Further evidence for dissociationcomes from experiments indicating aso-called “hidden observer.” Forexample, the hypnotist instructs asubject that he or she is deaf and thensays, “Although you are deaf, perhapspart of you can hear. If so, raise yourfinger.” The finger rises. When askedlater, the subject says he heard noth-ing but suddenly felt his finger rise.The experiment suggests that two dis-tinct systems of consciousness areoperating, separated by a partial ortotal barrier of amnesia.

A different understanding is reflect-ed in the social-cognitive theory ofhypnosis, which emphasizes sug-gestibility rather than dissociation.Social-cognitive theorists interpret thehypnotic trance not as an altered stateof consciousness but as one strikingeffect of the human susceptibility tosocial influence. Their idea is that thehypnotist and the subject have enteredinto an implicit agreement that certainthings will be allowed to happen andthe subject will describe or confirmcertain experiences. The subjectresponds to these “demand character-istics” of the situation, doing and say-ing what is expected to win the hypno-tist’s approval. The hypnotic trance is aperformance — not mere playactingbut the sincere adoption of a role. Ifthis view is correct, hypnotic suscepti-bility is a result of willingness to com-ply with suggestions, sensitivity tonuances in personal communication,and a high capacity for sincere make-believe and self-dramatization.

Social-cognitive theorists say thatthey can increase or decrease a per-son’s apparent hypnotic susceptibilitysimply by changing the instructionsand therefore the subject’s expecta-tions. For evidence, they rely heavilyon experiments with people who,according to standard tests, are noteasily hypnotized. When these simu-lators pretend to be hypnotized andact accordingly, they are said torespond just like a person in a “gen-uine” trance. Social-cognitive theorists

add that the hidden observer of dis-sociation theory is not real but aproduct of suggestion that can also bemanipulated by changes in theinstructions. Apparent individual dif-ferences in hypnotic susceptibility areexplained by differences in sug-gestibility and in the expectationsbrought to the situation.

In response, advocates of the dis-sociation theory argue that peoplewho are pretending to be hypnotizedrespond to suggestions only whenthey are being observed, unlike peoplewho are truly hypnotized. Also, some

people who are told to pretend mayactually go into a trance, and suscep-tibility to social influence may itselfsometimes be a hypnotic effect. Somebelieve the dispute between the theor-ies cannot be resolved, because in theend there is no difference betweenentering a special state of conscious-ness and immersing oneself in a per-formance so deeply that it is nolonger experienced as playacting. Ineither case there are likely to be signsof imaginative absorption, dividedattention, and selective recall.

tMAY 2002 www.health.harvard.edu HARVARD MENTAL HEALTH LETTER

The stagesPrecontemplation. People at this stagehave no serious intention of changingtheir behavior now or in the foresee-able future. (Some may express avague wish to change, which is differ-ent.) They are generally unaware oftheir problem or greatly underest-imate it. Family members, friends,neighbors, or employers may have aclearer view. When people seek treat-ment at this stage, it is often underpressure from others.

To decide whether a person is atthis stage, we ask whether he or sheseriously intends to deal with theproblem in the next six months. Wealso provide a questionnaire askingfor agreement or disagreement with

such statements as “I guess I havefaults, but there’s nothing that I reallyneed to change” and “As far as I’mconcerned, I don’t have any problemsthat need changing.”

Contemplation. At this stage peopleare aware that a problem exists andhave been seriously thinking aboutovercoming it but have not yet made acommitment to action. They say theyare seriously considering change in thenext six months. Answering the ques-tionnaire, they agree with such state-ments as “I have a problem and I reallythink I should work on it” and “I’vebeen thinking that I might want tochange something about myself.”Despite good intentions, it is commonto languish at this stage for a long time.

Using the Stages of ChangeBY JOHN C. NORCROSS, PH.D. AND JAMES O. PROCHASKA, PH.D.

People suffering from mental disorders and behavioral disturbances differ

greatly in their readiness to take action to solve their problems. At any

given time, about 40% don’t know they have a problem or resist

acknowledging the fact. Another 40% are aware of the problem but are not yet

ready to act. Only 20% are currently taking action. We have devoted 20 years to

investigating the stages of change in people with a variety of mental disorders

and behavior problems. We believe that by identifying these stages, mental

health professionals can improve their understanding of how therapeutic

change comes about, make treatment more effective, and reach millions of

people who are not getting the help they need.

