Transtheoretical Model
Encyclopedia
The Transtheoretical Model of Behavior Change assesses an individual's readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual through the stages of change to action and maintenance.
The Transtheoretical Model is also known by the acronym "TTM" and by the term "stages of change model." A popular book, Changing for Good, and articles in the news media
have discussed the model. It is "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted exceptional criticism."
of the University of Rhode Island
and colleagues developed the transtheoretical model beginning in 1977. It is based on an analysis 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. The model consists of four "core constructs": "stages of change," "processes of change," "decisional balance," and "self-efficacy."The TTM's waning importance and relevance fell under extreme scrutiny during the 1990's as "no more relevant than other existing single or dynamic cycles."
1990s
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.
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. These individuals are encouraged 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.
People here learn about the kind of person they could be if they changed their behavior and learned more from people who behave in healthy ways. They're encouraged 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 are encouraged to seek support from friends they trust, tell people about their plan to change the way the act, and think about how they would feel if they behaved in a healthier way. Their number one concern is: when they act, will they fail? They learn that the better prepared they are the more likely they are to keep progressing.
Stage 4: 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 are 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
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 alternative activities to cope with stress instead of relying on unhealthy behavior.
To progress through the early stages, people apply cognitive, affective, and evaluative processes. As people move toward maintenance or termination, they rely more on commitments, conditioning, contingencies, environmental controls, and support.
Prochaska and colleagues state that their research related to the Transtheoretical Model suggests 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.
Increasing information about self and problem: observations, confrontations, interpretations, and bibliotherapy. Both Dramatic Relief/Emotional Arousal and Environmental Re-Evaluation can be thought of as sub-techniques of Consciousness raising.
Dramatic Relief or Emotional Arousal
Experiencing and expressing feelings about one's problems and solutions: role playing, "stages" of grieving, etc.
Environmental Re-Evaluation
Assessing social and physical impacts of behavior: empathy training and documentaries.
Self-Reevaluation
Assessing feeling and thoughts about self with respect to the target behavior: value clarification, imagery, corrective emotional experience.
Commitment
Choosing and committing to an act: decision-making therapy, social contracts, New Year's resolutions, logo therapy.
Also known as countering, this is the substitution of thoughts, activities, places, people, and things that could provide stimuli for the old behavior: relaxation, desensitization, assertion, positive self-statements. The below steps can be thought of as also being counter-conditioning as well.
Helping Relationships
Someone who helps keep one accountable to their commitments, give feedback, supportive emotionally, and offer serves as a model for what change will bring them: therapeutic alliance, social support, self-help groups.
Reinforcement Management
Continuing the reinforcement of positive benefits to change.
Stimulus Control
Controlling stimuli that prompt previous behavior.
Sound decision-making requires the consideration of the potential benefits (pros) and costs (cons) associated with a behavior's consequences. Decisional balance is one of the best predictors of future change. TTM research has found the following relationships between the pros, cons, and the stage of change across 48 behaviors and over 100 populations studied.
Responses to such criticisms include:
The Transtheoretical Model is also known by the acronym "TTM" and by the term "stages of change model." A popular book, Changing for Good, and articles in the news media
News media
The news media are those elements of the mass media that focus on delivering news to the general public or a target public.These include print media , broadcast news , and more recently the Internet .-Etymology:A medium is a carrier of something...
have discussed the model. It is "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted exceptional criticism."
History and core constructs of the model
James O. ProchaskaJames O. Prochaska
James O. Prochaska is a Professor of Psychology and director of the Cancer Prevention Research Center at the University of Rhode Island and developer of the Transtheoretical Model of Behavior Change beginning in 1977. Prochaska earned his B.A. in Psychology at Wayne State University in 1964,...
of the University of Rhode Island
University of Rhode Island
The University of Rhode Island is the principal public research university in the U.S. state of Rhode Island. Its main campus is located in Kingston. Additional campuses include the Feinstein Campus in Providence, the Narragansett Bay Campus in Narragansett, and the W. Alton Jones Campus in West...
and colleagues developed the transtheoretical model beginning in 1977. It is based on an analysis 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. The model consists of four "core constructs": "stages of change," "processes of change," "decisional balance," and "self-efficacy."The TTM's waning importance and relevance fell under extreme scrutiny during the 1990's as "no more relevant than other existing single or dynamic cycles."
