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How Do People Change a Deeply Ingrained Behavior Such as Smoking?

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It starts with awareness of the problem, for example, a desire to quit smoking and the inability to do so. In a recent published study, we tested whether the Internet can be harnessed as a tool to change behavior (Annals of Behavioral Medicine, Volume 39, Issue 1, 2010, Page 48). In particular, we were interested in learning about a clinical intervention modeled on an in-person treatment approach, which included a defined sequence of steps: self-assessment, preparation, quitting, and relapse prevention. A unique feature of the study was that smokers needed to complete the tasks in a particular "session" before they could move on to the next. Putting the person through a set sequence differentiated ours from numerous other Internet programs which allow the user to browse the site and be self-directed. This browsing strategy may be less successful when the goal is behavior change, rather than education. What follows are some of the important lessons culled from this study, as well as from my many years of practicing psychotherapy.

What we traditionally call "insight" may develop with a slow or a sudden shift in perspective. Something clicks and you know what you want to do. Insight manifests itself in many forms but is only believed to be "genuine" or valuable when we see lasting results. In other words, the proof of having a good insight into a problem is when people actually make important changes in their lives.

A lot happens to a seed before a flower emerges in full bloom. So let's step back and look at the process of change and growth as one which unfolds in stages from the seed of an idea to a full blown behavioral change! I've found that there are five phases to making permanent changes in peoples' lives: taking stock of the habit which needs to be changed; preparing to risk change; trying out new behaviors; nurturing changes into "second-nature" behaviors; and learning to accept, even embrace, the realities, limitations and imperfections we might wish were different.

The first two phases involve "spade work," that is, preparing the ground for change. In phase one, you assess where you are and then come to understand something important about the problem you want to solve. When you are asking someone for directions, for instance, it helps first to know where you are! You have to take stock of who and where you are to make a effective plan to change your life.

In phase one, Ms. R. learned a crucial insight about herself: smoking was part of an "I don't care" attitude. When something troubled her, she would slough it off while puffing away as if to say "none if this matters to me" even when, in fact, it did mean quite a lot to her. This little bit of self-knowledge gave her a great advantage as she applied it to quitting, and began to come to grips with what certain things meant to her rather than just mindlessly lighting up a cigarette.

In phase one it is helpful to assess what kind of smoker you are, and to learn something about the obstacles you face and how you can handle them. In my book, Smoke-free in 30 Days, I describe six different kinds of smokers, and the obstacles they face. I make the case that all smokers are not alike, and that different kinds of smokers face different challenges in becoming permanently smoke-free. I believe it is time for smoking cessation books and programs to move beyond the "one size fits all" approaches of the past. Ms. R's insights and self-assessment, which helped guide her to long-term successful quitting, fit with those I describe as "Emotion-Triggered Smokers".

In phase two, you prepare yourself to change by gaining confidence and courage. People who want to stop smoking, for instance, often doubt that they can given their chemical dependence on smoking. They experience a form of "learned helplessness," a disconnect between efforts to change and a positive outcome. People are often discouraged about their ability to change and grow, clinging out of fear and familiarity to ways of life that are no longer fulfilling. It is difficult to move forward in addressing a specific problem without first building a realistic sense of hope that you can, and will, be successful.

In phase two, Ms R. decided on an aggressive nicotine replacement strategy: the nicotine patch plus the nicotine inhaler to build her confidence to quit. Few people realize that doubling up on two forms of nicotine replacement therapy, for example combining the patch and the gum or the patch and the nicotine inhaler has been shown in the most recent U.S. government clinical practice guidelines to be the most successful medication strategy available! In my experience, this strategy can provide a great confidence builder to prepare the way for change!

Phases one and two often go hand in hand as people struggle to gain an understanding of the problems they are wrestling with while they are also developing the confidence, courage, and commitment to change and try something new.

Phase three is akin to when the new flower first experiences the sun, rain, and wind: it begins to test out its new capacities and adapt to the environment. We've all had budding new behaviors encounter difficulties and environmental stresses. A new behavior, like a budding flower, will thrive under the best conditions possible, so it is important to support the new behavior with helpful beliefs instead of unhelpful ones. Phase three begins the process of testing our helpful and unhelpful beliefs against the real-world environment. This involves keeping an open and a curious mind, the kind of attitude of discovery that a good scientist brings to his or her work.

In phase three, Ms. R. began to test out her insight that she automatically smoked when people disappointed her, and that when she engaged with a situation (instead of withdrawing with a cigarette) her wish to smoke was greatly lessened. This made becoming smoke-free much more manageable, and her unhelpful belief that she needed to smoke to handle her life began to dissolve.

This brings us to phase four: learning to weather the challenges that life brings without letting them throw us off course. Once a new flower is blooming, it continues to need sun and water and all the favorable conditions which will help it thrive and grow. This represents what we call a supportive or loving environment. People in therapy often believe they have to be in a crisis to justify getting help and support, but all people need help, support, and guidance to keep growing-- even when things are going well.

In phase four, it began to feel normal for Ms. R. to actively engage herself in a problem situation when disappointed with someone, rather than to automatically reach for a cigarette.

Finally, there is the fifth phase: achieving grown-up happiness. In this phase, we accept the limits of change and continue to grow. By living within our limits we embrace our achievements as we take justified pride in our accomplishments. At some point, the process of change is no longer about "giving up" a problematic behavior or not slipping back into one. Instead, change becomes about living as good and creative a life as possible. If a person's emotional life is like a garden, you must keep weeding out problems and continue cultivating new habits. Acceptance of life as it is, and not as we wish it could be, is crucial to achieving grown-up happiness.

In phase five, Ms. R. began to accept her own and others limitations rather than just ignore problems altogether (and smoke) or withdraw when disappointed (and smoke).

Dr. Seidman is author of the new book Smoke-Free in 30 Days: The Pain-Free, Permanent Way to Quit with a foreward by Dr. Mehmet Oz (Fireside Trade Paperback Original, January 2010). An audio book is available from Random House. After 20 years of helping smokers at Columbia University, Dr. Seidman introduced his own program to stop smoking as a featured expert on The Oprah Winfrey Show with Dr. Oz early in 2008. For more details about the book go to