Harvard Heart Letter
Copyright: President and Fellows of Harvard College

 Volume 10, Number 7, April 2000

So often in the Heart Letter we give you advice on how to get heart-healthy: eat right, lose weight, exercise, stop smoking. For many of us, this means dropping a bad habit or instituting a new, healthy one; in other words, change. But change is difficult. Simply knowing that something is or isn’t good for you doesn’t make it any easier to actually start or stop that behavior. And yet, some people do. We all know someone who quit smoking or lost weight. What enabled these people to change and how did they summon the will to maintain their new, healthier behaviors?

In navigating the road to understanding successful change, psychologists James Prochaska, John Norcross, and Carlo DiClemente asked these very same questions. But rather than analyzing academic theory and expert opinion, they studied the strategies of thousands of people who changed a behavior without “outside help,” such as therapy or formal programs. Instead of trying to determine what people should do to successfully make a change, they studied what people actually did do to change.

The result of this analysis is a behavioral model called Stages of Change. The basic principle behind it is that most successful self-changers go through each of the following six stages: precontemplation, contemplation, preparation, action, maintenance, and termination. This “theory” has been applied to helping people change — and it works.

The Stages of Change model is a general guideline that you can apply to almost any habit that you want to change, from quitting smoking to controlling your anger to developing an active lifestyle. Try to thoroughly work your way through each step before proceeding to the next.

1. Precontemplation
If you are in the precontemplation stage, you may still be in denial of your problem, or you simply don’t want to change. Though you admit that you smoke, you are unwilling to admit that it has any negative consequences for you or the people around you. You might still be waiting for the “definitive” study to prove that smoking causes lung cancer, or you might cite the example of a grandfather who smoked and lived to be 85.

People who are in this stage are also likely to defend their behavior or blame others for their problems. If you know someone in this stage, the best thing to do is to raise his or her consciousness. Finding out what the “barrier” is (that is, what might help make a person want to change) can assist as well. If a friend is obese, for example, ask if he or she knows that being overweight significantly increases the risk of developing heart disease. The goal at this stage is to get the individual (or yourself) to acknowledge the negative consequences of his or her action, and to think about changing it. When you’ve let your defenses down and become aware of the facts and consequences of your behavior, it’s more difficult to reverse the process.

2. Contemplation
Once you become aware that you have a problem and have started thinking and learning about it, you’ve entered the contemplation stage. For example, you now admit that regular exercise is essential to a healthy lifestyle, or that it’s not alright to have four to five alcoholic drinks every evening. In this stage you are actively collecting information in preparation for change and are seriously thinking about making that change within the next six months. You should get to the point where you are convinced that your life would be substantially better if you altered your behavior.

But don’t fall into the trap of chronic contemplation. Someone who wants to become active could spend months trying to figure out which would be the best exercise program for him or her. On the other hand, it’s also important not to jump too quickly into action, because premature action is likely to lead to failure.

3. Preparation
Preparation is the transition from deciding to change to planning exactly how to go about changing. You’re still learning, but rather than collecting information about the problem, you’re gathering data about a solution. The first step is to determine what action would solve your problem. For example, if smoking or troubled drinking were the problem, then abstinence would be the solution. If a high-fat diet is the problem, the goal should be to get fewer than 30% of your total calories from fat. But the planning process involves more than just making a list of low-fat foods to substitute for the high-fat ones. First, you must prepare yourself to make this change a priority in your life. Adding exercise to your schedule might mean missing out on an extra hour of sleep. It’s also important to prepare those around you for the change. If you’re giving up smoking, for example, you should warn family, friends, and colleagues that your mood might be unpredictable.

Mental preparation is just as important as physical preparation. If you are giving up alcohol, know what you’re going to tell coworkers if they ask you to join them for a drink. And be aware that once you make your change, others might begin to see you differently. And you may view yourself in a whole new light.

Another thing you should do is to go public with your decision to change. Meeting the expectation of others can be a far more potent motivator than keeping a promise to yourself. Finally, set a date to begin your change and stick to it.

4. Action
When you’re fully committed to taking action, go for it! Join the gym, start counting calories, or swear off those cigarettes. Though this may be the most rewarding time, it will also be challenging. At first, avoid temptation. Don’t join your colleagues for a smoking break and expect that you will be able to resist lighting up. Fill up the hours that you might otherwise have spent going to the local bar. Call a friend, learn to cook, or take up piano lessons. You might also find it helpful to reward yourself for good behavior in this stage. If you stick to your exercise regimen for a month, allow yourself to splurge on a new outfit. Ask family and friends for positive reinforcement when you follow through on a change. While it isn’t unusual to slip up a few times during this stage, do your best not to. It can undermine your commitment to change. But if you do, don’t let one mistake obliterate your efforts.

5. Maintenance
After about six months in the action stage, you will find yourself transitioning into maintenance. Maintenance is the long haul, for most people, a lifetime commitment. Successful maintenance of change depends on more than avoiding temptation and rewarding yourself for good behaviors. You must rethink what you found appealing about the habit in the first place. You may remember that having a cigarette calmed your nerves after a stressful day at work. Now is the time to find new, less self-destructive ways to deal with that stress. Don’t delude yourself into thinking that you’re strong enough to have one drink, cigarette, or brownie, and then control yourself from having another. Also, expect and be prepared for social pressure and special situations. A friend is bound to offer you a piece of cake, “now that you’ve lost all that weight,” or a new client, unaware of your former drinking problem, might order a bottle of wine during a business dinner. Just think back to all the reasons why you stopped your negative behavior in the first place, and remember how hard it was to quit the first time. Again, relapses are not uncommon and in fact may be different for different problems. Many people cycle through the stages more than once before effecting a permanent change. Even so, work hard to prevent relapses.

6. Termination
Although psychologists disagree about whether anyone actually terminates the process of change, Prochaska and his colleagues view it as a point where you are no longer tempted to return to the way things were. Someone at this stage would not even want a cigarette if it were offered to him or her. They also note, however, that few “changers” reach this stage (permanent change) — perhaps only 20% — and the final success rates vary depending on the behavior change undertaken. For example, most smokers who quit eventually do reach the termination stage. Relapses, while discouraging, offer the chance to try again and often individuals find they can refine and improve what they’ve learned about themselves and the process of change as they re-cycle through the action and maintenance stages. In the face of repeated relapses, some people decide to seek professional help in their efforts.

It is not unusual, however, for many people to remain in the maintenance stage, still tempted by old habits, but resolved not to give in to them. And in terms of heart-health, this is truly a worthy accomplishment.

The stages of change model is detailed in the book “Changing for Good” by James Prochaska, John C. Norcross, and Carlo C. DiClemente (Avon Books, 1995).

For information on the Harvard Heart Letter go to www.health.harvard.edu/newsletters