TTM research breakthroughs
1980s- Discovery of the Stages of Change and the dynamic change processes and principles related to each stage
1990s
- First computer-tailored intervention based on the Transtheoretical Model (TTM) was developed
- Demonstrated tailored interventions for smoking cessation effective even when more than 80% were not ready to quit (French 1999)
- TTM applied to a variety of behaviors beyond smoking cessation
Stages of change
In the Transtheoretical Model, change is a "process involving progress through a series of stages":- Precontemplation – "people are not intending to take action in the foreseeable future, and are most likely unaware that their behaviour is problematic"
- Contemplation – "people are beginning to recognize that their behaviour is problematic, and start to look at the pros and cons of their continued actions"
- Preparation – "people are intending to take action in the immediate future, and may begin taking small steps towards change"In the 1983 version of the model, the Preparation stage is absent.
- Action – "people have made specific overt modifications in their life style, and positive change has occurred"
- Maintenance – "people are working to prevent relapse," a stage which can last indefinitely"
- Termination – "individuals have zero temptation and 100% self-efficacy... 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.
Stage details
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. These individuals are encouraged 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.
People here learn about the kind of person they could be if they changed their behavior and learned more from people who behave in healthy ways. They're encouraged 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 are encouraged to seek support from friends they trust, tell people about their plan to change the way the act, and think about how they would feel if they behaved in a healthier way. Their number one concern is: when they act, will they fail? They learn that the better prepared they are the more likely they are to keep progressing.
Stage 4: 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 are 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
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 alternative activities to cope with stress instead of relying on unhealthy behavior.
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 maintenance or termination, they rely more on commitments, conditioning, contingencies, environmental controls, and support.
Prochaska and colleagues state that their research related to the Transtheoretical Model suggests 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.
Precontemplation to Contemplation
Consciousness RaisingIncreasing information about self and problem: observations, confrontations, interpretations, and bibliotherapy. Both Dramatic Relief/Emotional Arousal and Environmental Re-Evaluation can be thought of as sub-techniques of Consciousness raising.
Dramatic Relief or Emotional Arousal
Experiencing and expressing feelings about one's problems and solutions: role playing, "stages" of grieving, etc.
Environmental Re-Evaluation
Assessing social and physical impacts of behavior: empathy training and documentaries.
Contemplation to Preparation
Some sources place emotional arousal in this phase.Self-Reevaluation
Assessing feeling and thoughts about self with respect to the target behavior: value clarification, imagery, corrective emotional experience.
Preparation to Action
"Self-liberation" is emphasized.Commitment
Choosing and committing to an act: decision-making therapy, social contracts, New Year's resolutions, logo therapy.
Action to Maintenance
Counter-ConditioningAlso known as countering, this is the substitution of thoughts, activities, places, people, and things that could provide stimuli for the old behavior: relaxation, desensitization, assertion, positive self-statements. The below steps can be thought of as also being counter-conditioning as well.
Helping Relationships
Someone who helps keep one accountable to their commitments, give feedback, supportive emotionally, and offer serves as a model for what change will bring them: therapeutic alliance, social support, self-help groups.
Reinforcement Management
Continuing the reinforcement of positive benefits to change.
Stimulus Control
Controlling stimuli that prompt previous behavior.
Social Liberation
Social Liberation is emphasized across all of the stages and all stages use techniques during the stage, not just during transition.Decisional balance
This core construct "reflects the individual's relative weighing of the pros and cons of changing."In the 1983 version of the model, "decisional balance" is absent. In the 1992 version of the model, Prochaska et al. mention "decisional balance" but in only one sentence under the "key transtheoretical concept" of "processes of change." Decision making was conceptualized by Janis and Mann as a decisional "balance sheet" of comparative potential gains and losses." decisional balance measures, the pros and the cons, have become critical constructs in the Transtheoretical Model. The pros and cons combine to form a decisional "balance sheet" of comparative potential gains and losses. The balance between the pros and cons varies depending on which stage of change the individual is in.Sound decision-making requires the consideration of the potential benefits (pros) and costs (cons) associated with a behavior's consequences. Decisional balance is one of the best predictors of future change. TTM research has found the following relationships between the pros, cons, and the stage of change across 48 behaviors and over 100 populations studied.
- The cons of changing outweigh the pros in the Precontemplation stage.
- The pros surpass the cons in the middle stages.
- The pros outweigh the cons in the Action state.
