By Steven Hayes
Originally published by Psychotherapy Networker, Inc. Sep/Oct 2007

I keep a supply of Chinese finger traps in my office to show to patients. When you push your fingers into each end of these straw tubes and then try to remove them, the tube diameter shrinks and grabs the digits firmly. The more you struggle, the more your fingers are trapped. The only way to create enough room to get your fingers back out is to do something counterintuitive: push them deeper into the tube, which only then relaxes its grip.

These toys demonstrate a basic principle about why so many of the issues people bring into therapy seem insoluble, despite determined and well-intentioned efforts to deal with them: fighting a problem can itself create a problem. I remember giving one of these finger traps to an especially anxious client and watching as he practically pulled his fingers out of their sockets in his frantic attempt to get them free. Suddenly, abandoning his struggle with the toy, he let his hands relax. “Okay,” he said knowingly, “I get it.” He pushed the ends of the tubes inward and then removed his fingers easily. I knew he meant more than understanding how the toy worked, though. He saw in that moment a model of how his battle with anxiety had constricted his life, and that the strange alternative I was putting on the table might not be so strange after all: only by moving into his pain could he ever find the room to live fully.

A moment or two after this small epiphany, he surprised me by voicing an even deeper issue. As if asking himself a question he had no idea how to answer, he added “And then what?” It’s an important question, with a surprising answer.

Dr. Steven Hayes, Ph.D.

During the past 10 years, a number of therapy approaches have come into the mainstream of clinical practice based on the core idea that the more we struggle with the Chinese finger traps of the human mind, the more confused and stuck we become. Mindfulness-Based Cognitive Therapy, Dialectical Behavior Therapy, and the approach my colleagues and I have developed, Acceptance and Commitment Therapy (ACT), all agree that a first step toward fundamental change is to come into the present moment–even if that moment is painful–and let go of the impulse to leapfrog into a desired future from which inner troubles have evaporated. These methods are based on the view that taking the obvious step of trying to escape from difficult thoughts and feelings usually makes them worse–just as with finger traps, in which doing the presumably “sensible” thing is counterproductive–and, in the process, takes us further and further away from a liberated life.

Rather than being preoccupied with changing the painful content of the mind, these methods change our relationship with what troubles us. For example, instead of disputing negative thoughts, patients learn to watch them mindfully and at enough distance to realize, in a visceral and not just analytical way, that they’re just thoughts. Instead of getting rid of sadness, patients learn to detect how sadness feels in their body, how it tugs at their behavior, how it ebbs and flows, and begin to feel at a deep level that they can carry sorrow with them while still living the life they want.

This is an important shift away from many of the traditional methods of psychotherapy, perhaps especially so in my own home territory of the behavioral and cognitive therapies, which have long focused on reducing negative emotions and thoughts as a method of life change. The first wave of behavior therapy aimed at directly changing the intensity of emotions and the form or frequency of overt behavior through desensitization, token economies (using “token” chips or points to reward positive behavior change), and the like. The second wave of behavior therapy put more emphasis on cognition, producing cognitive-behavioral therapy (CBT). But like the first wave, CBT targeted the form and frequency of these cognitions, such as whether they were rational or contained cognitive errors, and tried to change them through testing, disputation, and analysis.

By contrast, ACT and other mindfulness-based methods invite patients to step into the now and fundamentally change their relationship with their own experience. Instead of trying to manipulate and change their inner world into a more “desirable” form, these methods encourage patients to deepen and enrich their contact with a continuously unfolding present.

The Trap of the “Problem”

A basic principle of ACT, buttressed by 20 years of research into the nature of human cognition, is that common-sense problem-solving strategies, when applied to subjective experience, too often become traps. In fact, our research suggests that human problem solving itself contributes to the intractability of human suffering.

Consider how the focus of psychotherapy is defined within the first few moments of clients’ initial sessions. Clients typically begin by saying something like, “I’ve had anxiety for years and lately it’s gotten a lot worse,” or “My husband left me and I’m just lost,” or “I’m constantly worrying,” or “I just feel empty.” Patients frame their complaints as something happening that’s creating difficult thoughts, feelings, memories, or sensations. A thousand explanations will then be devised to explain the existence of these problems (“It’s my childhood,” or “It’s my neurotransmitters,” or “It’s my wife”). In the end, therapist and patient will typically agree, implicitly or explicitly, on the ultimate goal of whatever intervention follows: get rid of these unwanted thoughts, feelings, memories, or sensations.

In doing that, both are complicit in the assumption that these sources of distress need to be changed before real living can begin. You can see that agreement in the names of our most common “disorders,” through which anxieties, moods, thoughts, and other private experiences are appointed to play the role of “the problem.” And you can see it in the names of our treatments, which often suggest we need to restructure, manage, or master our experiences.

