ADDICTIONS NURSING NETWORKNOLUME 5, NUMBER 1,1993 2 Perspectives In Search of How People Change: Applications to Addictive Behaviors By James 0. Prochaska, Ph.D., Carlo C. DiClemente, Ph.D., and John C. Norcross, Ph.0. Abstract How people intentionally change addictive behaviors with and without treatment is not well understood by behavioral scientists. This article summarizes research on self-initiated and professionally facilitated change of addictive behaviors using the key transtheoretical constructs of stages and processes of change. Modification of addictive behaviors involves progression through five stages-precontemplation, contemplation, preparation, action, and maintenance-and individuals typically recycle through these stages several times before termination of the addiction. Multiple studies provide strong support for these stages as well as for a finite and common set of change processes used to progress through the stages. Research to date supports a transtheoretical model of change that systematically integrates the stages with processes of change from diverse theories of psychotherapy. Introduction Hundreds of psychotherapy outcome studies have demonstrated that people successfully change with the help of professional treatment (Lambert, Shapiro, & Bergin, 1986; Smith, Glass, & Miller, 1980). These outcome studies have taught us relatively little, however, about how people change with psychotherapy (Rice & Greenberg, 1984). Numerous studies also have demonstrated that many people can modify problem behaviors without the benefit of formal psychotherapy (Marlatt, Baer, Donovan, & Divlahan, 1988; Schachter, 1982; Shapiro et al., Reprinted from American Psychologist, September 1992, Vol. 47, No. 9. Bernadette Gray-Little served as action editor for this article. This research was supported in part by Grants CA27821 and CA50087 from the National Cancer Institute. 1984; Veroff, Douvan, & Kulka, 1981a, 1981b). These studies have taught us relatively little, however, about how people change on their own. Similar results are found in the literature on addictive behaviors. Certain treatment methods consistently demonstrate successful outcomes for alcoholism and other addictive behaviors (Miller & Hester, 1980, 1986). Self-change has been documented to occur with alcohol abuse, smoking, obesity, and opiate use (Cohen et al., 1989; Oxford, 1985; RoiZen, Cahaland, & Shanks, 1978; Schachter, 1982; Tuchfeld, 1981). Self-change of addictive behaviors is often misnamed “spontaneous remission,” but such change involves external influence and individual commitment (Orford, 1985; Tuchfeld, 1981). These studies demonstrate that intentional modification of addictive behaviors occurs both with and without expert assistance. Moreover, these changes involve a process that is not well understood. Over the past 12 years, our research program has been dedicated to solving the puzzle of how people intentionally change their behavior with and without psychotherapy. We have been searching for the structure of change that underlies both self-mediated and treatment-facilitated modification of addictive and other problem behaviors. We have concentrated on the phenomenon of intentional change as opposed to societal, developmental, or imposed change. Our basic question can be framed as follows: Because successful change of complex addictions can be demonstrated in both psychotherapy and selfchange, are there basic, common principles that can reveal the structure of change occurring with and without psychotherapy? This article provides a comprehensive summary of the research on the basic constructs of a model that helps us understand self-initiated and professionally assisted changes of addictive behaviors. The key transtheoretical concepts of the stages and processes ADDICTIONS NURSING NETWORKNOLUME 5, NUMBER 1,1993 of change are examined, and their applications to a variety of addictive behaviors and populations are reviewed. This transtheoretical model offers an integrative perspective on the structure of intentional change. Stages of Change One objective of treatment outcome research in the addictions is to establish the efficacy of interventions. However, study after study demonstrates that not all clients suffering from an addictive disorder improve: Some drop out of treatment, and others relapse following brief improvement (Kanfer, 1986; Marlatt & Gordon, 1985). Inadequate motivation, resistance to therapy, defensiveness, and inability to relate are client variables frequently invoked to account for the imperfect outcomes of the change enterprise. Inadequate techniques, theory, and relationship skills on the part of the therapist are intervention variables frequently blamed for lack of therapeutic success. In our earliest research we found it necessary to ask when changes occur, in order to explain the relative contributions of client and intervention variables and to understand the underlying structure of behavior change (DiClemente & Prochaska, 1982; Prochaska & DiClemente, 1983). Individuals modifying addictive behaviors move through a series of stages from precontemplation to maintenance. A linear schema of the stages was discovered in research with smokers attempting to quit on their own and with smokers in professional treatment programs (DiClemente & Prochaska, 1982). People were perceived as progressing linearly from precontemplation to contemplation, then from preparation to action, and finally into maintenance. Precursors of this stage model can be found in the writings of Horn and Waingrow ( 1966), Cashdan ( 1973), and Egan (1975). Variations of and alternatives to our stage model can be found in more recent writings of Beitman (1986); Brownell, Marlatt, Lichtenstein, and Wilson (1986); Dryden (1986); and Marlatt and Gordon (1985). Several lines of research support the stages of change construct (Prochaska & DiClemente, 1992). Stages of change have been assessed in outpatient therapy clients as well as self-changers (DiClemente & Hughes, 1990; DiClemente & Prochaska, 1985; DiClemente, Prochaska, & Gilbertini, 1985; Lam, McMahon, Priddy, & Gehred-Schultz, 1988; McConnaughy, DiClemente, Prochaska, & Velicer, 3 1989). Clusters of individuals have been found in each of the stages of change, whether the individuals were presenting for psychotherapy or attempting to change on their own. Stages of change have been ascertained by two different self-report methods: a discrete categorical measure, which assesses the stage from a series of mutually exclusive questions (DiClemente et al., 1991), and a continuous measure, which yields separate scales for precontemplation, contemplation, action, and maintenance (McConnaughy et al., 1989; McConnaughy, Prochaska, & Velicer, 1983). In our original research we had identified five stages (Prochaska & DiClemente, 1982). But in principal component analyses of the continuous measure of stages, we consistently found only four scales (McConnaughy et al., 1983, 1989). We misinterpreted these data to mean that there were only four stages. For seven years we worked with a fourstage model, omitting the stage between contemplation and action (Prochaska & DiClemente, 1983, 1985, 1986). We now realize that in the same studies on the continuous measures, cluster analyses had identified groups of individuals who were in the preparation stage (McConnaughy et al., 1983, 1989). They scored high on both the contemplation and action scales. Unfortunately we paid more attention to principal component analyses rather than the cluster analyses and ignored the preparation stage. Recent research has supported the importance of assessing preparations as a fifth stage of change (DiClemente et al., 1991; Prochaska & DiClemente, 1992). Following are brief descriptions of each of the five stages. Precontemplation is the stage at which there is no intention to change behavior in the foreseeable future. Many individuals in this stage are unaware or underaware of their problems. As G. K. Chesterton once said, “It isn’t that they can’t see the solution. It is that they can’t see the problem.” Families, friends, neighbors, or employees, however, are often well aware that the precontemplators have problems. When precontemplators present for psychotherapy, they often do so because of pressure from others. Usually they feel coerced into changing the addictive behavior by a spouse who threatens to leave, an employer who threatens to dismiss them, parents who threaten to disown them, or courts who threaten to punish them. They may even demonstrate change as long as the pressure is on. Once the pressure is off, however, they often quickly return to their old ways. 4 In our studies using the discrete categorization measurement of stages of change, we ask whether the individual is seriously intending to change the problem behavior in the near future, typically within the next six months. If not, he or she is classified as a precontemplator. Even precontemplators can wish to change, but this seems to be quite different from intending or seriously considering change in the next six months. Items that are used to identify precontemplation on the continuous stage of change measure include “As far as I’m concerned, I don’t have any problems that need changing” and “I guess I have faults, but there’s nothing that I really need to change.” Resistance to recognizing or modifying a problem is the hallmark of precontemplation. Contemplation is the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. People can remain stuck in the contemplation stage for long periods. In one study of self-changers, we followed a group of 200 smokers in the contemplation stage for two years. The modal response of this group was to remain in the contemplation stage for the entire two years of the project without ever moving to significant action (DiClemente & Prochaska, 1985; Prochaska & DiClemente, 1984). The essence of the contemplation stage is communicated in an incident related by Benjamin (1987). He was walking home one evening when a stranger approached him and inquired about the whereabouts of a certain street. Benjamin pointed it out to the stranger and provided specific instructions. After readily understanding and accepting the instructions, the stranger began to walk in the opposite direction. Benjamin said, “Youare headed in the wrong direction.” The stranger replied, “Yes, I know. I am not quite ready yet.” This is contemplation: knowing where you want to go but not quite being ready yet. Another important aspect of the contemplation stage is the weighing of the pros and cons of the problem and the solution to the problem. Contemplators appear to struggle with their positive evaluations of the addictive behavior and the amount of effort, energy, and loss it will cost to overcome the problem (DiClemente, 1991; Prochaska & DiClemente, 1992; Velicer, DiClemente, Prochaska, & Brandenburg, 1985). On discrete measures, individuals who state that they are seriously considering changing the addictive behavior in the next six months are classified as contemplators. On the continuous measure these individuals would be endors- ADDICTIONS NURSING NETWORKNOLUME 5, NUMBER 1,1993 ing such items as “I have a problem and I really think I should work on it” and “I’ve been thinking that I might want to change something about myself.” Serious consideration of problem resolution is the central element of contemplation. Preparation is a stage that combines intention and behavioral criteria. