mays Shothenpy coures, textbooks, and edsted rations al into thi category. Tn the third stage, the diferente pats ae ongnied and Integrated into the whole ‘st igner level Hers the onty end the cm plex af paychotherpy ace appreciated Beh {he vale diferencet and the exten sim lnrtessmongte school ar recognised Thats the deelopmental level to which we aspire fn the Stems of Bychatherapy txts resent both the fundamental siaaris and the we ful ifrences among the major systems of paychotnerapy. “The Transtheoretical Model ‘The trastheorticl model ives to surpass the relate felt trough commitment to a igner order theory of peehothespy tha, in Woe’ tems, apeelats the unity andthe ommpenty of the enterprise. Transheoreticl tRerapite comm to trumcending the crest reat by discovering or eonsructiog con- Cepts tat cu aro the Udine bound Ie ofthe psjehotherpies. The tanstheoetical therapist then ea cla peratingon a et teal andepisemelogcl commitment. ‘We stout to contract + model of pyc: therapy and behave change tat andor theente spectrum ofthe major theories the mane tranatheoreicl, We were guided by ‘umber oferta Fst, a5 we have empha Sted throughout tht book, sophitiated Integra Yell respect both the fundamen ta vented the went unity of peycho ‘therapy sptems The valuable and ccasionaly ‘nique contributions ofthe major system of psjhotherapy must be preserved educag ll Systems to thir leet common denominator ‘emotes thei ines and eetance, Seco, {he nto should empha empiric, in that the fundamental vables most be meaturble nd valisted, Why bother wih a ew mode If itis neve tested aii doesnot produce more ‘ompelingouomer than those ala val "He? Thi we sought amodel that cond account for bow people change without therapy as well 2s within therapy a the majrky of people with ‘halal sonders donot ce poesia an tance, Four the model should prove acess Fain geerlising to» broad range of oman problems incudingpyslcal heath a5 well ena health problems. ith and nally the tranabeoretcal model shoal encourage 93 hothepit fo become inorstors at simply ‘boeroers fom oer systems. “The tranatheorteal model to which we spire mat prod giding races for psc See and care pics fora comparative anal ‘st the same time, mo remsin Rei Encourage there choice ad to Incorprste ‘he ation of new peyhotherspy systems and ssarch develope Proceses of Change ‘he trantheoretcal model ress on three core mensions the process, sages, and lees of ‘change Let us cots each nu The st drnenson nals the process of ange. As introduced in Chapter I, process tre the covert or overt alisha people ngage in to alr emedon, thinking. Beha, tor rltonsipe related to particular peobless rpms of ing. The processes wee at ist ‘heoetcaly derived inthis bok comparative amalysiof tems ofpochotherapy Prochaska, 1978) and wee liter mood om the bai of pirical esearch on how people change bea toe with and without profesional trearpent (DiGlemente & Prochaska, 182; Prochaska & DjClemente, 199) The gos as Einstein empha sed. sto account for the ost facts wi he fevest principles. “Thefollowing 10 processes of change (fined tn Chapter 1 have vecelved the mast research sport + Consciousness raising (eduction and feedback) + Cathars dramatic eet ¢ Saleevalaton as + viconmentl evaluation 1 Seltivertion 1 Sociliberation 1 Stims control 1 Cautngency management 1 Helping elaonship Wichave observed repeatedly inthis book thst the mjor paehotheapes diverge much mare Interm ofthe content tobe changed than nthe proceed to ange that conten tn other frond dierent onenttons do not dicate the “pected 1o use as muchas they dete thin the therapeutic content and goals fo pu he eer 1963). Divergences in conten ate faction ofthe lie f personaly theories Father tha of «multe of change process CConsher the psychological testment of specie phobias. Freed (1919), the ntaps hic maser, srened that i the psychoanalyst etry induced the patient t0 expose hime rhe tothe feared imal, "a considerable Iodeation ofthe phobia” would be achieved “his ubueremon predates the contemporary onsenss on the supeioaty of some form of xposue (behavioral, cognitive, eye movesnent {sensation and reprocessing, marae) In alleviating, phobic behavior. The evidence pains othe neces of reducing phoble am Fer and avoidance through expose t0 the feed objec ths apposed nf many forms, [S considered the weatment of chic. Freud reniyundersoed the press of reducing Pobl behav, but he decide that the dese ‘ih content of peycoanalat—the therapeutic 1s to make the unconscious consis (oreo, 199). ‘A smimary ofthe change processes advo cated by papbotherpy spems shows more veegenee than would appear when we ate fistractd by the content of therapy. Table 17. lemonsttes where each of themjortherspe- ‘estes te scording othe salen proceses of ange ‘ne thing that becomes quickly apparent feom Table 17-1 thatthe change process ith the retest gcernent concise ring. ‘Compared with oer process of change, twice ‘Ss many therapies inetd an expansion of con ‘tious ar conta factor in behavior canes, Systems of Pychowheapy ‘Unles theorists he mised she nk hitb Indies that practiones of all eienltions lp pent proces informatio that wa pre ody uli their arenes and tha more scare shoul explore whic specie mahods prove most fective in tis ead “he tbe ls eve that pryebotbesy sy ter ave lel ignored the impact of com ton factors in peoduclg change. Anywhere from 10% to 35% of change can be attbuted fo expectation ané placebo (se Chapter and Tambor 203), Our asmpin Is tat hci lel pres of change In lace groups that lens have chown to change Tey have ade a Commie to change safe by con ‘ining stendace a placebo sessions. The pli {tbo sessions provides puble forum fr them to make their commaiment knowa, and public onnmitinent proves more ective thi apis ‘ate desion. rom this pola of view the crea question ‘becomes: ust which change proces people te tosohethelruvnproblenst Pjcoth-apiss Should ot be 0 arog to believe at peor fe do not change ther problems withet pro Fesional asian, One suategy four seach progam isto study people wo sucessfully range ther ove We will soon 6 ow everch on salchangers ed therpy hangers as enhance the tranatheoetial del fact our ste nate that people ln the natral eavonment ase many process of ‘hag o overcome probles (Prochast et as 1995), Mout paychotherapy systems, Eowever, Cphasze ony a or thre processes, One of ‘Gur potions that thera sould be a Teas cognirely complex as their cles. They ‘heal thinkin tems ofa ove compnensive etofehange proce andl apply echaiqus 0 gag cach pres when nde, Stages of Change ‘he optimal we of change process ivaes nderstanding the sages of change though sikh people roges. Te saps ae the 9 ‘ed dimension of change tat we dicovered ‘empiri "When we sed ostcs hoe request oo le appli the change processes in change And Psychotherapy, they kept saying that “ble 17 Summary of hatha Stns Accontng he Chane Poses Aste Bethe sence fener ‘Concours eg 1. bck Pen Paces heroy Paoyaumic py ‘Aberan benpy eset ray ea bey Fsences ey Marni irae, Gautbe Root ematnebevor heey Cape therapy ‘Tabet eis Communion ste therapy ‘Sra herp Brenan herp Soon foe tespy Nartve thre bat Minaines Teepy 2 Bain, nhs ‘a ory ineapensa cu ogi, ‘Tce ana ieaenee bhvr thr Cope ery car ary owen ray aka er Mitiwotlucse atari 1. Goce email esperince tether Pospcarl ey Inupeaoa hes Soe ei te utc ery 2. Drama ‘esa hry Canon sit Gomori orth atom emote bhai berpy bee” Exper py Femi hersy Malton ey Sua ne herpy Act Inpesonal hpy Ber tery atunodl hespy Coming cond ‘aan her Ratan eat hair erry Cae ew Nath ey > Gl cater te Behar tery es Neti oeey ‘cheng 1 Satheton Mattia eveng, ‘recnal anas Benatar Commenting ean Rana ep etal eapy Slt oan py it 2. Sac tration ‘era herr ‘Scud hey nih Tagen Toca Adeantengy Fetal ey enn-cenced ery Salter Commun hespy Sct herp uta ergy ber 0 epee what point th care of change eee ings ioe pu sey deen paces inthe orm nod poder pene and charges wee Serine pheumens enw i geo hang Sages congo et een