Self-efficacy
This core construct is "the situation-specific confidence people have that they can cope with high risk situations without relapsing to their unhealthy or high risk habit."In the 1983 version of the model, "self-efficacy" is absent. In the 1992 version of the model, Prochaska et al. mention "self-efficacy" but in only one sentence under the "key transtheoretical concept" of "stages of change." Self-efficacy conceptualizes a person's perceived ability to perform on a task as a mediator of performance on future tasks. A change in the level of self-efficacy can predict a lasting change in behavior if there are adequate incentives and skills. The Transtheoretical Model employs an overall confidence score to assess an individual's self-efficacy. Situational temptations assess how tempted people are to engage in a problem behavior in a certain situation.How do people move from one stage to another?
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 include:
- Consciousness-Raising—increasing awareness via information, education, and personal feedback about the healthy behavior.
- Dramatic Relief—feeling fear, anxiety, or worry because of the unhealthy behavior, or feeling inspiration and hope when they hear about how people are able to change to healthy behaviors
- Self-Reevaluation—realizing that the healthy behavior is an important part of who they are and want to be
- Environmental Reevaluation—realizing how their unhealthy behavior affects others and how they could have more positive effects by changing
- Social Liberation—realizing that society is more supportive of the healthy behavior
- Self-Liberation—believing in one’s ability to change and making commitments and re-commitments to act on that belief
- Helping Relationships—finding people who are supportive of their change
- Counter-Conditioning—substituting healthy ways of acting and thinking for unhealthy ways
- Reinforcement Management—increasing the rewards that come from positive behavior and reducing those that come from negative behavior
- Stimulus Control—using reminders and cues that encourage healthy behavior as substitutes for those that encourage the unhealthy behavior.
Controversy
Among the criticisms of the model are the following:- Little experimental evidence exists to suggest that application of the model is actually associated with changes in health-related behaviors.
- In a systematic reviewSystematic reviewA systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine...
published in 2003 of 23 randomized controlled trialRandomized controlled trialA randomized controlled trial is a type of scientific experiment - a form of clinical trial - most commonly used in testing the safety and efficacy or effectiveness of healthcare services or health technologies A randomized controlled trial (RCT) is a type of scientific experiment - a form of...
s, the authors determined that "stage based interventions are no more effective than non-stage based interventions or no intervention in changing smokingSmokingSmoking is a practice in which a substance, most commonly tobacco or cannabis, is burned and the smoke is tasted or inhaled. This is primarily practised as a route of administration for recreational drug use, as combustion releases the active substances in drugs such as nicotine and makes them...
behaviour." - A second systematic review from 2003 asserted that "no strong conclusions" can be drawn about the effectiveness of interventions based on the transtheoretical model for the prevention of pregnancyPregnancyPregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
and sexually transmitted diseaseSexually transmitted diseaseSexually transmitted disease , also known as a sexually transmitted infection or venereal disease , is an illness that has a significant probability of transmission between humans by means of human sexual behavior, including vaginal intercourse, oral sex, and anal sex...
s. - A 2005 systematic review of 37 randomized controlled trials claimed that "there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change."
- According to a randomized controlled trial published in 2006, a stage-matched intervention for smoking cessation in pregnancy was more effective than a non-stage-matched intervention, but this finding could have resulted from the "greater intensity" of the stage-matched intervention.
- A randomized controlled trial published in 2009 found "no evidence" that a smoking cessation intervention based on the transtheoretical model was more effective than a control intervention that was not tailored for stage of change.
- A 2009 review stated that "existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model" as related to dietary interventions for people with diabetesDiabetes mellitusDiabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...
. - A 2010 systematic review of smoking cessationSmoking cessationSmoking cessation is the process of discontinuing the practice of inhaling a smoked substance. This article focuses exclusively on cessation of tobacco smoking; however, the methods described may apply to cessation of smoking other substances that can be difficult to stop using due to the...
studies under the auspices of the Cochrane CollaborationCochrane CollaborationThe Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
found that "stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents."
- In a systematic review
- "Arbitrary dividing lines" are drawn between the stages.
- The model makes predictions that are "incorrect or worse than competing theories."
- The model "assumes that individuals typically make coherent and stable plans," when in fact they do not.
- The algorithms and questionnaires that researchers have used to assign people to stages of change have not been standardized, compared empirically, or validated.
- The designs of many studies supporting the model have been cross-sectionalCross-sectional studyCross-sectional studies form a class of research methods that involve observation of all of a population, or a representative subset, at one specific point in time...