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year. As a group, individuals who are prepared for action report some small behavioral changes, such as smoking five cigarettes less or delaying their first cigarette of the day for 30 minutes longer than precontemplators or contemplators (DiClemente et al., 1991). Although they have made some reductions in their problem behaviors, individuals in the preparation stage have not yet reached a criterion for effective action, such as abstinence from smoking, alcohol abuse, or heroin use. They are intending, however, to take such action in the very near future. On the continuous measure they score high on both the contemplation and action scales. Some investigators prefer to conceptualize the preparation stage as the early stimngs of the action stage. We originally called it decision-making. Action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. Modifications of the addictive behavior made in the action stage tend to be most visible and receive the greatest external recognition. People, including professionals, often erroneously equate action with change. As a consequence, they overlook the requisite work that prepares changers for action and the important efforts necessary to maintain the changes following action. Individuals are classified in the action stage if they have successfully altered the addictive behavior for a period of from one day to six months. Successfully altering the addictive behavior means reaching a particular criterion, such as abstinence. With smoking, for example, cutting down by 50% and changing to lower tar and nicotine cigarettes are behavior changes that can better prepare people for action but do not satisfy the field’s criteria for successful action. On the continuous measure, individuals in the action stage endorse statements such as “I am really working hard to change” and “Anyone can talk about changing; I am actually doing something about it.” They score high on the action scale and lower on the ADDICTIONS NURSING NETWORWVOLUME 5, NUMBER 1,1993 other scales. Modification of the target behavior to an acceptable criterion and significant overt efforts to change are the hallmarks of action. Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. Traditionally, maintenance was viewed as a static stage. However, maintenance is a continuation, not an absence, of change. For addictive behaviors this stage extends from six months to an indeterminate period past the initial action. For some behaviors maintenance can be considered to last a lifetime. Being able to remain free of the addictive behavior and being able to consistently engage in a new incompatible behavior for more than six months are the criteria for considering someone to be in the maintenance stage. On the continuous measure, representative maintenance items are “I may, need a boost right now to help me maintain the changes I’ve already made” and “I’m here to prevent. myself from having a relapse of my problem.” Stabilizing behavior change and avoiding relapse are the hallmarks of maintenance. Splral Pattern of Change. As is now wellknown, most people taking action to modify addictions do not successfully maintain their gains on their first attempt. With smoking, for example, successful self-changers make an average of from three to four action attempts before they become long-term maintainers (Schachter, 1982). Many New Year’s resolvers report five or more years of consecutive pledges before maintaining the behavioral goal for at least six months (Norcross & Vangarelli, 1989). Relapse and recycling through the stages occur quite frequently as individuals attempt to modify or cease addictive behaviors. Variations of the stage model are being used increasingly by behavior change specialists to investigate the dynamics of relapse (e.g., Brownell et al., 1986; Donovan & Marlatt, 1988). Because relapse is the rule rather than the exception with addictions, we found that we needed to modify our original stage model. Initially we conceptualized change as a linear progression through the stages; people were supposed to progress simply and discretely through each step. Linear progression is a possible but relatively rare phenomenon with addictive behaviors. Figure 1 presents a spiral pattern that illustrates how most people actually move through the stages of change. In this spiral pattern, people can progress from contemplation to preparation to action to maintenance, but most individuals will relapse. During relapse, individuals regress to an earlier stage. Some 5 a TERYINATION YAHTENANCE PRECONTEYPLATIOW CONTEYPLATKJN PREPARATKJ FIG. 1. A spiral model of the stages of change. relapsers feel like failures-embanassed, ashamed, and guilty. These individuals become demoralized and resist thinking about behavior change. As a result, they return to the precontemplation stage and can remain there for various periods of time. Approximately 15% of smokers who relapsed in our self-change research regressed back to the precontemplation stage (Prochaska & DiClemente, 1986). Fortunately, this research indicates that the vast majority of relapsers--85% of smokers, for example-recycle back to the contemplation or preparation stages (Prochaska & DiClemente, 1984). They begin to consider plans for their next action attempt while trying to learn from their recent efforts. To take another example, fully 60% of unsuccessful New Year’s resolvers make the same pledge the next year (Norcross, Ratzin, & Payne, 1989; Norcross & Vangarelli, 1989). The spiral model suggests that most relapsers do not resolve endlessly in circles and that they do not regress all the way back to where they began. Instead, each time relapsers recycle through the stages, they potentially learn from their mistakes and can try something different the next time around (DiClemente et al., 1991). On any one trial, successful behavior change is limited in the absolute numbers of individuals who are able to achieve maintenance (Cohen et al., 1989; Schachter, 1982). Nevertheless, in a cohort of individuals, the number of successes continues to increase gradually over time. However, a large number of individuals remain in contemplation and precontemplation stages. Ordinarily, the more action taken, the better the prognosis. Much more research is needed to better distinguish those who benefit from recycling from those who end up spinning their wheels. Additional investigations will also be required to explain the idiosyncratic patterns of movement through the stages of change. Although some transi- 6 tions, such as from contemplation to preparation, are much more likely than others, some people may move from one stage to any other stage at any time. Each stage represents a period of time as well as a set of tasks needed for movement to the next stage. Although the time an individual spends in each stage may vary, the tasks to be accomplished are assumed to be invariant. Treatment Impiicatlons. Professionals frequently design excellent action-oriented treatment and self-help programs but then are disappointed when only a small percentage of addicted people register, or when large numbers drop out of the program after registering. To illustrate, in a major health maintenance organization (HMO) on the West Coast, over 70% of the eligible smokers said they would take advantage of a professionally developed self-help program if one was offered (Orleans et al., 1988). A sophisticated action-oriented program was developed and offered with great publicity. A total of 4% of the smokers signed up. As another illustration, Schmid, Jeffrey, and Hellerstedt (1989) compared four different recruitment strategies for homebased intervention programs for smoking cessation and weight control. The recruitment rates ranged from 1%-5% of those eligible for smoking cessation programs and from 3%-12% for those eligible for weight control programs. The vast majority of addicted people are not in the action stage. Aggregating across studies and populations (Abrams, Follick, & Biener, 1988; Gottlieb, Galavotti, McCuan, 8c McAlister, 1990; Pallonen, Fava, Salonen, & Prochaska, in press), 10%-15% of smokers are prepared for action, approximately 30%-40% are in the contemplation stage, and 50%60% are in the precontemplation stage. If these data hold for other populations and problems, then professionals approaching communities and worksites with only action-oriented programs are likely to underserve, misserve, or not serve the majority of their target population. Moving from recruitment rates to treatment outcomes, we have found that the amount of progress clients make following intervention tends to be a function of their pretreatment stage of change (e.g., Prochaska & DiClemente, 1992; Prochaska, Norcross, Fowler, Follick, & Abrams, 1992). Figure 2 presents the percentage of 570 smokers who were not smoking at four follow-ups over an 18-month period as a function of the stage of change before random assignment to four home-based self-help programs, Figure 2 indicates that the amount of success smokers reported after treatment was directly ADDICTIONS NURSING NETWORWOLUME 5, NUMBER 1,1993 /=:I / --c- P I A PlQISt 1 6 12 ASSESSMENT PERIODS 18 FIG.2. Percentage abstinent over 18 months for smokers in precontemplation (PC),contemplation (C),and preparation (P/A) stages before treatment (n = 570). related to the stage they were in before treatment (Prochaska & DiClemente, 1992). To treat all of these smokers as if they were the same would be naive. And yet, that is what we traditionally have done in many of our treatment programs. If clients progress from one stage to the next during the first month of treatment, they can double their chances of taking action during the initial six months of