Although this appears to be a normal, logical, and reasonable approach, it may not be the most helpful. Consider a person with panic disorder trying to rid him- or herself of anxiety. It’s natural to focus on what seems to make anxiety more likely (stressful situations, not being able to leave a room easily, not having pills available, irrational thinking, and so on), and the apparent solutions that might lessen that anxiety (learning to relax, staying near the exit, being sure to have tranquilizers handy, thinking more rationally). But this commonsense approach is based on what Mark Williams, one of the originators of Mindfulness-Based Cognitive Therapy, calls a “discrepancy-based mode of thinking,” in which clients constantly measure and try to narrow the distance between what’s wrong or bad that’s going on now and what’s right or good that isn’t going on now. Thus their minds continuously cycle between an undesirable present and a desirable future.

This problem-solving approach works wonderfully in addressing many of the challenges of real-world survival, such as getting into a locked car or escaping from a burning building. To illustrate for trainees the vast cognitive capacities of the human animal that have allowed a species of weak, slow, defenseless creatures to take over the planet, I often give them the following challenge: “It turns out that all of the doors and windows are locked” I say, “and we have only one chance to leave here. We can implement any plan you like, but we have to agree on it without leaving our seats, and we can only implement the plan once, without pretesting it. If it fails, we’ll be stuck here forever.”

Usually the group quickly generates alternative escape plans: break the windows, call for help on a cell phone, crawl through the ductwork, kick down the door. Then they begin to consider and discuss the pros and cons of each. The door may not break easily. If we jump from the broken window, someone might get hurt. We may not have the right number to call or the phone battery may be dead. Eventually, a sound plan is agreed to without ever leaving our seats.

But when the target of our problem-solving efforts is our own thoughts and feelings, rather than the manipulation of our external environment, this rational approach typically becomes part of the problem. Once we buy into the idea that we’re in a bad situation that needs to be changed–whether that’s inside a locked room, in a finger trap, or in our own pain–our cognitive problem-solving skills will inevitably lead us to find ways to get out of the difficulty by applying our analytical skills. In the get-out-of-the-room situation, which involves manipulation of external events, rational problem solving works effectively. But applying that same process to an internal emotional state like panic is different, because the target actually tends to grow and spread in reaction to the problem-solving effort itself.

A person trying to “solve” the problem of panic by getting rid of it regularly evaluates the level of anxiety being experienced, and fearfully checks to see whether it’s going up or down. This process actually tends to elicit anxiety, and risks conditioning the person to experience anxiety in more and more circumstances. Anxiety gradually becomes a focus of life, and patients believe they can only live happily by constantly imagining themselves at some point in the future when they’re “cured” and anxiety has left the scene. Typically, life itself has to be put on hold while they continually and repeatedly attempt the impossible task of thinking themselves out of their anxiety.

In contrast, ACT takes the position that “experiential avoidance”–trying to steer away from psychological pain–limits our ability to be present in our own lives. Research has shown avoidance of pain is one of the most consistently troublesome processes in all of psychology, accounting for about 20 to 25 percent of the variance in successful outcome across a broad range of common psychological complaints–everything from depression, to difficulty in learning, to whether a traumatic event will lead to a post-traumatic stress disorder. The research evidence confirms the paradoxical proposition that trying to change your unpleasant thoughts and feelings typically just makes them more entrenched.

Coming into the Present

In contrast with traditional cognitive-behavioral therapies, ACT doesn’t try to change clients’ thoughts or feelings. It concentrates instead on helping them recognize that thoughts are just mental events to be noticed, not true or false pronouncements on the fundamental nature of reality itself. Similarly, feelings are something to be felt, not powerful and dangerous bullies to be avoided at all cost. According to ACT, the therapeutic task isn’t helping clients successfully dispute their thoughts or feelings; rather, it’s enabling people to say yes to their own experience, whatever it happens to be.

In the early development of ACT, my students and I created a protocol and tested it against traditional CBT for depression in a small randomized trial. We found we got better results by teaching patients to see depressive thoughts merely as thoughts than we did by trying to get them to change their thoughts. After nearly 15 years developing the model, we finally published it in book form in 1999. Since then, more than 20 randomized trials that we’ve conducted have shown that the approach can be effectively applied to stress, anxiety, psychosis, chronic pain, depression, burnout, and many other conditions.

How does ACT work? To help clients attain a present focus, it identifies three fundamental skills. The first is Cognitive defusion: separating the process of thinking from the world structured by thought. If you try to describe the present moment, you’ll notice something odd. Anything you have to say about “now” lags slightly behind now. Even if you quickly say the word now, the instant that you’re naming is the now that was there milliseconds ago, not the now that’s there when the word emerges. This is because language is based on the arbitrary relation between symbols and our ongoing experience, and no matter how quickly you relate one to the other, it takes time. Conversely, if you silently look about you for a few moments, everything you see is seen now, not a millisecond ago. There’s no time lag at the level of experience itself.

