The transtheoretical model of behavior change is an integrative theory of therapy that assesses an individual's readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual. The model is composed of constructs such as: stages of change, processes of change, levels of change, self-efficacy, and decisional balance.
The transtheoretical model is also known by the abbreviation "TTM" and sometimes by the term "stages of change",For example: although this latter term is a synecdoche since the stages of change are only one part of the model along with processes of change, levels of change, etc. Several self-help books—Changing for Good (1994), Changeology (2012), and Changing to Thrive (2016)—and articles in the news mediaExamples of articles in the news media include:
have discussed the model. In 2009, an article in the British Journal of Health Psychology called it "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted exceptional criticism".
History and core constructs James O. Prochaska of the University of Rhode Island, and Carlo Di Clemente and colleagues developed the transtheoretical model beginning in 1977. It is based on analysis and use of different theories of psychotherapy, hence the name "transtheoretical". Prochaska and colleagues refined the model on the basis of research that they published in peer-reviewed journals and books.
Stages of change This construct refers to the temporal dimension of behavioural change. In the transtheoretical model, change is a "process involving progress through a series of stages": Precontemplation ("not ready") – "People are not intending to take action in the foreseeable future, and can be unaware that their behaviour is problematic" Contemplation ("getting ready") – "People are beginning to recognize that their behaviour is problematic, and start to look at the pros and cons of their continued actions" Preparation ("ready") – "People are intending to take action in the immediate future, and may begin taking small steps toward behaviour change"In the 1983 version of the model, the Preparation stage is absent. Action – "People have made specific overt modifications in modifying their problem behaviour or in acquiring new healthy behaviours" Maintenance – "People have been able to sustain action for at least six months and are working to prevent relapse" Termination – "Individuals have zero temptation and they are sure they will not return to their old unhealthy habit as a way of coping"In the 1983 version of the model, the Termination stage is absent. In the 1992 version of the model, Prochaska et al. showed Termination as the end of their "Spiral Model of the Stages of Change", not as a separate stage.
In addition, the researchers conceptualized "Relapse" (recycling) which is not a stage in itself but rather the "return from Action or Maintenance to an earlier stage".In the 1983 version of the model, Relapse is considered one of the five stages of change.
The quantitative definition of the stages of change (see below) is perhaps the most well-known feature of the model. However it is also one of the most critiqued, even in the field of smoking cessation, where it was originally formulated. It has been said that such quantitative definition (i.e. a person is in preparation if he intends to change within a month) does not reflect the nature of behaviour change, that it does not have better predictive power than simpler questions (i.e. "do you have plans to change..."), and that it has problems regarding its classification reliability. See also the responses to West in the same issue:
Communication theorist and sociologist Everett Rogers suggested that the stages of change are analogues of the stages of the innovation adoption process in Rogers' theory of diffusion of innovations.
Details of each stage
StagePrecontemplationContemplationPreparationActionMaintenanceRelapse Standard time more than 6 months in the next 6 months in the next month now at least 6 months any time
Stage 1: Precontemplation (not ready)
People at this stage do not intend to start the healthy behavior in the near future (within 6 months), and may be unaware of the need to change. People here learn more about healthy behavior: they are encouraged to think about the pros of changing their behavior and to feel emotions about the effects of their negative behavior on others.
Precontemplators typically underestimate the pros of changing, overestimate the cons, and often are not aware of making such mistakes.
One of the most effective steps that others can help with at this stage is to encourage them to become more mindful of their decision making and more conscious of the multiple benefits of changing an unhealthy behavior.
Stage 2: Contemplation (getting ready)
At this stage, participants are intending to start the healthy behavior within the next 6 months. While they are usually now more aware of the pros of changing, their cons are about equal to their Pros. This ambivalence about changing can cause them to keep putting off taking action.
During this stage, participants envision the kind of person they could be if they changed their behavior and learn more from people who behave in healthy ways.
Others can influence and help effectively at this stage by encouraging them to work at reducing the cons of changing their behavior.
Stage 3: Preparation (ready)
People at this stage are ready to start taking action within the next 30 days. They take small steps that they believe can help them make the healthy behavior a part of their lives. For example, they tell their friends and family that they want to change their behavior.
People in this stage benefit by seeking support from friends they trust, telling people about their plan to change the way they act, and thinking about how they would feel if they behaved in a healthier way. A prominent concern is that if they act they will fail. They learn that the better prepared they are, the more likely they are to keep progressing.
Stage 4: Action (current action)
People at this stage have changed their behavior within the last 6 months and need to work hard to keep moving ahead. These participants need to learn how to strengthen their commitments to change and to fight urges to slip back.