the program. Of the precontemplators who were still in precontemplation at one month follow-up, only 3% took action by six months. For the precontemplators who progressed to contemplation at one month, 7% took action by six months. Similarly, of the contemplators who remained in contemplation at one month, only 20% took action by six months. At one month, 41% of the contemplators who progressed to the preparation stage attempted to quit by six months. These data demonstrate that treatment programs designed to help people progress just one stage in a month can double the chances of participants taking action on their own in the near future (Prochaska & DiClemente, 1992). Mismatching Stage and Treatment. A person’s stage of change provides proscriptive as well as prescriptive information on treatments of choice. Action-oriented therapies may be quite effective with individuals who are in the preparation or action stages. These same programs may be ineffec- ADDICTIONS NURSING NETWORWOLUME 5, NUMBER 1,1993 tive or detrimental, however, with individuals in precontemplation or contemplation stages. An intensive action- and maintenance-oriented smoking cessation program for cardiac patients was highly successful for those patients in action and ready for action. This same program failed, however, with smokers in the precontemplation and contemplation stages (Ockene, Ockene, & Kristellar, 1988). Patients in this special care program received personal counseling in the hospital and monthly telephone counseling calls for six months following hospitalization. Of the patients who began the program in action or preparation stages, an impressive 94% were not smoking at six-month follow-up. This percentage is significantly higher than the 66% nonsmoking rate of the patients in similar stages who received regular care for their smoking problem. The special care program had no significant effects, however, with patients in the precontemplation and contemplation stages. For patients in these stages, regular care did as well or better. Independent of the treatment received, there were clear relationships between pretreatment stage and outcome. Twenty-two percent of all precontemplators, 43%of the contemplators, and 76%of those in action or prepared for action at the start of the study were not smoking six months later. A mismatched stage effect occurred with another smoking program. An HMO-based self-help smoking cessation program for pregnant women was successful with patients prepared for action but had negligible impact on those in the precontemplation stage. Of the women in the preparation stage who received a series of seven self-help booklets through the mail, 38% were not smoking at the end of pregnancy (which was approximately 6 months posttreatment). This was triple the 12% success rate obtained for those who received regular care of advice and fact sheets. For precontemplators, however, 6% of those receiving special care and 6% receiving regular care were not smoking at the end of pregnancy (Ershoff, Mullen, & Quinn, 1987). These two illustrative studies portend the potential importance of matching treatments to the client’s stage of change (DiClemente, 1991; Prochaska, 1991). Stage Movements During Treatment. What progress do patients in formal treatment evidence on the stages of change? In a cross-sectional study we compared the stages of change scores of 365 individuals presenting for psychotherapy with 166 clients currently engaged in therapy (Prochaska & Costa, 1989). Patients entering therapy could usually be characterized as prepared for action because 7 their highest score was on the contemplation scale and second highest was on the action scale. The contemplation and action scores crossed over for patients in the midst of treatment. Patients in the middle of therapy could be characterized as being in the action stage because their highest score was on the action scale. Compared with patients beginning treatment, those in the middle of therapy were significantly higher on the action scale and significantly lower on the contemplation and precontemplation scales. We interpreted these cross-sectional data as indicating that, over time, patients who remained in treatment progressed from being prepared for action into taking action. That is, they shifted from thinking about their problems to doing things to overcome them. Lowered precontemplation scores also indicated that, as engagement in therapy increased, patients reduced their defensiveness and resistance. The vast majority of the 166 patients who were in the action stage were participating in more traditional insight-oriented psychotherapies. The progression from Contemplation to action is postulated to be essential for beneficial outcome, regardless of whether the treatment is action oriented or insight oriented (also see Wachtel, 1977, 1987). This crossover pattern from contemplation to action was also found in a longitudinal study of a behavior therapy program for weight control (Prochaska, Norcross, et al., 1992). Figure 3 presents the stages of change scores at pre- and midtreatment. As a group, these subjects entering treatment could be characterized as prepared for action. During the first half of treatment, members of this contingent progressed into the action stage, with their contemplation scores decreasing significantly and their action scores increasing significantly. The more clients progressed into action early in therapy, the more successful they were in losing weight by the end of treatment. The stages of change scores were the second best predictors of outcome; they were better predictors than age, socioeconomic status, problem severity and duration, goals and expectations, self-efficacy , and social support. The only variables that outperformed the stages of change as outcome predictors were the processes of change the clients used early in therapy. Processes of Change The stages of change represent a temporal dimension that allows us to understand when particular shifts in attitudes, intentions, and behaviors occur. ADDICTIONS NURSING NETWORWVOLUME 5, NUMBER 1,1993 8 STAGES OF CHANGE-WEIGHT r 35 CONTEMPLATION / / ACTION 31 29 27 Ft _.-.-.-. -.-.-.-. MAINTENANCE k N=53 ~ 5 I WEEKS FIG. 3. A longitudinal comparison of stages of change scores for clients before (week 1) and midway through (week 5) a behavioral program for weight reduction. The processes of change are a second major dimension of the transtheoretical model that enable us to understand how these shifts occur. Change processes are covert and overt activities and experiences that individuals engage in when they attempt to modify problem behaviors. Each process is a broad category encompassing multiple techniques, methods, and interventions traditionally associated with disparate theoretical orientations. These change processes can be used within therapy sessions, between therapy sessions, or without therapy sessions. The change processes were first identified theoretically in a comparative analysis of the leading systems of psychotherapy (Prochaska, 1979). The processes were selected by examining recommended change techniques across different theories, which explains the term transtheoretical. At least 10 subsequent principal component analyses on the processes of change items, conducted on various response formats and diverse samples, have yielded similar patterns (Norcross & Prochaska, 1986; Prochaska & DiClemente, 1983; Prochaska & Norcross, 1983; Prochaska, Velicer, DiClemente, & Fava, 1988). Extensive validity and reliability data on the processes have been reported elsewhere (Prochaska et al., 1988). The processes are typically assessed by means of a self-report instrument but have also been reliably identified in transcriptions of psychotherapy sessions (O’Connell, 1989). Our research discovered that naive self-changers used the same change processes that have been at the core of psychotherapy systems (DiClemente & Prochaska, 1982, 1985; Prochaska & DiClemente, 1984). Although disparate theories will emphasize certain change processes, the breadth of processes we have identified appear to capture basic change activities used by self-changers, psychotherapy clients, and mental health professionals. The processes of change represent an intermediate level of abstraction between metatheoretical assumptions and specific techniques spawned by those theories. Goldfried (1980, 1982), in his influential call for a rapprochement among the therapies, independently recommended change principles or processes as the most fruitful level for psychotherapy integration. Subsequent research on proposed therapeutic commonalities (Grencavage & Norcross, 1990) and agreement on treatment recommendations (Giunta, Saltzman, & Norcross, 1991) has supported Goldfried’s view of change processes as the content area or level of abstraction most amenable to theoretical convergence. Although there are 250-400 different psychological therapies (Herink, 1980; Karasu, 1986), based on divergent theoretical assumptions, we have been able to identify only 12 different processes of change based on principal component analysis. Similarly, although self-changers use over 130 techniques to quit smoking, these techniques can be summarized by a much smaller set of change processes (Prochaska et al., 1988). Table 1 presents the 10 processes receiving the most theoretical and empirical support in our work, along with their definitions and representative examples of specific interventions. A common and finite set of change processes has been repeatedly identified across such diverse problem areas as smoking, psychological distress, and obesity (Prochaska & DiClemente, 1985). There are striking similarities in the frequency with which the change processes were used across these problems. When processes were ranked in terms of how frequently they were used for each of these three problem behaviors, the rankings were nearly identical. Helping relationships, consciousness-raising, and self-liberation, for example, were the top three ranked processes across problems, whereas contingency management and stimulus control were the lowest ranked processes. Significant differences occurred, however, in the absolute frequency of the use of change processes ADDICTIONS NURSING NFMlORWOLUME 5, NUMBER 1,1993 9 Table 1. Titles, Definitions, and Representative Interventions of the Processes of Change Process Consciousness-raising Self-reevaluation Self-liberation Counter-conditioning Stimulus control Reinforcement management Helping relationships Dramatic relief Environmental reevaluation Social liberation Definitions: Interventions Increasing infomation about self and problem: observations, confrontations, interpretations, bibliotherapy Assessing how one feels and thinks about oneself with respect to a problem: value clarification, imagery, corrective emotional experience Choosing and commitment to act or belief in ability to change: decision-making therapy, New Year’s resolutions, logotherapy techniques, commitment-enhancing techniques Substituting alternatives for problem behaviors: relaxation, desensitization, assertion, positive self-statements Avoiding or countering stimuli that elicit problem behaviors: restructuring one’s environment (e.g., removing alcohol or fattening foods), avoiding high risk cues, fading techniques Rewarding one’s self or being rewarded by others for making changes: contingency contracts, overt and convert reinforcement, self-reward Being open and trusting about problems with someone who cares: therapeutic alliance, social support, self-help groups Experiencing and expressing feelings about one’s problems and solutions: psychodrama, grieving losses, role playing Assessing how one’s problem affects physical environment: empathy training, documentaries Increasing alternatives for nonproblem behaviors available in society: advocating for rights of repressed, empowering, policy interventions across problems. Individuals relied more on helping relationships and consciousness-raising for overcoming psychological distress than they did for weight control and smoking cessation. Overweight individuals relied more on self-liberation and stimulus control than did distressed individuals (Prochaska & DiClemente, 1985). Processes as Predictors of Change. The processes have been potent predictors of change for both therapy changers and self-changers. As indicated earlier, in a behavioral weight control program, the processes used early in treatment were the single best predictors of outcome (Prochaska, Norcross, et al., 1992). For self-changers with smoking, the change processes were better predictors of progress across the stages of change than were a set of 17 predictor variables, including demographics, problem history and severity, health history, withdrawal symptoms, and reasons for smoking (Prochaska, DiClemente, Velicer, Ginpil, & Norcross, 1985; Wilcox, Prochaska, Velicer, & DiClemente, 1985). The stages and processes of change combined with a decisional balance measure were able to predict with 93% accuracy which patients would drop out prematurely from psychotherapy. At the beginning of therapy, premature terminators were much more likely to be in the precontemplation stage. They rated the cons of therapy as higher than the pros, and they relied more on willpower and stimulus control than did clients who continued in therapy or terminated appropriately (Medieros & Prochaska, 1992). Integrating the Processes and Stages of Change The prevailing zeitgeist in psychotherapy is the integration of leading systems of psychotherapy (Norcross & Goldfried, 1992; Norcross, Alford, & DeMichele, 1992). Psychotherapy could be enhanced by the integration of the profound insights of psychoanalysis, the powerful techniques of behaviorism, the experiential methods of cognitive therapies, and the liberating philosophy of existentialism. Although some psychotherapists insist that such theoretical integration is philosophically impossible, ordinary people in the natural environment can be remarkably effective in finding practical means of synthesizing powerful change processes. The same is true in addiction treatment and research. There are multiple interventions but little integration across theories (Miller & Hester, 1980). One promising approach to integration is to begin to match particular interventions to key client characteristics. The Institute of Medicine’s (1989) report on prevention and treatment of alcohol problems identifies the stages of change as a key matching ADDICTIONS NURSING NETWORKNOLUME 5, NUMBER 1,1993 10 variable. A National Cancer Institute report of selfhelp interventions for smokers also used the stages as a framework for integrating a variety of interventions (Glynn, Boyd, & Gruman, 1990). The transtheoretical model offers a promising approach to integration by combining the stages and processes of change. A Cross=Sectional Perspective. One of the most important findings to emerge from our selfchange research is an integration between the processes and stages of change (DiClemente et d . , 1991; Norcross, Prochaska, & DiClemente, 1991; Prochaska & DiClemente, 1983, 1984). Table 2 demonstrates this integration from cross-sectional research involving thousands of self-changers representing each of the stages of change for smoking cessation and weight loss. Using the data as a point of departure, we have interpreted how particular processes can be applied or avoided at each stage of change. During the precontemplation stage, individuals used eight of the change processes significantly less than people in any of the other stages. Precontemplators processed less information about their problems, devoted less time and energy to reevaluating themselves, and experienced fewer emotional reactions to the negative aspects of their problems. Furthermore, they were less open with significant others about their problems, and they did little to shift their attention or their environment in the direction of overcoming problems. In therapy, these would be the most resistant or the least active clients. Individuals in the contemplation stage were most open to consciousness-raising techniques, such as observations, confrontations, and interpretations, and they were much more likely to use bibliotherapy and other educational techniques (Prochaska & DiClemente, 1984). Contemplators were also open to dramatic relief experiences, which raise emotions and lead to a lowering of negative affect if the person changes. As individuals became more conscious of themselves and the nature of their problems, they were more likely to reevaluate their values, problems, and themselves both affectively and cognitively. The more central their problems were to their self-identity, the more their reevaluation involved altering their sense of self. Contemplators also reevaluated the effects their addictive behaviors had on their environments, especially the people with whom they were closest. They struggled with questions such as “How do I think and feel about living in a deteriorating environment that places my family or friends at increasing risk for disease, poverty, or imprisonment?’ Movement from precontemplation to contemplation and movement through the contemplation stage entailed increased use of cognitive, affective, and evaluative processes of change. Some of these changes continued during the preparation stage. In addition, individuals in preparation began to take small steps toward action. They used counter-conditioning and stimulus control to begin reducing their use of addictive substances or to control the situations in which they relied on such substances (DiClemente et al., 1991). During the action stage, people endorsed higher levels of self-liberation or willpower. They increasingly believed that they had the autonomy to change their lives in key ways. Successful action also entailed effective use of behavioral processes, such as counter-conditioning and stimulus control, in order to modify the conditional stimuli that frequently prompt relapse. Insofar as action was a particularly stressful stage, individuals relied increasingly on support and understanding from helping relationships. Just as preparation for action was essential for success, so too was preparation for maintenance. Successful maintenance builds on each of the pro- Table 2. Stages of Change in Which Particular Processes of Change Are Emphasized Precontemplation Contemplation Preparation Consciousness-raising Dramatic relief Environmental reevaluation Self-reevaluation Action Maintenance Self-liberation Reinforcement management Helping relationships Counter-conditioning Stimulus control ADDICTIONS NURSING NETWORKNOLUME 5, NUMBER 1,1993 cesses that came before. Specific preparation for maintenance entailed an assessment of the conditions under which a person was likely to relapse and development of alternative responses for coping with such conditions without resorting to self-defeating defenses and pathological responses. Perhaps most important was the sense that one was becoming the kind of person one wanted to be. Continuing to apply counter-conditioning and stimulus control was most effective when it was based on the conviction that maintaining change supports a sense of self that was highly valued by oneself and at least one significant other. A Longitudinal Perspective. Cross-sectional studies have inherent limitations for assessing behavior change, and we, therefore, undertook research on longitudinal patterns of change. Four major patterns of behavior change were identified in a two-year longitudinal study of smokers (Prochaska, DiClemente, Velicer, Rossi, & Guadagnoli, 1992): (a) Stable patterns involved subjects who remained in the same stage for the entire two years; (b) progressive patterns involved linear movement from one stage to the next; (c) regressive patterns involved movement to an earlier stage of change; and (d) recycling patterns involved two or more revolutions through the stages of change over the two-year period. The stable pattern can be illustrated by the 27 smokers who remained in the precontemplation stage at all five rounds of data collection. Figure 4 presents these precontemplators’ standardized scores (M = 50, SD = 10) for the 10 change processes being used at six-month intervals over the two-year period. All 10 processes remained remarkably stable over the two-year period, demonstrating little increase or decrease over time. This figure graphically illustrates what individuals resistant to change were likely to be experiencing and doing. Eight of 10 change processes, like selfreevaluation and self-liberation, were between 0.4 and 1.4 standard deviations below the mean (i.e., 50). In brief, these subjects were doing very little to control or modify themselves or their problem behavior. This static pattern was in marked contrast to the pattern representing people who progressed from contemplation to maintenance over the two-year study. Significantly, many of the change processes did not simply increase linearly as individuals progressed from contemplation to maintenance. Selfreevaluation, consciousness-raising, and dramatic 11 relief-processes most associated with the contemplation stage4emonstrated