This difference creates a conundrum. Life can only go on now–it has no place else to go on. But our ability to generate symbolic meaning always lags behind, dampening the vitality of the immediate experience of the moment, and carrying us more and more into a symbolic world where now is merely a concept, not an experience.

There’s a solution to this conundrum, however. Without throwing out human language and all of its wonders and benefits, we can learn to see thinking itself as unfolding in the present. In ACT, we call this process “cognitive defusion.” ACT therapists and researchers have developed scores of defusion techniques. For example, if you have a client distill a painful thought into a single word and say it out loud repeatedly for 45 seconds or so, and by the end of that process, the word will have lost most of its punch based on its meaning. Instead, the client will become aware of the experience of saying the word–how it sounds or the feeling of saying it. Or clients may practice another mindfulness exercise, like viewing thoughts as things floating by like leaves on a stream. If, while doing this, they find themselves taking the thought or feeling literally–becoming emotionally engaged in the feeling of sorrow, anxiety, or anger, for instance–the sense of flow this exercise brings will stop. But once they’re able just to notice thoughts in the present–”I’m having the thought that I’m sad”–without either belief or disbelief, compliance or resistance, the flow continues again.

A thought like “I’m bad” invites us to argue about whether it’s true by providing evidence (usually from the past) on one side or the other. But whether it’s true or false is irrelevant to the fact that the thought is here, now. Simply noticing thoughts as processes, rather than as events that must be true or false, liberates clients from having to put their life on hold while cognitions are evaluated, accepted, rejected, argued with, or put in some sort of order.

The process of defusion dampens down the impact of thoughts and allows more flexibility in responding to them. For example, a panic-disordered person thinking “If I get anxious here, I’ll make a total fool of myself” might short cut the endless problem-solving, discrepancy-reducing mental rigmarole that makes the problem worse by simply thanking his mind for the thought, or by saying the thought again very slowly (“a toooooootaaal foooooool of myseeeeeelllllllfff”), singing the thought to the tune of a popular song, or saying it in a Donald Duck voice. The ACT defusion techniques all carry the same message: thoughts are just thoughts. Notice them and then do what works, not necessarily what they say.

The second fundamental ACT skill is Acceptance. When patients try to avoid, escape, or control painful feelings, the present becomes the enemy. Now is where and when feeling occurs, but they’re concentrating on the imagined future in which the now will be different. Coming into the present requires psychological acceptance–a voluntary and undefended leap into the multifaceted, multisensory moment. As with any leap, this means abandoning some degree of control. In a physical leap, we leave it to gravity to carry us safely back to earth. In a leap of acceptance, we give over control to the now, allowing our experiences to present themselves in their full breadth and depth.

ACT uses a variety of metaphors and experiential exercises, many borrowed from other experiential therapeutic traditions, to help clients get past the judgments and analytical mind-sets that keep them entangled in unproductive problem solving. When a client complains of being in the grip of a particularly painful feeling, which she feels she must get rid of, we’re likely to ask her to spend time getting thoroughly acquainted with it instead. One exercise, called the “Tin Can Monster,” suggests that overwhelming feelings are like huge monsters made up of tin cans, bubble gum, and rubber bands. The total effect can be overwhelming, but if we stop to examine their individual elements, we find nothing really fearsome there. In this eyes-closed exercise, we ask patients to get in touch with the difficult feeling and then notice carefully what their bodies do. The goal is to drop any struggle and just notice each specific bodily reaction. So, for example, as each reaction is named, the therapist takes the client into that sensation in great detail–where is it located, where does it begin and end? Or we might ask the client to imagine that the bodily sensation is an object on the floor and to describe its color, speed, texture, and weight. When the client is fully open to experiencing each sensation without defense, the next bodily reaction is sought. This dismantling process continues through urges to act, emotions, thoughts, and memories.

The task for clients is to drop their struggle with unwanted reactions and amplify contact with what is. Rather than trying to win a tug-of-war with difficult private experiences, clients learn to “drop the rope” and allow themselves to feel the experiences as they happen. That shift of perspective profoundly alters the function of feelings, changing them from something “bad” that must be evaluated and manipulated to something to be fully felt without fear or desperation.

The third basic ACT skill is the acquisition of a transcendent sense of self. Patients commonly confuse their passing thoughts, feelings, and judgments about themselves with their selfhood. They must develop a consciousness that they are their experiences, feelings, thoughts, and judgments, and, in some sense, independent of them. The problem is that we can’t really separate consciousness from the experiences that comprise it: we can’t examine the space where consciousness resides, because to do so would be like jumping to the side of oneself to look back at looking. At best, we can catch fleeting glimpses.