eed SEF che mer sem peter Ja nan sedatiyungeeconeouton fine taste mod “he sages rere spc conteltios of tate ions and bhi rated {2 thinning nthe le of Stang They proves empordenton ‘ta thange hr nie rine. ch Spe tec ely etd fine Bt ao ‘Vote reute far amereatothe et Sag hime nal pends ch ‘ipa the tals to be mpd re [ne tobe ant Change nfls oer sic Sap conenplaon, contemplation. Dar hom, atom, aitenance, and termination ong inay ems, ten eo Pe wl aye bck to eer sages. Whe Teg comple ands entiation irenel wt follows ins dex of xh sigcan nets tbe comple og Notte nowsage Precontemplation fe ths sage thee is no tention to change teavioein the foreveable foure. Many ad ‘ideal inthe preconterplation stage a una are or under-aware of thei problems. AS 1G. K. Chesterton nce ssid“ it that they ant ee the solution cis that they cat see the problem” Famils, frends neighbors or Employees, however, are ten wll ware that the prentemplatoe has problems Whe pre- Contemplate preset fo psychotherapy, they ‘fen do 40 because of pressure ffom othe nly they fel coerce ato changing by Spouse who thresens to leave, an exployer who threatens to dismiss them, parents who Threaten 9 dis them, oF Judges who threaten to pnih them. They may even dem fanstate change at long asthe pressure i 0. ‘nce the pressre iso however, they often ‘ikl een 2 tht old ways sytemef Paychotherpy Even procontmplats can wish to hangs, tot tha proves ute diferent fom intending fr sein consderiag change in the foresee the fre, ems hat are wed to ei pe entemplaion on a continuous stage-oFhange ‘wre ncude Aa far ae Tim concerned, Font dhe any problems that seed changing” and Bho ave fats bt tees nothing the teal need 4 change’ (MeConpaughy eal 1983), Rentance to ecognizng problem isthe halla preoetepltion. Precnleplatore are not considering ater ing thts bcaviow in the forsale future and, ssaeonsequence engage le chnge process tes, Tv onder to move abead they nes Sknowledge or “own the problem, Increase Srvrenes ofthe negative aspects ofthe probe Term and ccursaly evaluate slfegltion capitis. Contemplation Inrange ea aa ss ane i hning tora t hte ets cmmimen he ‘Senet conte meme nd SG] endo hem ch hve sp Josey inked wc nd "Sean igi von hang ‘Diego mya Sette cnn ‘Sera calm sol deen tec afte coven ge seroma snc red Penn 9 He ar alin ee ithe ran poate nd ‘Spe ow etalon of alae Papemed atthe ngs np cep tts, bere wae onto and spn inure th ‘Cote oa optic SEES he ath woes Sones es tw Ke ge mat oT in cots tse Kang wo gt 9 oats eterna nn coneaon sagen ete oon orca wee eal a pony of 0 ce Fo 2 eT sol eee Compartve Cnchsons sug remain te enon ge othe ene 2 yew eer moving ‘nificant action. oe Conte, thes, are eating opto ‘Tomoye feed in he le of chang ey tt ri the tp of bce rmination Yeon we cal hook cntempatoc= [eda chm econ begin taken Shee ual soe of pcnny action thee “Day ged the ino tee stage. Preparation ‘he preparation stage combine nteton and beaborsl eter, Indvisle im this sage tre intending to take acon invedisely sod ‘eper small behavioral changes sich as sak. ing ve fewer eigarets or delaying thee st cig of the dy for 30 minutes longer than precontemplators or contemplaters. Alou they have seduced their problem bebevies, Indigo in preparation have not yet each 2 eerie for efecive action, such a6 aba- rence fom smoking alcool, or heroin. They ir intending,homeve, to tae sch ation a the very near fate, Ona continuous meas, they score high on both the contemplation ed sion sae, Tike anyone on the verge of momentcut ‘actions, indvidals in the preparation stge hee 10 set goals and priorities. In aditian, they need to dedicate themselves tan action plan they choose, Often they are alrenly engaged in change proceses that “would Increase self-repultion and intatebehavor change Action In this stage, indvidals modify ther behav, ‘experiences, andlor environment to overcome {hel probes. Action involves the most ee ‘behavoral changes and equa considera ‘ommlment of time and energy. Moats ffs problem made