(To be continued …)

y HARVARD MENTAL HEALTH LETTER www.health.harvard.edu MAY 2002

Preparation. At this stage, peoplehave already tried to change, so farwithout success — for example, theyhave tried to quit smoking or have toldsomeone about symptoms of depres-sion. A person at this stage is still think-ing about change and intends to takeaction in the next month.

Action. This is the stage at whichmajor change occurs, and it requires aconsiderable commitment of time andenergy. People who reach the actionstage have successfully changed theirbehavior or environment for a periodlasting from one day to six months.Answering questionnaires, they expressagreement with statements like the fol-lowing: “I am really working hard tochange,” and “Anyone can talk aboutchanging; I am actually doing some-thing about it.”

Maintenance. At this stage, the aim isto consolidate gains and avoid relapse.The standard of success is remainingfree of the problem behavior, findingsome effective substitute for it, orboth, for more than six months.Answering our questionnaire, peopleseeking help at the maintenance stageagree that “I may need a boost rightnow to help me maintain the changeI’ve already made” and “I’m here toprevent myself from having a relapseof my problem.”

Movement along the stagesMost people acting on their own donot successfully negotiate all the stageson their first attempt. Smokers, forexample, make an average of three orfour attempts before they quit perma-nently. People often try dozens of timesbefore they succeed in maintainingweight loss. Most patients in treat-ment have come to the sobering real-ization that slipping back into depres-sion or anxiety is the rule rather thanthe exception.

During a relapse, people regress toan earlier stage, and that may makethem feel like failures — embarrassed,ashamed, and guilty. They maybecome demoralized, resist thinking

about change, and return to the pre-contemplation stage. Fortunately, ourresearch indicates that the vast majori-ty — 80% or more — eventually moveback to contemplation or preparation.They begin to consider plans for theirnext action while trying to learn frommistakes and failures. The pattern is aspiral rather than a circle; they do notregress all the way, and as they repeatthe stages, they manage the process dif-ferently the next time around.

Treatment implicationsOne lesson is the need to set realisticgoals allowing movement to proceedone stage at a time. People who advanceone stage during the first month oftreatment can double their chance oftaking action in the following sixmonths. It is realistic to expect them toprogress from precontemplation tocontemplation or from contemplationto preparation during that month.

Therapists should also anticipaterecycling—the spiral of change. Theyshould let patients understand thatsome degree of initial failure is nearlyuniversal, help them learn how toavoid relapses, and provide boostersessions to maintain improvement.

Above all, therapists should matchthe treatment to the stage of change.It is especially important not to treatall patients as though they are in theaction stage. The vast majority, whenthey first see a professional, are not atthis stage, and offering only action-oriented programs will serve thempoorly. Professionals often provideexcellent action-oriented treatmentsand are disappointed when mostclients drop out.

Research has shown which methodsare effective at various stages. Arecent meta-analysis of 47 studiesconfirms that experiential and psycho-dynamic methods are most useful atthe precontemplation and contem-plation stages. The methods associat-ed with cognitive and behavioraltherapies are best suited to the stagesof action and maintenance. The stage

of change also determines therequirements for a therapeutic rela-tionship. Precontemplators, for exam-ple, respond best to therapists andfamily members who gently and per-sistently provide general support andinstruction, like a nurturing parent.At the action stage, people usuallyrespond best to the kind of enthusias-tic support and specific advice sup-plied by a coach.

Therapists should be especiallycareful to avoid two kinds of mis-match between stages of change andtherapeutic methods. Some thera-pists (and people who undertakechange on their own) move intoaction while relying chiefly on meth-ods more appropriate for the con-templation stage — raising awarenessand emotional work. It is a commoncriticism of classical psychoanalysis—insight alone does not necessarilybring change. Others make the oppo-site mistake of trying to use behav-ioral techniques such as skills trainingand rewards before the contempla-tion and preparation stages have beentraversed. It is a common criticism of purely behavioral treatments —change resulting from action withoutinsight is likely to be temporary.

A person’s stage of change predictsthe likelihood that he or she will dropout of treatment. We have found thatwe can predict dropping out ofpsychotherapy with 90% accuracyamong clients with a variety of men-tal health problems. Patients wholeave soon (after fewer than three ses-sions) and prematurely (as judged bytheir therapists) are generally in theprecontemplation stage. Patients whoterminate therapy early but appropri-ately are typically in the action stage.Among those who continue in thera-py, the majority are at the contempla-tion stage.