In ACT we produce these fleeting glimpses by exercises that first draw attention to the ongoingnesss of experience and then suddenly call attention to the person who’s aware of these experiences. For example, an ACT therapist might lead a client through the mindfulness exercise of “I’m not that.” It usually begins with eyes open. The client is asked to briefly examine objects in the area, notice the features of each one, and then say, “I’m not that.” The goal is to directly experience the distinction between what’s seen and the conscious person seeing it. After a time, the exercise continues with eyes closed. The therapist asks the client to explore sensations, emotions, thoughts, and memories following the same process–note the features of the inner experiences and then tell himself he isn’t the same as the consciousness noting them. This exercise arrives at a transcendent sense of self by a kind of subtraction. In this way, the constantly changing nature of thoughts and feelings is contrasted with the sense of continuity–the essence of consciousness, in which “you” have been “you” your entire life.

And Then What?

But as mindfulness and acceptance methods help clients more fully inhabit the present moment in their lives, they face an unavoidable question: what will they do with the now-ness of their lives? Once they’ve quit fighting their own experience, what should they do with it? It isn’t enough simply to help clients “live in the present moment.” The real issue, once they’ve “made friends,” so to speak, with their problems and learned to avoid avoidance, is how they should live. What should they live for? Or, as my patient put it so succinctly, “And then what?”

Jack Kornfield’s delightful book about spiritual exploration, After the Ecstasy, the Laundry, captures perfectly the eternal truth that no matter how stimulating and inspiring our adventures into consciousness and expanded awareness are, there’s still everyday life to be lived. For some people, there can be almost a narcotic quality to contacting the present moment, particularly if they’ve spent years trying to escape it. People can often experience dramatic reductions in anxiety or depression just by abandoning their attempts to reduce them in favor of accepting and being mindful of them.

The experience of living in the present, paradoxically, can tempt us into experiential avoidance all over again, just in a new form. It’s quite possible to trade escape from the now for escape into the now. The recent enthusiasm for mindfulness and acceptance in the West needs to be channeled properly or we risk creating just another form of Western self-indulgence. By themselves, mindfulness methods as they’re often used in Western psychotherapy don’t give sufficient attention to the organizing influence of purpose in human life. In the spiritual traditions from which such practices were drawn, “right action” is specified through ethical principles. But Western therapists are encouraged to take a value-neutral professional stance, and not direct our clients to any particular belief or “right action” enjoined by a religious or spiritual tradition. Nevertheless, we still can help our clients gain access to their deepest aspirations and turn a life lived in the present moment into a life worth living.

Avoidance and mindlessness can help us on this journey, if we know how to use them. The things that hurt us do so because we care. A person who fears relationships because of past betrayals is a person who values trust and intimacy: otherwise, the betrayal wouldn’t have hurt in the first place. An ACT saying expresses this idea: in your pain you’ll find your values, and in your values you’ll find your pain. That’s part of why experiential avoidance is so harmful: as we avoid our hurts, we can’t help but undermine our values. So, by helping clients accept their pain and stop avoiding it, we can help them open up to what they most deeply want in their lives. Their pain can serve as a powerful guide to therapy.

In the wake of a painful betrayal, the normal human reaction is avoidance of intimacy. It’s common to hear people who’ve been hurt say, “I’ll never let myself be so vulnerable again.” And yet, such a refusal also cuts one off from the possibility of deep human connection, and thus from one of life’s basic needs. Intimacy implies vulnerability–someone close to you truly can wound you, by definition. People vowing not to be vulnerable think they’re avoiding only the pain, but in fact, they’ve resolved to avoid intimacy itself precisely because they so deeply want it in their lives. This act of self-deception creates a wound far greater than the original hurt: we’re dealing now not just with betrayal, but with the pain of a life unlived.

Acceptance and mindfulness aren’t just about some trendy notion of “being here now,” but comprise a set of skills that enable clients to learn to live with emotions they might otherwise find intolerable–and use them as guideposts to a life of deeper purpose. An ACT therapist might commonly ask the intimacy-avoiding client, “If moving powerfully in the direction of the intimacy you long for implied learning how to carry the pain of your past betrayals, would you do so?”

We take clients into pain because it’ll inevitably come up when they move toward what they really want. Defusion and acceptance help clients realize that plain hurt isn’t devastating. By contrast, the kind of denied, convoluted hurt that comes from avoidance is deeply harmful because it blocks us from achieving full consciousness and full humanity.