in the action stage tend 16 bbe mow vile and reeve the greatest ext. al cognition. People inetuding profession, en eroneou equate ation with the ally of change. Ars consesuence, they verlogk fe este work at eepres changes for ston snd the huge efforts necenar 19 maintain the ‘anges flowing action, Individuals are inthe action stage Wf they have sucefulyallered « problem behavior {or petod of 1 day to 6 months Succes, ering a peoblem behavior means reaching 2 specie cterion, such as abstinence. With aking or evmpls iting doy 0 oF ‘Sangig to lower tar and Dcotne iartes help prepare people for action, bat they do aot sats the eel foe succesfl action. On & Continuous messae, navi in the ation singe endorse statements suchas “1am rly working hart change” and “Anyone can ak Shout changing: Iam actually doing some {Bing out I” They score high on the ection real and lower on the scleasessing the ter ages of change People inthe ation stage requ the sills to use the key aton-centd change process, ch a8 countecondoning, mele conta nd contingency management, 10. iterupt Tubal paterot of behavior and adopt more productive ptr, They become ae ofthe als tht might undermine continued ato, Irhether these aze cope (abtinence il ton expectation) betel apparent ie sant decison), emotional (eescbaton of Stes or depesin), environmental (ak of Feinforement or spousal supper) in mature n this way they wil segue eect ates prevent pss or sp frm becoming compete relapses. Maintenance In ths sage, people work to prevent late and ‘iowolidte the gains stained during acon. “radon, maintenance as been viewed ar 2 static sags, Homerer, alten ls «cot tution, not an absence, of change For chron problems, this stage extend ram 6 months 10 4p indeterminatepetod past the nial action. For some problems, sch addictions, rate: ce can tat a tine, Remaining lee ofthe chronic problem ad) ‘or consistently engaging in anew compte ‘havior for more than 6 monte is the erie ‘on for the maintenance tage. On the contin- ‘vous measure, representative mulntenance m ters ae “Lmny need a boost ight now to help se maintain the changes Tve already made? fd "Tn here to prevent yell fam having ‘relapse of my problem” Saizing behvior ‘hange aad avolcng elapse ace the hallmarks of maintenance Recycling As Is ow well known, most people taking ction fo change behavior do not saceessuly Tata thei gsne on the Gest attempt Many New Year) resolvers for example, fet Sor more year of consecutive pledges before maintaining the Behevioral goa for at least 6 months (Norcross & Vangarell, 1989) Relapse and recyling through the stages occur for most Individuals 2 they stem to ‘modify bavi. ‘Although pecbotherspy epialy proves ffctive i the short ran, elapse 1s an all 00 ‘commen long-term outcome inthe treatment of adiicdons nd mental disorders. Ina cs Sh teview of icame Icatre om aoe Ihrln adaet and habitual smokers, relapse rvs scos these dilrent substances showed {ingly sila pater: Wit 8 moms ‘of treatment completion, nearly two-thirds of patients had elapsed ih many ofthe reaps nearing wah the st month lon ing estnent termination (Hunt etal, 1971, Ey tetment approaches focused on chang- ing behavior but trey on ealtaning those changes over tie, This ested In “evo= {ng door” oF recelng in which treatment com- pletrs sere to trestment folowing exch eps. Relapse prevention (RP) is sclEmanage rent taining designed (0 avoid recycling and to enhance the maintenance sage (Marit 8 Donovan, 2007). With sls waning asthe cor ‘erton, RP teaches clients how 0: aaertand elapse asa process ent high-risk suaions Cope wil eratngs and urges to engage nthe probe behavior Roce the hat of tlape by mining the negative consequences Lear from previous elapse experiences Sten of Pychoterapy + Achieve a balanced stl, centred on the {ilerom of moderation ‘We should note ia patig thatthe acum Ining research on RP yields postive fds. ‘A metnamalpieevaluted the efectienes of ‘Rp in 26 sues cepesentng a sarmple of 9304 pln (Irvin