significant decreases as self-changers moved through the action stage into maintenance. Conversely, self-liberation, stimulus control, contingency control, and counter-conditioning-processes most associated with the action stageevidenced dramatic increases as self-changers moved from contemplation to action. These change processes then leveled off or decreased when maintenance was reached (Prochaska, DiClemente, et al., 1992). Progressive self-changers demonstrated an almost ideal pattern of how change processes can be used most effectively over time. They seemed to increase the particular cognitive processes most important for the Contemplation stage and then to increase more behavioral processes in the action and maintenance stages. Before over-idealizing the wisdom of selfchangers, note that only 9 of 180 contemplators found their way through this progressive pattern without relapsing at least once. The longitudinal results of the 53 clients completing a behavior therapy program for weight control provide additional support for an integration of the processes and stages of change (Prochaska, Norcross, et al., 1992). As mentioned earlier, this group progressed from contemplation to action during the 10-week therapy program. Figure 5 presents the six change processes that evidenced significant differences over the course of treatment. As predicted by the transtheoretical model, clients reported significantly greater use of four action-related change processes; counter-conditioning, stimulus control, interpersonal control, and contingency management. They also increased their reliance on social liberation and decreased their reliance on medications, wishful thinking, and minimizing threats. In other words, these clients were substituting alternative responses for overeating; they were restructuring their environments to include more stimuli that evoked moderate eating; they reduced stimuli that prompted overeating; they modified relationships to encourage healthful eating; and they paid more attention to social alternatives that allow greater freedom to keep from overeating. Integrative Conclusions Our search for how people intentionally modify addictive behaviors encompassed thousands of research participants attempting to alter, with and without psychotherapy, a myriad of addictive behav- ADDICTIONS NURSING NETWORKNOLUME 5, NUMBER 1,1993 12 64 PRECONTEMPLATORS 62 60 58 56 * Process 54 52 50 48 46 44 42 40 38 36 34 I 1 I I 1 1 2 3 4 5 ROUND FIG.4. Use of change processes (T scores) for 23 smokers who remained in the precontemplation stage at each of five assessment points over two years. iors, including cigarette smoking, alcohol abuse, and obesity. From this and related research, we have discovered robust commonalities in how people modify their behavior. From our perspective the underlying structure of change is neither techniqueoriented nor problem-specific. The evidence supports a transtheoretical model entailing (a) a cyclical pattern of movement through specific stages of change, (b) a common set of processes of change, and (c) a systematic integration of the stages and processes of change. Probably the most obvious and direct implication of our research is the need to assess the stage of a client's readiness for change and to tailor interventions accordingly. Although this step may be intuitively taken by many experienced clinicians, we have found few references to such tailoring before our research (Beutler & Clarkin, 1990, Norcross, 1991). A more explicit model would enhance efficient, integrative, and prescriptive treatment plans. Furthermore, this step of assessing stage and tailoring processes is rarely taken in a conscious and ADDICTIONS NURSING NETWORKNOLUME 5, NUMBER 1,1993 I ’1 z ... 3 a w - ................/-.0 CONDITIONING SELF-LIBEXTION C . Y oc LL 2 - sTlMuLuscoNTRoL MERPERSONAL CONTROL MEDICATKNS 1 - L meaningful manner by self-changers in the natural environment. Vague notions of willpower, mysticism, and biotechnological revolutions dominate their perspectives on self-change (Mahoney & Thoreson, 1972). We have determined that efficient self-change depends on doing the right things (processes) at the right time (stages). We have observed two frequent mismatches. First, some self-changers appear to rely primarily on change processes most indicated for the selfcontemplation stage+onsciousness-raising, reevaluation-while they are moving into the action stage. They try to modify behaviors by becoming more aware, a common criticism of classical psychoanalysis: Insight alone does not necessarily bring about behavior change. Second, other self-changers rely primarily on change processes most indicated for the action stage-reinforcement management, stimulus control, counter-conditioning-without the requisite awareness, decision-making, and readiness provided in the contemplation and preparation stages. They try to modify behavior without awareness, a common criticism of radical behaviorism: Overt action without insight is likely to lead to temporary change. We have generated a number of tentative conclusions from our research that require empirical confirmation. Successful change of the addictions involves a progression through a series of stages. Most selfchangers and psychotherapy patients will recycle 13 several times through the stages before achieving long-term maintenance. Accordingly, intervention programs and personnel expecting people to progress linearly through the stages are likely to gather disappointing and discouraging results. With regard to the processes of change, we have tentatively concluded that they are distinct and measurable both for self- and therapy changers. Similar processes appear to be used to modify diverse problems, and similar processes are used within, between, and without psychotherapy sessions. Dynamic measures of the processes and stages of change outperform static variables, like demographics and problem history, in predicting outcome. Competing systems of psychotherapy have promulgated apparently rival processes of change. However, ostensibly contradictory processes can become complementary when embedded in the stages of change. Specifically, change processes traditionally associated with the experiential, cognitive,and psychoanalytic persuasions are most useful during the precontemplation and contemplation stages. Change processes traditionally associated with the existential and behavioral traditions, by contrast, are most useful during action and maintenance. People changing addictive behaviors with and without therapy can be remarkably resourceful in finding practical means of integrating the change processes, even if psychotherapy theorists have been historically unwilling or unable to do so. Attending to effective self-changers in the natural environment and integrating effective change processes in the consulting room may be two keys to unlocking the elusive structure of how people change.. References Abrams, D.B., Follick, M.J., Biener, L., Individual versus group self-help smoking cessation at the workplace: Initial impact and 12-month outcomes. In T. Glynn (Chair). Four National Cancer Institute-funded self-help smoking cessation trials: Interim results and emerging patterns. 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Dr. Prochasku is with the Cancer Prevention Research Consortium, University of Rhode Island. Dr. DiClemente is at the University of Houston, and Dr. Norcross is at the University of Scranton. Counseling Session 1 Counseling Session 1 Program Transcript Welcome to the first day of counseling for Marge, an alcoholic who has just been admitted to the addictions facility. Please carefully read the paperwork developed by a support staff member during Marge’s intake process earlier today. Marge’s husband, Ken, was also briefly interviewed during this time. After reviewing this information, click the “continue” button to begin Marge’s first counseling session. Using your cursor, rollover buttons A and B to review your question options. Click what you think is the best question to ask Marge out of the two options offered. If you ask an effective counseling question, you will receive more information from Marge. If you ask an ineffective question, you will receive an equally unhelpful response. Choose wisely, because the better you counsel Marge, the better her treatment experience. *Please keep in mind that the video has been made in a way that gives you a realistic vantage point from where you would sit and counsel your client in real life. A close up view of the individual has not been added because you, as a counselor, will not have varying angles of your client to work with. Paperwork: • • • • • • • • • Marge C. 41-year-old female Married Husband, Ken, works two jobs to make ends meet, so he is not home much. Husband noted that he didn’t know what else to do about his wife’s drinking, and that he had brought her to the facility out of desperation. Patient has three children, ages 10, 12, and 16 Patient was a teacher, but she lost job for alcohol-related reasons Patient had a one-car, alcohol-related accident three days earlier. She received minor injuries and was issued a ticket for DUI. Husband, family members, and friends determined that they needed to intervene to prevent Marge from harming herself and/or others. An intervention occurred earlier today, culminating in her being brought for treatment. Patient will go through a week of detoxification during her first week in treatment to address the physical withdrawal from alcohol [Opening scene: Marge’s admission into residential treatment. Her counselor is meeting with her for the first time and is conducting Marge’s initial assessment. Marge is disheveled, wears no makeup, and her eyes are red from crying. An adhesive bandage is on her forehead, and she has a black eye and abrasions from a one-car accident she had several days ago She was charged with driving while under the influence, her first such charge. © 2014 Laureate Education, Inc. 1 Counseling Session 1 Her posture is closed—arms crossed, turned away from counselor, and avoiding eye contact initially. She is tremulous throughout the interview due to impending physical withdrawal from alcohol. She tries to control her shakes but is not successful. Her mood is labile (up and down, unstable). She presents herself at the first part of the session as if she is the victim of an injustice and blames her husband. She’s initially defensive. This shell begins to melt quickly as the session moves forward and ends with a receptive, open Marge who seems to have surrendered to the fact that she may need help. Her