By reducing the need to avoid painful feelings, acceptance and mindfulness can actually help people become braver and live with the anxiety, pain, and discomfort required to attain something they deeply value. From an ACT perspective, values are consciously undertaken actions aimed at achieving purposes that are deeply important to one’s sense of selfhood. Research suggests that the only values that can transform lives are those that are purposely chosen, reflect what you really want, and are fully expressed in your actions. Only doing what you truly value for its own sake, because it’s what you want, will ultimately contribute to your development, even your happiness, as a human being.

It’s also important to remember that valuing something isn’t the same as achieving life goals. Values are like directions on a compass. They’re never “achieved,” but in each and every step they influence the quality of the journey. Values dignify and clarify our life course by putting pain in a proper context: it’s now about something that matters to us, which we want with our entire selves. In the realization that values can’t ever be achieved, only lived moment to moment, comes joy, because from the first moment clients acknowledge what their values are, they’re living them. Values aren’t something you can both have and be finished with, like objects you can put in a box and store away–they’re ongoing, active, and perpetually generative.

If a client really owns up to wanting to be a good father, for example, in that very act of acknowledgement, values are coming alive. The path this value implies will never be complete, but a consciousness of that value will enable a coherent journey through a continuously unfolding now. Said another way, the value directs the journey, but it’s the journey that ultimately matters.

There are no shortcuts to living joyfully: we can’t just take refuge in the moment and avoid the messy process of life itself. When we learn to carry our fears, we still have to face all life’s day-to-day decisions and difficulties. But once we’re aware of our values and develop a deeper commitment to our own purposes, life becomes much more vital than it is when we’re merely trying to keep our demons at bay.

If we stay connected with what we most care about, life itself will present us with exactly what needs to be accepted. We can begin to do that by staying right here, right now, in this present moment. But acceptance is then about something. It provides an answer to my client’s question: “And then what?” Acceptance and mindfulness aren’t ends in themselves. Rather, they empower us to live a value-filled, meaningful, committed life by helping us to open up to the full range of thoughts and feelings we experience from moment by moment.

About Steven Hayes, Ph.D.:

Professor of psychology at the University of Nevada at Reno. He’s written 300 peer-reviewed articles and 27 books, including his latest, Get Out of Your Mind & Into Your Life.

The more difficult the decision we face, the more likely we are not to act, according to new research by UCL scientists that examines the neural pathways involved in ‘status quo bias’ in the human brain.

The study, published today in Proceedings of the National Academy of Sciences (PNAS), looked at the decision-making of participants taking part in a tennis ‘line judgement’ game while their brains were scanned using functional MRI (fMRI).

First author Stephen Fleming, Wellcome Trust Centre for Neuroimaging at UCL, said: “When faced with a complex decision people tend to accept the status quo, hence the old saying ‘When in doubt, do nothing.’

“Whether it’s moving house or changing TV channel, there is a considerable tendency to stick with the current situation and choose not to act, and we wanted to explore this bias towards inaction in our study and examine the regions of the brain involved.”

The 16 study participants were asked to look at a cross between two tramlines on a screen while holding down a ‘default’ key. They then saw a ball land in the court and had to make a decision as to whether it was in or out. On each trial, the computer signalled which was the current default option – ‘in’ or ‘out’. The participants continued to hold down the key to accept the default and had to release it and change to another key to reject the default.

The results showed a consistent bias towards the default, which led to errors. As the task became more difficult, the bias became even more pronounced. The fMRI scans showed that a region of the brain known as the subthalamic nucleus (STN) was more active in the cases when the default was rejected. Also, greater flow of information was seen from a separate region sensitive to difficulty (the prefrontal cortex) to the STN. This indicates that the STN plays a key role in overcoming status quo bias when the decision is difficult.

Stephen added: “Interestingly, current treatments of Parkinson’s disease like deep-brain stimulation (DBS) work by disrupting the subthalamic nucleus to alleviate impaired initiation of action. This is one example of how knowing about disease mechanisms can inform our knowledge of normal decision making, and vice-versa.

“This study looked at a very simple perceptual decision and there are obviously other powerful factors, such as desires and goals that influence decisions about whether or not to act. So, it would be of interest to investigate how these regions respond when values and needs come into play.”

Provided by University College London

Below is a link to a lecture given by Dr. Gabor Maté to a Canadian First Nation group. He gives a great overview of some of the science behind substance addiction. He also gets to the root of passing the behavior to our children. This lecture is very educational and explains some of the “causes and conditions” that lead from substance use, to abuse, to addiction.

http://www.youtube.com/watch?v=BpHiFqXCYKc

This is a great example of a professional in the drug treatment industry with an enlightened view: examining not only the symptoms, but also the “causes and conditions” that lead to substance abuse. By understanding why we behave as we do, we can learn new skills and retrain how we think. Through this understanding and acceptance we can overcome self destructive behavior.

