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

Journal of Psychotherapy Integration, Vol. 9, No.
1, 1999
Why Don't Continents Move? Why Don't

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
People Change?
James O. Prochaska1 and Janice M. Prochaska23
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 integ-
rative 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.
1
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
Correspondenceshould be directed to Janice M. Prochaska, Pro-Change Behavior Systems,
P. O. Box 755, W. Kingston, Rhode Island 02892.
83
1053-0479/99/0300-0083$16.00/0 © 1999 Plenum Publishing Corporation
84 Prochaska and Prochaska
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 chang-
ing 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 con-
trol. 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 inten-
tional change.
Changes that we are referring to are intentional changes in which
individuals apply psychological processes to improve their own psychologi-
cal 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 health-
related 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-
Why Don't Continents Move? 85
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 behav-
iors. 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 psychologi-
cal processes.
One of the intriguing issues for the field of psychopathology and psy-
chotherapy 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 long-
term consequences, like death and disease. We can understand people not
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 Norwe-
gian 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-year-
old 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.
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 thera-
pists 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 dis-
orders 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, espe-
cially 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
their current interpersonal patterns. Adult children of alcoholics, for exam-

ple, 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 ana-
lyze intrapersonal conflicts that can be the basis of symptoms like dysfunc-
tional 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

DONT 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, & Vel-
icer, 1990; Prochaska & DiClemente, 1982; Prochaska, DiClemente, Velicer,
Ginpil, & Norcross, 1985; Prochaska et ai, 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 Man-
ual (4th ed.) disorders (Prochaska & Norcross, 1983; McConnaughy, Pro-
chaska, & Velicer, 1989; McConnaughy, DiClemente, Prochaska, & Velicer,
1989; Norcross & Prochaska, 1986; Norcross, Prochaska & DiClemente,
1986; Prochaska, Rossi, & Wilcox, 1991; Beitman, Beck, Carter, David-
son, & 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 precontempla-
tion 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 defen-
siveness. 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 per-
ceive 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, defen-
siveness, 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 gen-
der, we were unable to predict who would terminate prematurely. Using
stage-related measures, we were able to correctly predict 93% of the therapy

dropouts. The premature terminators clearly had stage profiles of pre-
contemplators (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 behav-
iors 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 ai, 1991). While contemplators are in-
tending 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 pro-
gram, the majority did not even try to quit for one day (Prochaska, DiClem-
ente, 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
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 ai, 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 ai, 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 rela-
tionships, 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
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 ap-
ply 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 Contemplation ' Preparation Action Maintenance
Processes Consciousness-raising
Dramatic relief
Environmental reevaluation
Self-reevaluation
Self-Liberation
Contingency management
Helping relationship
Counterconditioning
Stimulus control
we will apply with their particular problems. In some treatment programs

potential participants will say that they have already tried what the thera-
pists 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 conscious-
ness-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 arefindingthat 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 long-
term maintenance.
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 con-
certed 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. Contempla-
Table II. Stage X Reasons Why People Don't Change

Precontemplation Contemplation Preparation Action Maintenance
Can't change
Don't want to change
Don't know how to change
Don't know what to change
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 attribu-
tions 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 follow-
ing five levels have received the most clinical and empirical support to
date (Norcross, Prochaska, Guadagnoli, & DiClemente, 1989; Norcross,
Prochaska, & Hambrecht, 1985):
1. Symptom/Situational Level.
2. Maladaptive Cognitions.
3. Interpersonal Conflicts.
4. Family of Origin Conflicts.
5. Intrapersonal Conflicts.
What is the key level of content for psychotherapy? The answer obvi-
ously depends on the therapist's preferred theory of personality and psycho-
pathology 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).
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? Re-
search based on attribution theory, for example, suggest that the naive
psychology of the public attributes behavior to either situational or disposi-
tional 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 depres-
sion, 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 insuffi-
cient 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 ai, 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
1. Symptom and situational difficulties .87
2. Maladaptive cognitions .89
3. Interpersonal conflicts .89
4. Family/systems conflicts .91
5. Interpersonal conflicts .88
6. Spiritual determinism .92
7. Biological deficiencies .89
8. Bad luck .87
9. Chosen lifestyle .79
10. Insufficient effort .87
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 nonpsycho-
logical 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 psycho-
logical 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 contempo-
rary cognitions or situations. Masters and Johnson (1970) demonstrated how
many sexual dysfunctions that were once attributed to distant unconscious
intrapersonal conflicts could be readily reversed by modifying more im-

mediate 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 resis-
tance 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/situa-
tional 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-
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 prob-
lem behaviors; the cognitions used to process these antecedents and conse-
quences; 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 con-
sciousness 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 transthe-
oretical 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.
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 demor-
alized.
5. When they understand the complexities of change rather than