tal, 1989) Resuls nds that RP was generally eft, certainly mae {ethan ‘o-tretment conte and Partc- Ian eftie frac and polybstance use discus, Becaue reapse o replings the ue rater ‘than the excepto n beni change, we ound that we needed to medify our orginal sage model atally we concepumized change 8 2 Tear progression through the stages, people vweresppoved to progres simpy and dscretly Uheough ach ep Linear progzessin sa post be bat celaiey rate phenomenon with conic Alaaeders sich 98 the adictons, etal disor events asp pateen of how many people octal move tg the ogre ‘ot change. Uo th spiral pater, people ror test fom contemplation to preparation to lon to mantenance, bot many nis sll laps Dering relapse individuals regress oan euler stage, Some relapses fel ke Tauesembarrated, ashamed, ed guilty. “Thee individuals become demoralized and redt thinking abowt behavior change. AS 3 esl, they return to the. precontemplaton ‘age and can remain therefor valous peiods lof tie. Apposintely 15% of lasers regress bck to the preconempation sage (rochaa DiClemente, 1983) octunately, the research indicates that the vast majority of elapsers—858 of sel ‘hangers, for example-recjle Back to the ‘contemplation or preparation tage. They con- ‘de plans for thee next action attempt, while tying to learn from thee recent efforts. The Spal pattern suggests that mort reapers do ‘ot revolve endlealy i izle and that they do oot egret all the way back o where they Dogan. Inead, each tne relapses secyle through the stags, they potently lean from {ele mistakes and try something diferent the next time around. Comparative Canelusions gure 171 Spi Pater oe Stags of Change “Termination ‘Termination of problem oceus when a person no longer expereces ny empaion to eer {o toubled beharors ad no longer aso mak any eflorts to kp fom relapsing, Obvious, Cernination of testent and leroaion of problem are net coincident, Psychotherapy Fequelly ends blo serious problems term ate enaiely Consequent, for many linia Alsorder, patients el etarn for ose sex Sons mest fer when they aleve they maybe Alpping sc rm previous guns Alia bee testment tericates before mow problems hare reached their termination, hens fend 0 expe ene nse ard dses over he eatin of therapy In summary ndviduals who sek ou peo fesionalastaace donot ative at on door sep inthe erial tage of change, Paints nrg trestment a two outpatlent cnies hd at slcablum Iresiment canter demon sated variety of profes on the stager-of- lange scale (DiClemente & Hughes, 199; ‘MeConnaughy eta, 1983). With couple and family therapy. tis almost sxiomatic that some of the members wll occupy diferent stages: The type f ereening and the particle demands made bythe teatmentprogeam il Influence the members of people in iferent age who prernt for help, but ually that any program would recrut cies oaly ftom one stage sales tpe-aseeed stage of change a seleton criterion. For most poe Utioners and programs, pallens represent Ieterogencous group in ems of readies change esearch on the Stages erally thousands of publbed cesach td ies have wel masires ofthe sages of change. We wll eview re the ets of han of representative studies onthe cnc ity and edict valid ofthe ages, "The amount of progress cents make during ychotberpy tends fo be a finction of their retest stage of change, A met-analels ‘of 39 stds, encompassing 8250 patient, ‘ound tha the sages rela and robustly pre it oucomes in psychotherapy (Norcross tl, 2011) Those begining ws the pepuaion sad ction stages do beter tha those beginning in recoatespation or contemplation, T reat all Drvhotherpy patent ae if thy ee the same ‘would be nave; et tha i what bad been done fordectdes “This strong sage lfc has been found foe looens of health order cross multiple et= ‘ment setinge: for bre-mpired. patents Jn ‘ehablaon programs (Lam ta 1983) pace ‘duordere patents reciving antianiety med lato (Betinan et al, 199), eardine pants tdergong counseling (Ockene etal, 1992), tnd Merle Americ enealle