Thank you to Darren Littlejohn, The 12-Step Buddhist, for passing this video on to me.

About Dr. Maté: Vancouver, Canada-based physician and author. He is staff physician at the Portland Hotel Society, which runs a residence and harm reduction facility as well as Insite, North America’s only supervised safe-injection site. His four books, all bestsellers in Canada, include Scattered: How Attention Deficit Disorder Originates and What You Can Do About It, When the Body Says No, and his latest, In the Realm of Hungry Ghosts: Close Encounters with Addiction.

Before you begin to make changes in your life, it might be useful to understand the process. The theory called the Stages of Change Model (SCM) describes the mind/body stages we go through when we do change.

James Prochaska, Ph.D and Carlo Diclemente, Ph.D (1982) developed SCM  in the late 1970’s and early 1980’s while at the University of Rhode Island. They were studying how smokers were able to give up their habits. The model has been applied to a broad range of behaviors including weight loss, injury prevention, overcoming alcohol, and drug problems among others.

This a model of change which is unique in many ways. First, it is empirically driven: it is based on the researchers’ scientific investigation of change in humans. Second, the model conceptualizes change as entailing a number of stages which all require alterations in attitude in order to progress. Third, the model depicts change as a cycle, rather than an all or nothing step or series of steps. The authors contend that it is quite normal for people to require several trips through the stages to make lasting change. Additionally, each of us progresses through the stages at our own rate.

One of the reason the SCM is attractive, is that it recognizes change as flexible to individual needs. Some people make lasting change quite rapidly, others require a few times through the stages to acquire more knowledge and build skills. Just as some can master skiing on the first try, others require a couple of seasons to get to the intermediate level.

In this sense relapse can be viewed as a normal part of the change process, as opposed to a complete failure. This does not mean that relapse is desirable or even invariably expected. It simply means that change is difficult, and it is unreasonable to expect everyone to be able to modify a habit perfectly with out any slips. Relapses can vary in severity, as can our reactions to them. Some relapses can be so discouraging that people return to a precontemplative stage for a long time before contemplating change again. Others get right back on track, considering the antecedents to relapse, where they need to put more effort, and swiftly move back into action again.

We enter the stages of change from a state of precontemplation– during which the idea of change is not seriously considered. The cycle begins when we start to contemplate the need for change. Hopefully we will tip the scales in favor of change and become determined to take action. Then specific alterations in thinking and behaving will be initiated. It is hoped that the alterations become accepted and eventually ingrained or automatic. If we are able to maintain our accomplishments, we can exit the cycle entirely.

The Stages of Change

In brief, the stages of change are:

• Precontemplation – Not acknowledging that there is a problem behavior that needs to be changed.
• Contemplation – Acknowledging that there is a problem but not yet wanting to make a change.
• Preparation - Planning to make the changes.
• Action - Actively changing behavior and thoughts.
• Maintenance – Maintaining the behavior change.
• Lapses - Returning to old behaviors and abandoning the new changes. This can happen at any point in the stages.

Stage One: Precontemplation

In the precontemplation stage, people are not thinking seriously about changing and are not interested in any kind of help. People in this stage tend to defend their current bad habit(s) and do not feel it is a problem. They may be defensive in the face of other people’s efforts to pressure them to quit. They do not focus their attention on quitting and tend not to discuss their bad habit with others. It would be easy to call this “denial,” but a much more accurate view would be to describe Precontemplation as a state when a person is “uninformed” in the sense that no personally convincing reason for change has been presented as of yet. In this stage people simply do not yet see themselves as having a problem.

Stage Two: Contemplation

In the contemplation stage, people are more aware of the personal consequences of their habit. They start to think about their problem. Although they are able to consider the possibility of changing, they tend to be ambivalent about it. In this stage, people are weighing the pros and cons of quitting or modifying their behavior. Although they think about the negative aspects of their bad habit and the positives associated with giving it up (or reducing), they may doubt that the long-term benefits associated with quitting will outweigh the short-term costs. It might take as little as a couple weeks or as long as a lifetime to get through the contemplation stage. On the plus side, people are more open to receiving information about their bad habit. They become more likely to use educational interventions and reflect on their own feelings and thoughts concerning their bad habit.

Stage Three: Preparation

People in the preparation/determination are planning to take action and are making the final adjustments before they begin to change their behavior. Their motivation for this change may be reflected by statements such as: “I’ve got to do something about this. What can I do?”

This is sort of a research phase as they start taking steps toward cessation of their behavior. They attempt to gather information about what they will need to do to change their behavior, or seek help to understand how to successfully change. At this stage it is important to gather resources and knowledge that will help with success.