, but longitudinal studyLongitudinal studyA longitudinal study is a correlational research study that involves repeated observations of the same variables over long periods of time — often many decades. It is a type of observational study. Longitudinal studies are often used in psychology to study developmental trends across the...
data would allow for stronger causal inferences. - In a 2002 review, the model's stages were characterized as "not mutually exclusive"; furthermore, there was "scant evidence of sequential movement through discrete stages."
Responses to such criticisms include:
- Many studies that show the model to be ineffective have tailored interventions only to stage of change; if the studies had tailored interventions based on all core constructs of the model, they might have shown positive findings. In particular, the "processes of change" have been characterized as "under-researched." In 2008 Hutchison and colleagues published a systematic review of 34 articles examining 24 interventions based on the transtheoretical model for behavior change in physical activityPhysical exercisePhysical exercise is any bodily activity that enhances or maintains physical fitness and overall health and wellness. It is performed for various reasons including strengthening muscles and the cardiovascular system, honing athletic skills, weight loss or maintenance, as well as for the purpose of...
; only 7 of the 24 interventions addressed all four dimensions "stages of change," "processes of change," "decisional balance," and "self-efficacy." - A 2007 meta-analysis by Noar et al. of 57 studies of tailored print health behavior change interventions found that the "number and type of theoretical concepts tailored on" were associated with behavior change. Specifically, programs that tailor on stage do better than those that do not; programs that tailor on attitudes (e.g., decisional balance) do better than those that do not; programs that tailor on self-efficacy do better than those that do not; programs that tailor on social support do better than those that do not; and programs that tailor on processes of change do better than those that do not.
- Studies that find the model ineffective are poorly designed; for example, they have small sample sizes, poor recruitment rates, or high loss to follow-up.
- The conversion of continuous data into discrete categories is necessary for the model, similar to how decisions are made about the treatment of high cholesterolCholesterolCholesterol is a complex isoprenoid. Specifically, it is a waxy steroid of fat that is produced in the liver or intestines. It is used to produce hormones and cell membranes and is transported in the blood plasma of all mammals. It is an essential structural component of mammalian cell membranes...
levels depending on the discrete category the cholesterol level is placed into.
Further reading
- Prochaska, JO; DiClemente, CC. The transtheoretical approach: crossing traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin; 1984. ISBN 087094438X.
- Miller, WR; Heather, N. (eds.). Treating addictive behaviors. 2nd ed. New York: Plenum Press; 1998. ISBN 0306458527.
- Connors, GJ; Donovan, DM; DiClemente, CC. Substance abuse treatment and the stages of change: selecting and planning interventions. New York: Guilford Press; 2001. ISBN 1572306572.
- Velasquez, MM. Group treatment for substance abuse: a stages-of-change therapy manual. New York: Guilford Press; 2001. ISBN 1572306254.
- Burbank, PM; Riebe, D. Promoting exercise and behavior change in older adults: interventions with the transtheoretical model. New York: Springer; 2002. ISBN 0826115020.
- DiClemente, CC. Addiction and change: how addictions develop and addicted people recover. New York: Guilford Press; 2003. ISBN 1572300574.
- Prochaska, JO; Norcross, JC. Systems of psychotherapy: a transtheoretical analysis. 6th ed. Australia: Thomson/Brooks/Cole; 2007. ISBN 9780495007777.
- Glanz, K; Rimer, BK; Viswanath, K. (eds.) Health behavior and health education: theory, research, and practice, 4th ed. San Francisco, CA: Jossey-Bass; 2008. ISBN 9780787996147.
External links
- Cancer Prevention Research Center, University of Rhode Island. Summary overview of the transtheoretical model.
- HABITS [Health and Addictive Behaviors: Investigating Transtheoretical Solutions] Lab, Psychology Department, University of Maryland Baltimore CountyUniversity of Maryland Baltimore CountyThe University of Maryland, Baltimore County is an American honors public research university, located in Baltimore County, Maryland, mostly in the community of Catonsville, Maryland...
. The transtheoretical model of behavior change. - Lenio, James A. Analysis of the transtheoretical model of behavior change. University of Wisconsin – Stout, Journal of Student Research, Fifth Edition, 2006.
- Pro-Change Behavior Systems, Inc. Company founded by James O. Prochaska. Mission is to enhance the well-being of individuals and organizations through the scientific development and dissemination of Transtheoretical Model based change management programs.
- Zimmerman, GL; Olsen, CG; Bosworth, MF. A 'stages of change' approach to helping patients change behavior. Am Fam Physician 2000 Mar 1;61(5):1409–16.