body posture, facial expressions, and tone of voice reflect this change as it occurs through the session.] Question #1: Option A: Counselor: Marge, I will be your counselor. I want you to know I’m glad you’re here. I imagine this has been a hard day for you. Right now, I just want us to begin get to know each other better. I also want to know more about your drinking so we can begin to plan your treatment. It’s natural to be anxious and upset right now. You look like you feel like that now. Are you? Marge: Yes, of course I am! And furthermore, I don’t want to be here; I don’t need help. Option B: Counselor: Hello, Marge. I will be your counselor. I want you to know I’m glad you’re here, and I want to help you in any way I can. I imagine this has been a hard day for you, and I know that you and your husband have already answered many questions during your admission process. Right now, I just want us to begin get to know each other better. I also want to know more about your drinking so we can begin to plan your treatment. It’s natural to be anxious and upset right now. Tell me your thoughts and feelings right now. Marge: You’re right, I am anxious, and I’m more than that right now! I’m hurt, I’m scared, and I’m furious at my husband Ken for dragging me to this place. I want you to know right now I am not here on my own; I am here only because he and my so-called friends threatened to have me committed involuntarily for “my own safety,” as they say, if I didn’t agree to do it myself. I know I drink too much, but I can handle it myself. I don’t need to be put in this rehab and hid away from the rest of the world to do it. I’m not like the other people you have here; they might need help, but I can do it on my own. I don’t need help. © 2014 Laureate Education, Inc. 2 Counseling Session 1 Question #2 Option A: Counselor: You “don’t need help”? Marge: No. I am strong willed. I know I drink too much, but I have to because of all the stress. Raising a family, and then when I was teaching…it was double hard. I have diabetes on top of it all, and I’m unemployed and now this damn DUI hangs over my head. Then, as if that’s not enough, there’s Roger, my 12-yearold son; he’s always getting in trouble at home and school. It’s never ending. I could go on and on. Yeah, I admit. I drink too much, but I do it to deal with all my problems and my constant depression. You would too if you were me. No one understands that. But I can go to AA and go back to that counselor at the community mental health clinic and stop without all this ridiculous fuss of coming here. I’ve tried it before; I just didn’t give it all I had. Option B: Counselor: I think you’re wrong; I think you do need help, and I want to help you see that. Marge: No, I don’t; you’re just like them. No one seems to want to listen to me; they just jump to their own conclusions about my life. I’ve tried to stop on my own before; I just didn’t give it all I had. I’ll tell you again for the umpteenth time, I DON’T NEED HELP! Question #3 Option A: Counselor: You say you’ve tried to stop drinking before, Marge. Please tell me more about that. Marge: I could do it for a while. I went to AA and that counselor, like I said, and I went a month or two once. But always things would start piling up, and I’d take a drink just in the afternoon after 5 like I used to, and then before I knew it I’d be drinking all day again. I just didn’t try hard enough. I will now; I know I can do it. I feel guilty because I’ve been too weak and just never tried hard enough. I know what alcoholism is, believe me, my father was one, so was my uncle—they went to their graves drinking. I just need to get strong and build up my willpower to make my mind up © 2014 Laureate Education, Inc. 3 Counseling Session 1 to stop. I need to stop being such a weakling and an irresponsible mother and wife. It’s almost immoral the way I’ve been doing, but I can do it now. I just need a change. I need to go home. Option B: Counselor: You said earlier that you’ve tried to stop drinking before but were not successful. That tells me you need to help. Don’t you agree? Marge: No. Question #4 Option A: Counselor: Marge, let me share something with you that you may not know. We look at alcoholism and other addictions as a disease. Some people have a genetic predisposition for it. It’s not a moral issue, Marge, or a matter of lack of will power. That puts a different light on your situation, doesn’t it, Marge? Marge: No. Option B: Counselor: Marge, I think I hear what you’re saying. You admit you drink too much, and you seem to think you can stop on your own without coming here for 30 days. You think you just haven’t tried hard enough, and you feel that you’re a weak and immoral person for that. Let me share something with you that you may not know. We look at alcoholism and other addictions as a disease. Some people have a genetic predisposition for it. People who are genetically predisposed to the disease when faced with the right combination of conditions can’t handle alcohol. They may start just drinking socially in a controlled way and then drink to deal with stress or other problems. Because of their genes, they need more and more and eventually need to drink just to keep from going into withdrawal. It’s not a moral issue, Marge, or a matter of lack of willpower. What are your thoughts about what I just said? Marge: (Marge’s whole demeanor has changed during this last exchange from the counselor—she begins to make eye contact with the camera/counselor and relax her defensive, closed posture. She begins to convey a sense of surrender combined with a touch of desperation). (After a moment’s silence, reflecting on what the counselor said, then tearfully begins to talk after a moment of silence) I…………..I never thought of it that way. Well, I guess I have, but (stammers)…..well…, I…, uh……I can see how that © 2014 Laureate Education, Inc. 4 Counseling Session 1 could be. ….A disease maybe? It could explain why even though I don’t really want to be like this I am and that I though I’ve really tried to stop I just haven’t known how…..(looks down staring at her hands now folded in her lap, the truth has sunk in). When we first got married and began to have our children, I would have glass of wine several times a week with dinner, or maybe even with Ken when we both got home after a long day at work and the children had gone to bed. Then it was every day, then in the morning, and then I was hiding my drinking habits and drinking just to feel normal. I was teaching, and it got to where I would drink vodka before I went to school. I thought no one would smell vodka, but it didn’t work. I was fired. My life has spiraled since then, my children, my marriage, my health, everything. If I don’t drink now I get horribly ill; you can’t imagine how ill. I start feeling things on my skin or seeing things; it’s bad. I get crazy, just like my father and uncle used to get. I know Ken has tried to protect me all these years. He means well. He would call the school when I was too drunk to go and tell them I was sick. That’s what he’s always told the children, “Your mother’s ill, she can’t help it.” Oh help me, please… (Marge breaks down at this point, head in hands, sobbing out of control….LONG SILENCE as Marge’s sobs become more controlled.) Question #5 Option A: Counselor: Marge, you just turned the corner, and I’m proud of you. You’ve just made a giant step today, and you’ve just started on your road to recovery. What are your thoughts and feelings now as we conclude our first session? Marge: (Marge has softened; she’s beginning to feel relief that she’s finally admitted she has a problem and that help is here. She is still hurt and maybe embarrassed perhaps.) I guess I just feel grateful that someone is listening to me and understands. (Wipes her eyes, pauses, takes deep breath) I feel so embarrassed….my husband has put up with so much, and I know the kids have needed me and I haven’t been around. I just wanted to take care of it by myself, do at least one thing without having to rely on someone else for help, © 2014 Laureate Education, Inc. 5 Counseling Session 1 you know? I should at least do that, since I’ve messed up so much already. (Deep breath) I don’t want to leave the kids alone for 30 days, but….I guess I’ve left them alone anyway. I’m scared, but I am willing to try. If you really think you can help me, I promise I’ll do my best. I have to make it work…for my kids and for Ken. Option B: Counselor: Marge, I know this is hard, but until you admit you have a problem, your drinking will only continue to get worse and cause you and your family more problems. I want you to think about that before we meet again, OK? Marge: Yes, I will. Listen, I know you mean well…..but uh… well…uh…I just don’t think you or anyone else in my life hears me. Final Text: Congratulations. You have now completed your counseling session with Marge. © 2014 Laureate Education, Inc. 6 History of Psychology 2012, Vol. 15, No. 3, 233–246 © 2011 American Psychological Association 1093-4510/11/$12.00 DOI: 10.1037/a0025649 TOUGH LOVE: A Brief Cultural History of the Addiction Intervention Claire D. Clark This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Emory University Popular media depictions of intervention and associated confrontational therapies often implicitly reference—and sometimes explicitly present— dated and discredited therapeutic practices. Furthermore, rather than reenacting these practices, contemporary televised interventions revive them. Drawing on a range of literature in family history, psychology, and media studies that covers the course of the last 3 decades, this paper argues that competing discourses about the nuclear family enabled this revival. Historians such as Stephanie Coontz, Elaine Tyler May, and Natasha Zaretsky have demonstrated that the ideal nuclear family in the post-WWII United States was defined by strictly gendered roles for parents and appropriate levels of parental engagement with children. These qualities were supposedly strongly associated with middle-class decorum and material comfort. By the 1970s, this familial ideal was subjected to a variety of criticisms, most notably from mental health practitioners who studied— or attempted to remedy—the problematic family dynamics that arose from, for example, anxious mothers or absent fathers. After psychological professionals began to question the logic of treating maladjusted individuals for the sake of preserving the nuclear family, a therapeutic process for doing exactly that was popularized: the addiction intervention. The delayed prevalence of