in comanity programs for smoking cessation (Got e aly 1990) la short. the fther along cents ate the stages of change tthe bepaning of therapy, the ore quel they are kl to progress. ‘When therapy infles two or move cents eekig tops a in coupe and parent-child ‘eames thn therapy can be expected to prog. ‘st most smoothly when each ofthe ents est ‘the same stage of change [rane members realy fer ation while the other as not contemplated nha change wll mean then weatment el be “cult Bet. The therapists then in thee ‘il posion of eng damned by ane pouse or Ihovlng too sloly or rested bythe other for ‘owing oo quiche lets progres from one stage of change tothe next ring he st mont of treatment, they ca double thse chances of taking ation ‘cing the nil 6 spoths ef the treatment, Of the peecntemplatore who were stl in pee- eoaterpltion a I-month follow-up, eal 3% {ok ation by 6 moat ofthe pecontepla tore who bad progressed to contemplation at {month 7% took ation 6 months Silay, ofthe contemplate wh remained in contem plton a 1 month, only 20% tok action by ‘Srmoath: ofthe contemplaters who had pro: [resed to the preparation stage at 1 month, {1 rtempted to quit by 6 oaths. These data lemonstate that tretments that hep people progress ast one stage In a month can dow bie the chances of participants taking action fn their own in the near fare (Prochaska & Diclemente, 1982) ‘Several studies have demonstrated that the stapes of change can predict who remains in pspehoterapy (eg lle et al 2000; Dersley ‘Reynolds, 200; Smith et 1995) For some tne lniclans have kaon tat approximately ‘one quarter of patents prematurely discon. Finuepoychatherpy (Sell & Grenberg, 012) however the characterises of these Aropouts have not been reliably Known none Study (Boga et aly 1989), premature term! foton wat predicted sing valbles trad ‘nally among the best predictors of therapy ‘outcome client characteristics, such as dem ‘geapice, and problem characterises, sch {SS curation aad intensity bat these variables Thad zor ably to predit therapy dropouts ‘When the stages and proceste of change were sed, 93% of the premature terminators— ened hay cot de nt appropriate terminatrt—were correctly ‘lene "The stage protic of the 408 who trapped out of therapy was that of prev templates The stage profile ofthe 20% who terminated guichly but appropriately was that ‘of people lathe action stage. The stage profile ofthe therapy contiaurs was sms to that of ‘contemplates sytemsofPiychotheray A patents sage of change provides prose tive a walla positive information on the teeiment of choice Acton-oented therapies nny prove gute fective with indviduals who the inthe preparation of action stage. These fame programs may be inefictve o deter {a owen thal nthe prcontem plo or contemplation tage ‘An intensive action: and_ maintenance crete smoking esston progam for exdlac Paints a highly sues for those palents {the preparation and action stages (Ockene ‘ly 1389) Patents nhl specia are roam Freived personal eouneng ia he hospital and ‘monthly lephone counseling cl foré months Falowing boeptalition. OF the patents who pan the program in the action of preparation stag an ipeave 94% were not Smoking ot font follow-up. Ths same program fled, however, wih stokes i he precontemplation ‘nd contemplation stage Fo pts these Slog lens expesive and lets intensive eegular caredidas wo Tndependent of the treatment reeied, a ear relationship emerged between preueat- nent tage and outeome, Patents who were not Smoking at 12 months ichded 22 ofthe pe enempitrs, 43% of the contempstors, and 5 of thaw tn ston oF prepaze for acton 1 the stat ofthe sad. Tals the predictable ower ofthe stages of change, Integration of Stages and Processes Another power finding to emerge rom Feveatch of the tanstheoretal mod i that pastel proces af change are more elle tive during particular sages of change. Thy fre years of reset in beasoeal medicine and Daehotherapy converge in sowing that ier Eat pct of change are