People in this stage progress by being taught techniques for keeping up their commitments such as substituting activities related to the unhealthy behavior with positive ones, rewarding themselves for taking steps toward changing, and avoiding people and situations that tempt them to behave in unhealthy ways.
Stage 5: Maintenance (monitoring)
People at this stage changed their behavior more than 6 months ago. It is important for people in this stage to be aware of situations that may tempt them to slip back into doing the unhealthy behavior—particularly stressful situations.
It is recommended that people in this stage seek support from and talk with people whom they trust, spend time with people who behave in healthy ways, and remember to engage in healthy activities (such as exercise and deep relaxation) to cope with stress instead of relying on unhealthy behavior.
Relapse (recycling)DiClemente, CC; Prochaska, JO; Gibertini, M. Self-efficacy and the stages of self-change of smoking. Cognit Ther Res 1985;9(2):181–200. Accessed 2009 Mar 22.
Relapse in the TTM specifically applies to individuals who successfully quit smoking or using drugs or alcohol, only to resume these unhealthy behaviors. Individuals who attempt to quit highly addictive behaviors such as drug, alcohol, and tobacco use are at particularly high risk of a relapse. Achieving a long-term behavior change often requires ongoing support from family members, a health coach, a physician, or another motivational source. Supportive literature and other resources can also be helpful to avoid a relapse from happening.
Processes of change
The 10 processes of change are "covert and overt activities that people use to progress through the stages".
To progress through the early stages, people apply cognitive, affective, and evaluative processes. As people move toward Action and Maintenance, they rely more on commitments, counter conditioning, rewards, environmental controls, and support.Prochaska, JO; Redding, CA; Evers, KE. The Transtheoretical Model and Stages of Change. In: Glanz, K; Rimer, BK; Viswanath, K. (eds.) Health Behavior and Health Education. 4th ed. San Francisco: Jossey-Bass; 2008. p. 105. .
Prochaska and colleagues state that their research related to the transtheoretical model shows that interventions to change behavior are more effective if they are "stage-matched", that is, "matched to each individual's stage of change".In the 1983 version of the model, the processes of change were said to be emphasized in only the Contemplation, Action, and Maintenance stages.
In general, for people to progress they need: A growing awareness that the advantages (the "pros") of changing outweigh the disadvantages (the "cons")—the TTM calls this decisional balance. Confidence that they can make and maintain changes in situations that tempt them to return to their old, unhealthy behavior—the TTM calls this self-efficacy. Strategies that can help them make and maintain change—the TTM calls these processes of change.
The ten processes of change include: Consciousness-raising (Get the facts) — increasing awareness via information, education, and personal feedback about the healthy behavior. Dramatic relief (Pay attention to feelings) — feeling fear, anxiety, or worry because of the unhealthy behavior, or feeling inspiration and hope when hearing about how people are able to change to healthy behaviors. Self-reevaluation (Create a new self-image) — realizing that the healthy behavior is an important part of who they want to be. Environmental reevaluation (Notice your effect on others) — realizing how their unhealthy behavior affects others and how they could have more positive effects by changing. Social liberation (Notice public support) — realizing that society is supportive of the healthy behavior. Self-liberation (Make a commitment) — believing in one's ability to change and making commitments and re-commitments to act on that belief. Helping relationships (Get support) — finding people who are supportive of their change. Counterconditioning (Use substitutes) — substituting healthy ways of acting and thinking for unhealthy ways. Reinforcement management (Use rewards) — increasing the rewards that come from positive behavior and reducing those that come from negative behavior. Stimulus control (Manage your environment) — using reminders and cues that encourage healthy behavior and avoiding places that don't.
Health researchers have extended Prochaska's and DiClemente's 10 original processes of change by an additional 21 processes. In the first edition of Planning Health Promotion Programs,Bartholomew, L.K.K., Parcel, G.S.S., Kok, G., Gottlieb, N.H.H., 2001. Planning Health Promotion Programs: An Intervention Mapping Approach. 1st ed. San Francisco: Jossey-Bass. Bartholomew et al. (2001) summarised the processes that they identified in a number of studies; however, their extended list of processes was removed from later editions of the text, perhaps because the list mixes techniques with processes. There are unlimited ways of applying processes. The additional strategies of Bartholomew et al. were: Risk comparison (Understand the risks) – comparing risks with similar dimensional profiles: dread, control, catastrophic potential and novelty Cumulative risk (Get the overall picture) – processing cumulative probabilities instead of single incident probabilities Qualitative and quantitative risks (Consider different factors) – processing different expressions of risk