It is also important to establish a goal which works with you. A goal which is reasonable for one person, may be unreasonable or inadequate for another. Our goals must be consistent with our capabilities, our values, and our needs. Sometimes, especially by experts in the field of addiction treatment, a successful outcome is mandated as the only realistic goal.

Too often, people skip this stage: they try to move directly from contemplation into action and fail because they haven’t adequately researched or accepted what it is going to take to make this major lifestyle change. For example, many people with intentions for change believe that they must undergo a drastic lifestyle and identity change in order to alter a habit. For example, many recovering substance abusers believe that they must abstain not only from the substance they have abused, but also from all past behaviors, deny all pleasure, and assume a stoic lifestyle. Rarely is this drastic a lifestyle change necessary, or even ideal for lasting change. Often with this “all-or-nothing” approach to change, is that people find that it is virtually impossible to bare, or that they just hate it. They eventually become discouraged and stop the whole change process.

So, at this stage, it is important to examine what specifically you want to modify in your life, and what about your lifestyle is better left unchanged. Understand what you want to change, the motivation for the change, and most importantly, have a destination or way-point defined so that you can recognize the change.

Stage Four: Action

This is the stage where people not only have a desire to change, but also believe they have the ability to change their behavior and are actively involved in taking steps to change their behavior.

The amount of time people spend in action varies: but, in general it lasts about 6 months. This step requires the greatest commitment of time and energy. Mentally, they review their commitment to themselves, practice new skills, and develop plans to deal with both personal and external pressures that may lead to slips. They may use short-term rewards to sustain their motivation, and analyze their behavior change efforts in a way that enhances their self-confidence. People at this stage also tend to be open to receiving help and are also likely to seek support from others: this can be a very important element.

As people make conscience efforts to quit or change the behavior, they are at greatest risk for relapsing to old behaviors. Being mindful of triggers, and the reactions to them, is important. This is where actively building skills, changing thoughts toward the old behavior, and developing alternative coping behaviors comes in to play.

Stage Five: Maintenance

Maintenance involves being able to successfully practicing new skills and avoiding the temptations to return to the old habit. The goal of the maintenance stage is to maintain the new status quo. People in this stage tend to remind themselves of how much progress they have made, while still being cognizant of what it took to make the change.

People in maintenance constantly reformulate the rules of their lives and are acquiring even more skills to deal with life and avoid relapse. They are able to anticipate the situations in which a relapse could occur and prepare coping strategies in advance. They remain aware that what they are striving for is worthwhile and personally meaningful. They are accepting of themselves and recognize that it takes time to let go of old behavior patterns and to become proficient at new ones: realizing that ultimately the new behavior will become as comfortable to live with as the old. Even though they may have thoughts of returning to their old bad habits, they resist the temptation and stay on track.

As you progress through your own stages of change, it can be helpful to re-evaluate your progress in moving through these stages.

Lapses

Along the way to permanent cessation of a habit, many people experience a lapse. These are often accompanied by feelings of discouragement and seeing oneself as a failure.

There is a real risk that people who lapse will experience an immediate sense of failure that can seriously undermine their self-confidence. One of the most significant problems with the 12-step model is the all-or-none manner in which lapses are construed. Regardless of the intensity, slips and lapses have been viewed as failure, time to “start over.”

It is important to remember that experiencing a lapse is common.  In fact, most successful self-changers go through the stages three or four times before they make it through successfully without a lapse. Many will return to the contemplation stage of change; others return to the planning stage to implement what they have learned from the lapse. Consequently, the Stages of Change Model considers a lapse to be normal.

Rather than seeing a failure, analyze how the slip happened and use it as an opportunity to learn how to cope differently. People who lapse may need to learn a more effective ways anticipate high-risk situations, control environmental cues that tempt them to engage in their bad habits,  learn how to handle unexpected episodes of stress, or redefine their personal boundaries. Analyzing what happened gives a stronger sense of self control and the ability to get back on track. In fact, relapses can be important opportunities for learning and becoming stronger.

Transcendence

In addition, there is one more stage that Marc Kern Ph.D., CAS added which is not part of Prochaska-DiClemente original Stages of Change model: Transcendence.

Eventually, if you “maintain maintenance” long enough, you will reach a point where you will be able to work with your emotions and understand your own behavior and view it in a new light. This is the stage of “transcendence.” In this stage, not only is your old habit no longer an integral part of your life but to return to it would seem atypical, abnormal, even weird to you. When you reach this point in your process of change, you will know that you have transcended the old habits and that you are truly becoming a new “you”, who no longer needs the old behaviors to sustain yourself.

References

DiClemente, C. C. & Prochaska, J. O. (1982). Self-change and therapy change of smoking behavior: A comparison of processes of change in cessation and maintenance. Addictive Behaviors, 7, 133-142.