therapeutic interventions arises from a tension between the psychological establishment that increasingly viewed the nuclear family as the primary site and source of social and psychological ills, and the producers of popular media, who relied on the redemptive myth of the nuclear family as a source of drama. Keywords: popular culture, addiction, intervention, confrontational therapy, nuclear family Senator Walter Mondale: I recall somebody said— maybe it was you—the cocktail hour had replaced the family hour. Dr. Urie Bronfenbrenner: The children’s hour. Senator Mondale: The children’s hour. Is there any way to chart that? How do you know? Dr. Bronfenbrenner: It is very hard to chart that partly because of the very existence of the neglect of concern for children and families. Nobody has even been looking. We do not know what the problems are. That is how deeply they are buried from public consciousness or even scientific consciousness. (American families: Trends and pressures: Hearing before the Subcommittee on Children and Youth of the Committee on Labor and Public Welfare, 1973) This article was published Online First November 7, 2011. Claire D. Clark, Department of Behavioral Sciences and Culture, Science & History, Rollins School of Public Health and Graduate Institute of Liberal Arts, Emory University. Correspondence concerning this article should be addressed to Claire D. Clark, Graduate Institute of Liberal Arts, 537 Kilgo Circle, S415-Callaway Center, Atlanta, GA 30322. E-mail: cdclar4@emory.edu During the heyday of the idyllic postwar nuclear family, public visions of domestic problems were rare. According to historian Natasha Zaretsky (2007), 1973 marked a moment in which concerns previously contained within the home had officially spilled out into the family therapy session, the streets, and the U.S. Senate. After an anomalous period of postwar prosperity and (according to Bronfenbrenner’s testimony) the unhealthy repression and denial of the dangers of its indulgences, middle-class dysfunction was going public. It has not gone back. Alongside these 1973 senate hearings, PBS debuted the documentary miniseries An American Family, a vérité-style exposé that caused controversy by jointly disproving Norman Rockwell and Leo Tolstoy: Beneath every identically happy American family, the series suggested, is a similar mess of “laughs, tears,” and 233 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 234 CLARK “mistakes.”1 The show chronicled an uppermiddle-class nuclear family (the aptly named “Louds”) in Santa Barbara, California, throughout the parents’ separation, and concluded with their eventual divorce. With the entrance of the Louds, the documented life of the “real” American family became the subject of public entertainment as well as professional inquiry. While the American public has vacillated between the desire to view depictions of happy and unhappy families, the psychological profession has experimented with various approaches to treating the problems that arise in real ones. What is the relationship between popular and professional visions of the development of the postwar American family? Family historians who concentrated on the “inward turn” and “domestic containment” that accompanied White class mobility in the 1950s noted TV’s role in promoting consumerism along with idealized insularity.2 Betty Freidan (1963) famously observed that this consumerism also included psychiatric services, especially for discontented mothers and wives. In contrast, media historians have documented how scientific researchers and professional experts (including psychologists) used a variety of media to “educate” the public over the course of the twentieth century. These historians analyzed how technological development, economic infrastructure, and government regulation have influenced the content and form of psychologists’ messages.3 So far, stories that have combined these two narratives have usually concluded that as society became more mediasaturated, the information conveyed by media became more spectacular, and that, in general, this phenomenon had a negative effect on both individual psychology and family life. How did this argument work? Partly by suggesting that the cocktail hour and the TV set worked in concert, dulling the senses and promoting interfamilial distraction rather than connection. In his testimony, Brofenbrenner noted a study that recorded audio in middle-class homes and found that children heard their fathers’ voices less than 40 times a week. In the 1950s and 1960s, family therapists increasingly stepped in to address disequilibrium in families rendered dysfunctional by, for example, avoidant-dismissive mothers or absent dads. For both left- and right-leaning historians, these “helping” professionals only exacerbated the problem by continuing to encourage a psychological outlook that was both self-centered and overly reliant on the external validation promoted by hyperconsumerism—what Christopher Lasch (1979) later described as a “culture of narcissism.”4 Screen-cultures scholar Lynn Spigel (1988, 1992) describes how the physical presence of the TV in the postwar American household supported this psychological outlook. Promoted as a “window on the world,” the TV allowed families to look “out” at places and products that represented the good life, and encouraged viewers to imagine similar families across the nation who might be sharing the experience of TV-watching in their own living rooms. At the same time, the window metaphor also implied that the TV might be a way for other people to see into the once-private space of the family home. In the 1950s, the people who wanted to get into the family home via TV were not, on the whole, interested in cold war spy tactics or even Bronfenbrenner-style observational microphones. They sought to impart knowledge, not to observe domestic behavior. TV historian Anna McCarthy (2010) shifts the scholarly attention away from the “proverbial living room to the boardrooms of the Waldorf Astoria,” where elite businessmen and professionals imagined the TV set as a legitimate way to 1 The TIME magazine cover story, from which these quotes were drawn, was titled “Show business: A sample of one?” (1973). The invocation of the language of social science in reference to reality-based television, as well as the relationship between this genre and sociology and anthropology, is explored in Simon (2005). The changing definition of reality television in general is explored in the collection in which Simon’s article is featured: G. Edgerton and B. Rose (Eds.), 2005, Thinking outside the box: A contemporary television genre reader, Lexington, KY: University of Kentucky Press. 2 See Elaine Tyler May (2008) for a discussion of “domestic containment” and Stephanie Coontz (2000) for a discussion of how television promoted an unrealistic, inward-looking, and nostalgic vision of the nuclear family. 3 For a discussion of the co-optation of scientific expertise by the “superstitious” and sensationalistic twentiethcentury mass media, see Burnham (1987). For a discussion of the details of the production of scientific programming on radio and television, see LaFollette (2008). 4 On this point, Lasch agrees with Coontz and May, though they are more concerned about the substitution of consumerism for political action than its role weakening individual psyches and wills (or the effect this weakening has on the “haven” of the nuclear family). This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. TOUGH LOVE: A BRIEF HISTORY OF THE ADDICTION INTERVENTION educate, inspire, and shape democratic citizens (p. 9). Whether sponsoring debates about desegregation or demonstrations of “better living through chemistry,” TV, in its early years, could be used by elites for the good of the hypothetical public. Some of these goods were unabashedly psychological; demonstrations of group therapy techniques, for example, were broadcast as part of the “public service” program The Johns Hopkins Science Review. While dramatizations of the psychoanalytic “talking cure” had been a prominent feature of Hollywood films such as The Snake Pit (1948), the initial appearance of psychological techniques on TV was distinguished from these cinematic depictions by their didactic format, the prominence given to actual scientific or psychological professionals, and the intimate positioning of the screen inside the homes of the intended audiences who were supposedly dutifully receptive of the programs’ messages. Whether spectators were actually so dutiful is debatable, but changes in government regulation and ownership of the airwaves brought about the end of the “American viewing public,” which splintered into demographic “markets.” The “technocratic elites” of the postwar period lost their monopoly (McCarthy, 2010, p. 7). As a result, station programming became saturated with sitcoms (1970s), syndication brought talk shows (1980s–1990s), and cable networks introduced “reality” programming (1990s–present). Although it has been credited as the first “reality show,” An American Family (1973) aired at a time when this process of deregulation was underway, but well before the less restrictive cable TV labor market began to influence production. While produced and distributed under different conditions than the talk shows and reality programs that would follow it, the documentary series was received, both then and now, as a prescient indicator of later cultural and familial shifts.5 As Natasha Zaretsky (2007) noted, beginning in the 1970s, “fears about the fate of the family shaped debates about American national decline, and fears about the nation’s future were mediated through the family” (p. 17). While Zaretsky (2007) examines challenges to the trope of the ideal nuclear family, I focus more clearly on the conditions in which this “mediation” took place and the roles played by the cooptation (or dramatization) of psychological practice in this process. Changes in the production and distri- 235 bution of popular representations of psychological practices has meant that credentialed practitioners have less control about the ways in which their methods are portrayed. Yet these portrayals have presumably affected the professional landscape; for example, public interventions are often accompanied by exhortations to seek private psychological assistance via help lines, self-help books, or residential rehabilitation facilities. Surprisingly, a series of discussions of these addiction interventions suggest that, rather than contributing to the ideas challenging to the nuclear family, TV’s distorted