dentally fee {evel certain sages of change, A metaanaysis (oven, 2000) of 47 crosesectiona sadies alning the rdttanship ofthe stages and the process of change showed age effet tes (ds between 070 and 080) “The integration ofthe sages and processes of change can gidepeyebotherapst asl ingteatment nthode Once a patient stage of thang evident, thers aow which Pro estes to oppyt bet ap that patient progress Compartive Cnehsons to the next stage of change, Rather than apy fhe change process in 2 haphazand or tr: and-esror manne traps can use ther ich more systema and efficent ye “able 172 diagrams the negation betwen the stages and processes of change (Prochaia, Nevers, & DiClemente, 1995). Specicals, {he table shows the change processes used most sen during age change. Ll us new how this stage matching can sytematicly Aiet psychotherapy During precontempation, individuals ese ‘mange proceee signesntly les tha people Sn anyother stage, We found that precontet ators process less information about thi Problems spend les time and energy revs flag themselves experience fever emtion] feacton tothe negative aspects of the ec lems ate Tess open with significant thes shout thee problems and do itl to shit ae ‘tention of thet environment im the dic: ton of overcoming their problems. Ifyou dont Iie you haves problem, why bother wth changing In weatment, these patents have been historically labeled resistant, defense, ov in denil ‘What an help people move Fm preconten plaion to contemplation? Table 172 soggsts that several chang procetes are most eect. int, consciousness rlsing methods—stch ab seers, eestion, and interpretation sss cent in becoming more aare of Be Eauses,consoquences, and cures oftheir pcb lems Tomovetotheconempaion tage. cheats ns ‘en mst mare aware oftheir defenses beoce they can Become more conscious of what hey sae defending asnat, Second, the proces of “ramatic ele (or ears) provides patents ‘wth motivating emotional experience, ich a « those wed in Gestalt and experi methods Ike the empey chai These beating expei- ‘nets can relate emlions tated to peotem ‘bho Life event can also move preontem- tors emotionally sch she dss or death ‘fa tend oe lover, In moving through contemplation, cients ‘become icreaangy avare of theseves and ‘the nature of ther problems, and thus ae freer fo reevahne themes aectvely and cogal- tiv The selfteeraluation process icles fn asesiment of which values cas wil uy te actulze, act on, and make rea, and which they wil et de The more cet pobers are to cea core vals, the mote their eevalo- stion el Involve changes in thee sense of Sell Conterplators also use environmen {al reevaluation that i they deeply conser the fet thee Behaviors exert oth socal ceiroament, especially the people they care Shout mort ‘Movement from precontemplation 19 con templatnn and movement through he oats lon tage, voles incensed use of ognite, fective and evalatve processes of change. > beter prepare plient for action, progress Is gute in how they thnk nd feel abou their problems and how they value her destructive tyes “abe 172 sags of Change in Wh Change Process Ave Most Eph Stags of Change Precnemplation Contain ‘Cocoon ing Braet ee nvipamiel aren selection raion Aton Naetenance Softer Contingency mangement Cowman er Prepon nde a ede to dane inthe er tre nd incorporation of wl Dilesons om pastchange stomp. rpaes treonhe verge oftkng aon an ee se soar and pies secodiag They freely Eetop an acon lan for they wl pro: {eu nao, they wl he fi omit tren to fallow tog on the ston ep In faethe aro sendy engage in prseses thn woud! nee seseguton sn ntate har cage tnd ely bea y aking sme nal (or tby) ep tov son They may tie counterconditonig sad stimu om trl fo bein eng thir problem bo tors, Coustecndoning svar bing Ii ee ono is poems ach elon tenet or seaplane intend of cooling ‘ental dig eh oppose of he rab deo mult con aofes mang. the Fpeence abunce of stains or ces at ‘ic pone sch ot topping Bat Sterno acted dul ay Shy tht Coe af bans