That voice we all hear in our head telling us to engage in destructive behaviors can be very convincing: it will try to rationalization, make up excuses, and lie relentlessly to get its way. So how do we fight giving in? Most people understand how to win an argument with a two-year old: don’t argue. Similarly, the way to fight an urge is to not argue with it. Put your foot down, and say NO to the urge. Instead of arguing with every well rehearsed reason the urge will throw at you, engage in a different conversation with yourself.

DISARM

Destructive Self-talk Awareness and Refusal Method (DISARM) is a tool which exposes the self-talk and images which tell us to use. It challenges those urge-producing thoughts at every opportunity, shooting them down and eventually reducing them to the point of absurdity. All humans, not just humans with substance abuse problems, have thoughts, urges, or other impulses, which, if followed, would harm their long-term interests. Realizing the power to control what we think and believe, especially about our strong urges to use, and understanding how to change the distorted thinking is crucial to success.

“It is a man’s own mind, not his enemy or foe, that lures him to evil ways.” ~Siddhārtha Gautama

We are wise to learn how to make ourselves aware of our destructive self-talk: the thinking that is contrary to our values and long-term interests. Once we recognize it, we can then adamantly refuse to go along with it.

When a strong urge is recognized, ask and answer the following questions:

1. Question: Do I have to give in to the urge because it is intense and hard to resist?
   Answer: No, I don’t have to give in. Because the urge is strong, it would be easy to give in, but I don’t HAVE TO. I have had urges that I did not give in to, therefore it must be possible to resist.
2. Question: Will it be awful to deny myself by not giving into the urge?
   Answer: No, it won’t be awful. It may be quite unpleasant, but unpleasant is not awful, it’s just unpleasant. If I don’t give in to the urge, it will get weaker and come less frequently. If I do give in, the urge will stay strong, be harder to resist next time and show up more frequently.
3. Question: Is it really unbearable not to give into this urge?
   Answer: I don’t like the way it feels to deny my urge, but since it doesn’t kill me not to give in, I can keep on resisting. (Remember, individuals drinking large amounts of alcohol may need to go to a detox center when they first stop because the sudden end of alcohol really could be injurious.)
4. Question: Am I somehow entitled to be able to give up using without strong urges to go back to using?
   Answer: No! I don’t have a note from God, my mother, or anyone else which entitles me not to have strong urges to use. It may be unpleasant to resist some of my urges, but no one gave me a ‘get out of unpleasantness free’ card.

We cannot simply will ourselves to not have certain thoughts and feelings. However, we can learn how to recognize the thoughts driving urges and how to refuse to go along with them: we can learn to DISARM them. We can then walk away from the situation, or get our mind involved with something else, rather than dwelling on the urge to use. DISARM allows the individual experiencing the craving and to carefully and rationally answer a few key questions. The results of using DISARM will help an individual to understand that urges can truly be overcome. As success is experienced, the urges will eventually become less strong and will occur less frequently.

DISARMING the ‘ENEMY’

Some people find it helpful to use a technique to dissociate themselves from the voice inside each of us which says, ‘It’s a good idea to do something self- destructive.’ It is a game you can play with yourself, which might help you to:

1. Identify the specific thoughts which, if followed, would lead to using when you have already decided that, in the long term, this choice is not for you, and
2. Steadfastly refuse to go along with this thinking no matter how attractive it might seem.

Instead of talking yourself into lapsing you can develop powerful countering and coping statements. To do this, it may help to invent and personify an ‘enemy’ who lives in your mind, and whose only purpose is to get you to use. The Enemy (your alter ego) knows you well, and can change form to take advantage of your weakest moments. Name your enemy (i.e., salesman, gangster, diplomat, bad cop). When urges come, ask yourself, ‘What is she/he telling me now? How is she/he trying to trick me?

When thoughts are identified:

1. Without debate, ATTACK the enemy with powerful counter statements: ‘Nice try, jerk. You can’t fool me!’ You can be as aggressive or profane as your nature allows with the Enemy – after all, it’s trying to screw up your life.
2. Then quickly FOCUS on some other thoughts, images, or activities which are consistent with what you want in the long run and inconsistent with what the Enemy is saying. The Enemy then looses its perceived power and fades away.

Once the urge has passed, you can submit the Enemy’s tricks to an ABC analysis in order to rationally dispute them. You usually discover irrational themes and patterns to the thoughts and arguments the Enemy throws at you. While the coping statements used in DISARM alone will often work, it is important not to omit disputing. If your coping statements aren’t working, it is because you don’t believe them as strongly as you believe the Enemy. Through disputing we can develop powerful coping statements you fully believe for use in the future. Through actually resisting the Enemy’s suggestions, you become increasingly more skilled at doing it.