adoption of psychological practices has worked to recuperate the familial ideal of midcentury. The nuclear family ideal was defined by Elaine Tyler May (2008) as the unrealistic belief that “family life in the postwar era would be secure and liberated from hardships past”; that “affluence, consumer goods, satisfying sex and children would strengthen families, allowing them to steer clear of potential disruptions”; and that “adhering to traditional gender roles and prizing material stability” was the best path to the good life (p. 14). The addiction intervention is a staged encounter that brings to the surface the tensions that were both dulled and exacerbated by the proverbial “cocktail hour.” Perhaps because confrontational therapeutic techniques have largely fallen out of favor in professional psychological practice, scholars have been reluctant to recognize the persistent prevalence of depictions of the intervention as an appropriate, if overly dramatic, therapeutic strategy. Taking an approach that might be broadly termed “cultural studies,” this paper combines cultural history’s concern with the discursive tension between the public and private spheres with a “history of ideas” approach that traces the appearance of a concept (the addiction intervention) through a series of historical moments (Lovejoy, 1936). Rather than offering an exhaustive account of every representation of the therapeutic “intervention”— or even every intervention technique—this paper identifies and analyzes key “moments” in which variations of 5 Print and television advertisements for Cinema Verite, HBO’s April 2011 docudrama based on the series, dubbed it “the first reality show” and opened with a series of intertitles contextualizing the appearance of Louds within a series of significant historical events, including the Vietnam War. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 236 CLARK the psychological practice have been reenacted in popular and televisual culture.6 Focusing on confrontational therapies and the addiction intervention, this paper details three instances in which the popular media’s adoption of these techniques served to recuperate the status of the fragmented nuclear family (both specific and archetypal) in which the confrontations took place. I begin with Betty Ford’s addiction intervention, which, 10 years after the professional technique was generated, first brought the concept of the intervention into popular consciousness. I continue with an analysis of daytime talk shows of the 1990s, reading these as a throwback to confrontational encounter therapies of the 1970s. I argue that, originally, these therapies provided a way to reformulate new visions of family or to cope with the widespread loss of long-term committed relationships; when the confrontational therapeutic tactics later reemerged in popular culture, however, they were instead used to police, rather than challenge, the normalized nuclear family. In these cases, the distinctions between the private space of the nuclear family home and the public sphere of popular media discourse are complicated in significant ways. Throughout my discussion, I demonstrate that popular media has used the rhetoric of space to dramatize the dysfunctional power dynamics of the “private” families being represented and that this visibility signaled the vulnerability of the ideal nuclear family in general.7 This discussion of space culminates in my final example, which examines intervention-based reality shows, such as A&E’s Intervention and TLC’s Addicted. Scenes in which families screen recordings of the bad behavior of the addict in crisis literalize and affirm the trope of welcome, even curative, surveillance introduced in the prior popular iterations of the therapeutic confrontation. I reach the conclusion that, over the past 30 years, the ideal of the nuclear family was exploited as popular culture reversed the course of psychology’s challenges to it. Vernon Johnson, Betty Ford, and the Double Bind in the Nuclear Family On Saturday afternoon, April 1, 1978, former First Lady Betty Ford was pacing across her home in Rancho Mirage, California, contemplating phoning her son and daughter-in-law in Pittsburgh, when suddenly they appeared at her front doorstep. What seemed, at first, to be a pleasant surprise, then, moments later, a humorless April Fool’s Day joke, became an entirely solemn “intervention.” Additional family members assembled, along with a Navy doctor, and seated themselves in a semicircle in front of Ford. One by one, her husband, sons, daughter, and daughter-in-law recounted Ford’s failures as both mother and public figure, and connected these lapses to her dependency on alcohol and prescription pain medication: She slurred her words at the ballet; she was unavailable to babysit her grandchildren; she refused to come to the dinner table when called, preferring instead to finish her cocktail by the TV. The accumulation of sins, delivered with accusatory compassion by those closest to her, caused Ford to “collapse into tears,” admit that she needed help for chemical dependency, and accept the aid offered by naval doctor Joe Pursch, head of the Alcohol and Drug Rehabilitation Service at Long Beach. Later, after emerging from the facility at Long Beach that would come to bear her name, Ford would justify and contextualize the event using the rationale of a particular branch of the addiction treatment industry. Her description became both popular archetype and the how-to manual for the addiction intervention, a confrontational therapeutic technique first promoted by Episcopalian minister Vernon John6 The dramatic mode of the intervention has expanded from Vernon Johnson’s (1990) model, which concentrated on alcohol and drug users in nuclear families to include confrontations by family, friends, coworkers, and others about “strange” addictions, inappropriate clothing choices, real estate listings, and school lunches. 7 Academic debates on the rhetoric of space are wideranging and multidisciplinary; indeed, they encompass entire fields (architecture and cartography, for example). For our purpose here, a crude summary of literature in critical theory views space as a construction, a concept that links more concrete “places” (such as “living rooms” or “subway stations”) by the process of categorical “spatialization.” These representational linkages might come in predictable forms, such as maps, but they can also be conveyed through language, staging, or classical Hollywood editing. Who is granted access to particular spaces, and how they move through them, can be indicative of other categorical power dynamics (between people of varying races, genders, or abilities, for example). This paper follows Jürgen Habermas’s (1962) well-known distinction between public and private “spheres,” and builds upon subsequent studies of their gendered associations and dimensions. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. TOUGH LOVE: A BRIEF HISTORY OF THE ADDICTION INTERVENTION son almost a decade earlier. In her autobiography, Ford (1978) wrote, “The thinking used to be that a chemically addicted person—whether on pills or alcohol— had to hit bottom, decide he wanted to get well, before he could begin to recover; but now it’s been demonstrated that a sick person’s family, along with others significant and important to the patient, can intervene to help him despite himself” (p. 281). Although Ford’s name was already associated with one public health cause— cancer awareness—following her hospitalization at Long Beach, “Betty Ford” became synonymous with addiction rehabilitation facilities. Ford’s intervention did not occur on TV, but it was recounted in her autobiography and later dramatized in a made-for-TV movie. Therefore, as a public event, it provided a model for later portrayals of the addiction intervention. Furthermore, the narrative’s conclusion in Ford’s successful residential treatment, and her subsequent support of treatment centers, implicated the psychological profession and suggested legitimacy for the intervention’s rhetoric. The addiction intervention, and popular representations of confrontational therapies more generally, are as much about saving the ideal of the nuclear family as they are about “helping the addict despite himself.” Indeed, feminist scholar and cultural theorist Helen Keane (2002) has argued, “In spite of the concern with the authentic inner self and its destruction by addiction, this intervention [was] largely about Mrs. Ford’s failure to keep up appearances and meet her maternal and wifely duties. According to this irrational but omnipresent fear of surveillance, Ford’s lapses at both the public ballet and in the privacy of her living room were equally damning. The Ford family seemed to be accusing her not so much of being an addict, but of letting her addiction show and interfere with the smooth running of their lives” (p. 83). The smooth running of their lives takes place, meaningfully, within the home, which becomes both the subject of inquiry and the setting in which the drama of confrontation unfolds. The scene of Ford’s domestic intervention references TV, both explicitly and implicitly. Ford’s recollection that the semicircle formed by her concerned family members during her intervention remains “burned in her brain” resonates with Spigel’s (1992) discussion of the postwar “family circle,” featured in popular photography as a 237 family of TV viewers “grouped around the set in semicircle patterns” (p. 16). TV watching was thus framed as a “family activity” and the “cement” that would solidify families previously separated by the war. As Keane (2002) explains, these familial, gendered expectations create the drama that the staged addiction intervention resolves. Keane (2002) concentrates on the intervention as it appears in a kind of classical form and deconstructs the paradox outlined in the script presented in Johnson’s (1990) “complete guide for families,” entitled Everything You Need to Know About Chemical Dependence. Keane (2002) notes that, according to Johnson’s script, placing the addict in the center of the semicircle encourages scrutiny that assumes wrongdoing. The subject of the intervention is not allowed to “to have her own equally true stories to tell about the betrayals, disappointments and bad behavior” (p. 81). But Keane’s observation that the intervention removes the complicated factors of “contradictory and conflicting versions of reality operating simultaneously, interwoven with webs of power, resentment and love”—and that th...
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