ah day or may el he umber ef ttn a which they rym he sadness Ae thy bet preps fr he ction stag cl cos at on see of selberation otwl- wee They ted Yo tle tha they owes {ie suonoy and power fo chang ht es tn key wap Sal bern i bse a pat 00 een of telelecy Onda, 1977, 83) {heb tones wcfot ply aesea oe overnite ce of alia stunts ‘Theat og het oes ae tbat atc sl copie metas. Chen mas is be cece with bail process Soch as couterconningsimuts con fd colingency management cope Wi ee conion, tat can come them In ‘opsng Tei an pote sls waning {Tnscsary. i btvorprcee nrc the poby tt lets wl be sees whe they do fake aco, contingency an Xgemem pcb seve 2 power fare ar sn lp pens ate thet tren pte of laremet fr the dsied ‘avo dager: Sol erton i empho Shed most when pent sesk sol aoc) systems of Paychoherapy ad interpersonal stony ie eb of om Imus ta pp hee cose ese, Thy opening 4 comple aod dye sere of hemes ‘thorn in Tle 172, cel male nee bale on ech ange ces hat bas Tome bul and abo eacmpenes = cand ‘Sesient ofthe conden ane wih ape nino epee er het her seiner ping sich cere condons Shot rng fo sdesing dlees Tn pulogcal apo Pets mos eo hl bie ste hat one becoming mae ot {hein of personae wens be Conuuing imei igre ma {he whens based on te comcton that taining change ming» sre of Sf thvishighy vate by oneself et one Suter tee "To sum up We have deermlaed htc tw tha hang depends on gh ht {Rg (voces etn tine 6g) Se trating aging the change proces ah the pute agence the prob of tree sce and cae: paychbray He hve obiered vo feet ssanaches snopes Ft some cents (acca) ‘iyprinaronchunpepcesesmostindated {er becotenponsieconcosces a inp vloton we hye mgt theeton age hey ry to oly Behr by econ ne se, coon es OF caste poehonalye night hoe oes fo meena brig about behavior change Seton ether lena nn) prima ‘yon change proces mest ated fore selon sage cogey management Sn {seo comeing ne ie aveenesa, coon fk ad ce “nang pied inthe tempion and Jrepraton ages They ty fo oy bkeior Mhowt werent «cmon ct ofa {alvin ont acon iho ih Tk to end to temporary change Praha cea 199 ‘Competing apes of paychotheny ave promulgate appre cd process ot eange Hwee osensly contradic {ory roves become complementary when Comparative Consions cembedded in the sags of change, Specially, change procetestraitonally sociated with the experiential, copntive, and prchoanalytic persaslons are mos useful during the peor templation and contemplation stages Change processes tralionally aisocated withthe exe tential and behavior traditions. by contr, ae most uteful during the action ad mainte ance sage. esearch has song supported and shaped the core constructs of the trantheoeio pproach and the iategraton of the stages sod [proces of change Longtainal eee am The rlevance ofthese constructs for predicting premature tevilaton and treatment cuore Comparative otcome se atest tothe valve of stage-matchedIntervetens.Population- based ties highligh the need for poychowciat Interventions toca tothe neds of nial, at al sages of change (ee Krebs, Novrss, Prochasks, 2011, and Poche al 1995, for revi Levels of Change At thls poln in our analyst may appear hat we are restcing ar dacastion tO singe ‘ell dened problem. However, as we all el ine, realty snot so acommodating una bho not so simple. Akhough we can so Ine eran disorder, these occur in he contest ‘of camper ntrslaed Teel f uma fone: tioning The third coe dimension ofthe tan ‘heortcal model addrese this ee “he levels of change represent a leach ‘rpaizaton af five distinct bt interred ev cls of peyhological problems addressed In pay- ‘hotherapy. These level ae: 1. Syapom/statonal problems 2 Maladapaive cogatons 5, Current iotgpesonl confit 4. Famiyystems confit 5: Intapertonal cones Pachotherapy systems have atebuted psy: chelogial problems primi to one or t90 levels ofchange and have targeted thelr methods to thee levels Behavior therapss have focsed ‘on the symptom and situational determinants, 7

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