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Identify and briefly describe the six stages of change presented in the transtheoretical 

     model of behavior change. 

Jun 4th, 2015

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The Transtheoretical Model

The Transtheoretical Model (TTM):

  • uses the Stages of Change to integrate the most powerful principles and processes of change from leading theories of counseling and behavior change;
  • is based on principles developed from over 35 years of scientific research, intervention development, and scores of empirical studies;
  • applies the results of research funded by over $80 million worth of grants and conducted with over 150,000 research participants; and
  • is currently in use by professionals around the world.

Overview of the Model

The Transtheoretical Model (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992) is an integrative, biopsychosocial model to conceptualize the process of intentional behavior change. Whereas other models of behavior change focus exclusively on certain dimensions of change (e.g. theories focusing mainly on social or biological influences), the TTM seeks to include and integrate key constructs from other theories into a comprehensive theory of change that can be applied to a variety of behaviors, populations, and settings (e.g. treatment settings, prevention and policy-making settings, etc.)—hence, the name Transtheoretical.

The Stages of Change

Stages of Change lie at the heart of the TTM. Studies of change have found that people move through a series of stages when modifying behavior. While the time a person can stay in each stage is variable, the tasks required to move to the next stage are not. Certain principles and processes of change work best at each stage to reduce resistance, facilitate progress, and prevent relapse. Those include decisional balance, self-efficacy, and processes of change. Only a minority (usually less than 20%) of a population at risk is prepared to take action at any given time. Thus, action-oriented guidance misserves individuals in the early stages. Guidance based on the TTM results in increased participation in the change process because it appeals to the whole population rather than the minority ready to take action.

The stage construct represents a temporal dimension. Change implies phenomena occurring over time. Surprisingly, none of the leading theories of therapy contained a core construct representing time. Traditionally, behavior change was often construed as an event, such as quitting smoking, drinking, or overeating. TTM recognizes change as a process that unfolds over time, involving progress through a series of stages. While progression through the Stages of Change can occur in a linear fashion, a nonlinear progression is common. Often, individuals recycle through the stages or regress to earlier stages from later ones.

The Stages of Change 'curve'

Precontemplation (Not Ready)

Contemplation (Getting Ready)

Preparation (Ready)

Action

Maintenance

Precontemplation (Not Ready)

People in the Precontemplation stage do not intend to take action in the foreseeable future, usually measured as the next six months. Being uninformed or under informed about the consequences of one’s behavior may cause a person to be in the Precontemplation stage. Multiple unsuccessful attempts at change can lead to demoralization about the ability to change. Both the uninformed and under informed tend to avoid reading, talking, or thinking about their high-risk behaviors. They are often characterized in other theories as resistant, unmotivated, or unready for help. The fact is, traditional programs were not ready for such individuals and were not designed to meet their needs.

Contemplation (Getting Ready)

Contemplation is the stage in which people intend to change in the next six months. They are more aware of the pros of changing, but are also acutely aware of the cons. In a meta-analysis across 48 health risk behaviors, the pros and cons of changing were equal (Hall & Rossi, 2008). This weighting between the costs and benefits of changing can produce profound ambivalence that can cause people to remain in this stage for long periods of time. This phenomenon is often characterized as chronic contemplation or behavioral procrastination. Individuals in the Contemplation stage are not ready for traditional action-oriented programs that expect participants to act immediately.

Preparation (Ready)

Preparation is the stage in which people intend to take action in the immediate future, usually measured as the next month. Typically, they have already taken some significant action in the past year. These individuals have a plan of action, such as joining a health education class, consulting a counselor, talking to their physician, buying a self-help book, or relying on a self-change approach. These are the people who should be recruited for action-oriented programs.

Action

Action is the stage in which people have made specific overt modifications in their lifestyles within the past six months. Because action is observable, the overall process of behavior change often has been equated with action. But in the TTM, Action is only one of six stages. Typically, not all modifications of behavior count as Action in this Model. In most applications, people have to attain a criterion that scientists and professionals agree is sufficient to reduce risk of disease. For example, reduction in the number of cigarettes or switching to low-tar and low-nicotine cigarettes were formerly considered acceptable actions. Now the consensus is clear—only total abstinence counts.

Maintenance

Maintenance is the stage in which people have made specific overt modifications in their lifestyles and are working to prevent relapse; however, they do not apply change processes as frequently as do people in Action. While in the Maintenance stage, people are less tempted to relapse and grow increasingly more confident that they can continue their changes. Based on self-efficacy data, researchers have estimated that Maintenance lasts from six months to about five years. While this estimate may seem somewhat pessimistic, longitudinal data in the 1990 Surgeon General’s report support this temporal estimate. After 12 months of continuous abstinence, 43% of individuals returned to regular smoking. It was not until 5 years of continuous abstinence that the risk for relapse dropped to 7% (USDHHS).

Termination

Termination is the stage in which individuals are not tempted; they have 100% self-efficacy. Whether depressed, anxious, bored, lonely, angry, or stressed, individuals in this stage are sure they will not return to unhealthy habits as a way of coping. It is as if their new behavior has become an automatic habit. Examples include adults who have developed automatic seatbelt use or who automatically take their antihypertensive medication at the same time and place each day. In a study of former smokers and alcoholics, researchers found that less than 20% of each group had reached the criteria of zero temptation and total self-efficacy (Snow, Prochaska & Rossi, (1992). The criterion of 100% self-efficacy may be too strict or it may be that this stage is an ideal goal for population health efforts. In other areas, like exercise, consistent condom use, and weight control, the realistic goal may be a lifetime of maintenance.


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Jun 4th, 2015

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