reducing it all to one process, such as consciousness-raising, count-
erconditioning, 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 mis-
matches 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
Beitman, B. D., Beck, N. C , Carter, C , Davidson, J., & Maddock, R. (1994). Patient stages
of change predicts outcome in a panic disorder medication trial. Anxiety, 1, 64-69.
Bergin, A. (1983). Religiosity and mental health: A critical reevaluation and meta-analysis.
Professional Psychology: Research and Practice, 14, 170-184.
Brogan, M., Prochaska, J. O., & Prochaska, J. M. (1999). Predicting termination and continua-
tion status in psychotherapy using the transtheoretical model. Accepted for publication
in Psychotherapy.
Calhoun, K. S. (1975). Factors in the modification by isolation of electroconvulsive shock-
produced retrograde amnesia in the rat. Journal of Comparative and Physiological Psy-
chology, 88, 373-377.
DiClemente, C. C , & Hughes, S. O. (1990). Stages of change profiles in outpatient alcoholism
treatment. Journal of Substance Abuse, 2, 217-235.
DiClemente, C. C , Prochaska, J. O., Fairhurst, S., Velicer, W. F., Velasquez, M., & Rossi,
J. S. (1991). The process of smoking cessation: An analysis of precontemplation, contem-
plation and preparation stages of change. Journal of Consulting and Clinical Psychology,
59, 259-304.
Howard, K. I., Kopta, M. S., Krause, M. S., & Orlinsky, D. E. (1986). The dose-effect
relationship in psychotherapy. American Psychologist, 41, 159-164.
Hunt, W. A., & Mattarazzo, J. D. (1973). Three years later: Recent developments in the
experimental modification of smoking behavior. Journal of Abnormal Psychology, 81,
107-114.
Jones, B., & Nisbett, R. (1972). The actor and the observer: Divergent perceptions of the
causes of behavior. In E. Jones, D. Anouse, H. Kelly, R. Nisbet, S. Valins, & B. Weiner
(Eds.), Attribution: Perceiving the causes of behavior. NJ: General Learning Press, pp.
1-186.
Kotte, T. B., Battista, R. N., DeFriese, G. H., & Brekke, M. L. (1988). Attributes of successful
smoking cessation interventions in medical practice: A meta-analysis of 39 controlled
trials. Journal of the American Medical Association, 259, 2882-2889.
Masters, W., & Johnson, V. (1970). Human sexual inadequacy. Boston: Little, Brown.
McConnaughy, E. A., DiClemente, C. C , Prochaska, J. O., & Velicer, W. F. (1989). Stages
of change in psychotherapy: A follow-up report. Psychotherapy: Theory, Research and
Practice, 4, 494-503.
McConnaughy, A., Prochaska, J. O., & Velicer, W. F. (1989). Stages of change in psychother-
apy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice,
20, 368-375.
Norcross, S. C , & Prochaska, J. O. (1986). Psychotherapist heal thyself—I. The psychological
distress and self-change of psychologists, counselors and by persons. Psychotherapy:
Theory, Research and Practice, 23, 102-114.
Norcross, J. C , Prochaska, J. O., & DiClemente, C. C. (1986). Self change of psychological
distress: Layperson's vs. psychologist's coping strategies. Journal of Clinical Psychology,
42, 834-840.
Norcross, J., Prochaska, J., Guadagnoli, E., & DiClemente, C. (1984). Factor structure of the
Levels of Attribution and Change Scale (LAC) in samples of psychotherapists and smok-
ers. Journal of Clinical Psychology, 40, 519-528.
Norcross, J. C , Prochaska, J. O., & Hambrecht, M. (1985). The levels of attribution and
change (LAC) scale: Development and measurement. Cognitive Therapy and Research,
9, 631-649.
Orleans, C. T., George, L. K., Houpt, J. L., & Brodie, K. H. (1985). Health promotion in
primary care: A survey of U.S. family practitioners. Preventive Medicine, 14, 636-647.
Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more
integrative model of change. Psychotherapy: Theory, Research, and Practice, 19, 276-278.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self change of smoking:
Toward an integrative model of change. Journal of Consulting and Clinical Psychology,
51, 390-395.
Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing the
traditional boundaries of therapy. Homewood, Illinois: Dow Jones Irwin.
Prochaska, J. O., & DiClemente, C. C. (1986a). Toward a comprehensive model of change.
In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change.
New York: Plenum, pp. 3-27.
Prochaska, J. O., & DiClemente, C. C. (1986b). The transtheoretical approach: Towards a
systematic eclectic approach. In J. C. Norcross (Ed.), Handbook of eclectic psycho-
therapy. New York: Brunner/Mazel, pp. 163-200.
Prochaska, J. O., DiClemente, C. C , Velicer, W. F., Ginpil, S. E., & Norcross, J. C. (1985).
Predicting change in smoking status for self-changers. Addictive Behaviors, 10, 395-406.
Prochaska, J. O., DiClemente, C. C , Velicer, W. F., & Rossi, J. S. (1990). Standardized,
individualized, interactive and personalized self-help programs for smoking cessation.
Health Psychology, 12, 399-405.
Prochaska, J. O. & Norcross, J .C. (1983). Psychotherapists' perspectives on treating themselves
and their clients for psychic distress. Professional Psychology: Research and Practice,
14, 652-655.
Prochaska, J. O., Norcross, J. C , & DiClemente, C. C. (1994). Changing for good. New York:
Avon Books.
Prochaska, J. O., & Norcross, J. C. (1998). Systems of psychotherapy. Pacific Grove, CA:
Brooks/Cole Publishing Company.
Prochaska, J. O., Rossi, J. S., & Velicer, W. F. (1990). A comparison offour minimal interven-
tions for smoking cessation: An outcome evaluation. Paper presented at the 7th World
Conference on Tobacco and Health, Perth, Australia.
Prochaska, J . O., Rossi, J. S., & Wilcox, N. S. (1991). Change processes and psychotherapy
outcome in integrative case research. Journal of Psychotherapy Integration, 1, 103-120.
Prochaska, J. O., Velicer, W. F., DiClemente, C. C, Guadagnoli, P., & Rossi, J. S. (1991).
Patterns of change: Dynamic typology applied to smoking cessation. Multivariate Behav-