The stage of change at the begin-ning of treatment predicts progress intherapy. For example, in an intensiveaction-oriented smoking cessationprogram for cardiac patients, 22% of

uMAY 2002 www.health.harvard.edu HARVARD MENTAL HEALTH LETTER

precontemplators, 43% of contempla-tors, and 76% of patients who were inaction or prepared for action at thestart had succeeded in quitting 12months later.

Another implication of our re-search is that more outreach is neces-sary. Traditionally, mental health professionals wait for people to seektheir services, one at a time. But at anygiven time, most people sufferingfrom mental disorders are at the pre-contemplation stage; they do not seekcare and therefore do not receive it.

Many suffer because of the lack ofresources for outreach.

In a test of outreach, we offered ther-apy to a representative sample of 5,000smokers, letting them know that serviceswould be available for every stage ofchange. By adapting our appeal to thestage of change, we persuaded 80% ofthe smokers to participate. Our resultswere similar in another study involving4,000 smokers in an HMO and a thirdstudy involving 4,000 teenagers withbehavior problems and their parents.These successes suggest that it may be

possible to produce an enormousimpact on mental health by reachingout to people with behavior problemsand mental illnesses while keeping inmind the remarkable diversity in theirreadiness to change.

John C. Norcross, Ph.D., is Professor of Psychologyat the University of Scranton and editor of InSession: Journal of Clinical Psychology.

James O. Prochaska, Ph.D., is Professor ofPsychology and Director of the Cancer PreventionCenter at the University of Rhode Island.

Drs. Prochaska and Norcross are authors of Changingfor Good (Avon, 1995) and Systems of Psychotherapy:A Transtheoretical Analysis (Wadsworth, 2002).

In Brief

The selective serotonin reuptakeinhibitors (SSRIs) fluoxetine(Prozac), paroxetine (Paxil), andsertraline (Zoloft) are the mostwidely used antidepressants andamong the most often prescribed ofall drugs. They account for morethan $3 billion in prescriptioncosts, and sales are growing by 25%each year. All three have similartherapeutic effects, but there aresome differences in their durationof action, side effects, and the easewith which they can be discontin-ued. Sometimes one of the drugsfails and another proves effective.But a recent study of depressedpatients visiting general practition-ers indicates that, in practice, there’sno clear reason for any individualpatient or group of patients startingtreatment to choose one drug overanother.

Nearly 600 people at 37 clinicsreceived antidepressants for ninemonths in the study, which was nota formal clinical trial but based onobservations of everyday practice.Everyone knew which drug eachparticipant was taking. Patientswith alcoholism, anxiety disorders,

and medical illnesses were notexcluded, as they usually are in clin-ical trials of antidepressants. Par-ticipants were not randomlyassigned to drugs, either — doctorsand patients decided which drug tostart with and whether and when totry another one.

Researchers judged the outcomeby telephone interviews after one,three, six, and nine months, record-ing measures of depression, hope-fulness, somatization (unexplainedphysical symptoms), anxiety, self-esteem, quality of social interac-tions and intimate relationships,work effectiveness, pain, sleep, sex-ual functioning, overall health, con-centration, and memory.

The proportion of patients withmajor depression fell from 74% to32% in three months and 26% innine months. On average, all symp-toms improved substantially. Nomatter which drug a patient startedwith, the rates of improvement andside effects were the same.

About half of the patients in eachof the three groups continued totake the medication they startedwith. The rest discontinued or

switched either because of sideeffects or because they were notresponding. The 20% who changedmedications improved just as muchas the others. Satisfaction with treat-ment (over 80%) was the same in allgroups. Troublesome side effectswere also the same—mainly gastro-intestinal complaints (about 5%),insomnia (1.3%), dizziness (1.1%),and headache (0.4%). Surprisingly,in contrast with many other studies,there were few complaints of sexualproblems.

An editorial commentator con-cludes that, although some day thechoice of an antidepressant maydepend on individual genetic differ-ences, for now — in most cases —starting with the least expensivedrug is probably the most sensiblechoice.

Kroenke, K. et al. “Similar Effectiveness ofParoxetine, Fluoxetine, and Sertraline inPrimary Care: A Randomized Trial,” Journal ofthe American Medical Association (December 19,2001): Vol. 286, No. 23, pp. 2947–55.

Gregory Simon, “Choosing a First-LineAntidepressant: Equal on Average Does NotMean Equal for Everyone,” Journal of theAmerican Medical Association (December 19,2001): Vol. 286, No. 23, pp. 3003–04.

SSRIs: Take Your Pick