ioral Research, 26, 83-107.
Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G., Marcus, B.H., Rokowski, W.,
Fiore, C, Haslow, L., Redding, C. A., Rosenbloom, D., & Rossi, S. R. (1994). Strong
and weak principles for progressing from precontemplation to action on the basis of 12
problem behaviors. Health Psychology, 13, 39-46.
Rotter, J. (1970). Some implications of a social learning theory for the therapeutic practice
of psychotherapy. In D. Levis (Ed.), Learning approaches to behavioral change. Haw-
thorne, NY: Aldine Publishing, pp. 208-241.
U.S. Department of Health and Human Services. (1990). The health benefits of smoking
cessation. USDHHS Public Health Service, DHHS Publication No. (CDC) 90-8416.
Velicer, W. F., DiClemente, C. C, Prochaska, J. O., & Brandenburg, N. (1985). A decisional
balance measure for assessing and predicting smoking status. Journal of Personality and
Social Psychology, 48, 1279-1289.

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Journal of Psychotherapy Integration, Vol. 9, No.

Why Don't Continents Move? Why Don't

As a 10 year-old, Jim explored an atlas and discovered that South

Just as we seldom see continents move, so too do we seldom observe

WHY DON'T PEOPLE CHANGE?

Under what conditions are people unable to change? We cannot change

iors. Believing that alcoholism is due to one's genetic makeup, obesity is

Don't Want to Change

Even if people believe in their power to change, there are conditions

wanting to make these changes from a psychoanalytic perspective, which

Don't Know How to Change

This strong-willed individual was frustrated to find that the willpower

Don't Know What to Change

their current interpersonal patterns. Adult children of alcoholics, for exam-

tional drinking. Conflicts over unresolved oral dependency needs can be

A TRANSTHEORETICAL INTEGRATION OF WHY PEOPLE

Precontemplation is a stage in which people are not intending to change

stage-related measures, we were able to correctly predict 93% of the therapy

Contemplation is a stage in which people are intending to change

immediate benefits of their problem behavior. They often go on thinking

Preparation is a stage in which people are intending to take action in

To progress to the action stage, people must apply more existential

than progress. Similarly, psychodynamic therapists who want to continue

Table I. Stages by Processes of Change

we will apply with their particular problems. In some treatment programs

Maintenance is the stage in which people are working to consolidate

Integrating Stages and Reasons for Not Changing

To integrate the most common reasons why people don't change, we

Table II. Stage X Reasons Why People Don't Change

What To Change Depends on the Levels of Change

The field of psychotherapy cannot agree on what to change in order

While therapists of different theoretical persuasions can present a case

reports people attributing both functional and dysfunctional behavior to

Table III. The 10 Levels of Change and Reliability Coefficient

problems that are inherent in a particular lifestyle. On the other hand,

intrapersonal conflicts could be readily reversed by modifying more im-

Similarly, if therapists are trying to solve situational problems that clients

ing on situational or cognitive variables. If insufficient progress is made at

levels of change. With multilevel problems, change processes are applied

PEOPLE CAN CHANGE

2. When they apply processes that are appropriate to their current

5. When they understand the complexities of change rather than

The research in this paper was supported by Grants CA 27821 and

Patterns of change: Dynamic typology applied to smoking cessation. Multivariate Behav-

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

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