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The Transtheoretical Model of Behaviour Change
James Prochaska, Ph.D. is the Director of the Cancer Prevention Research
Consortium and Professor of Clinical and Health Psychology at the University of
Rhode Island. He received his Ph.D. in Clinical Psychology in 1969 at Wayne State
University. He has published more than 100 papers on behavioural change for health
promotion and disease prevention. A recent study conducted by the Institute for
Scientific Information and the American Psychological Society listed him among the
10 most influential authors in Psychology. He has been Principal Investigator on
over $40M in research grants on prevention of cancer and other chronic diseases. He
is also a Consultant to the American Cancer Society, the Centres for Disease Control
& Prevention, numerous health maintenance organizations, corporations, research
journals and universities & research centres’. He has been an invited speaker at
many regional, national & international meetings & conferences.
Carlo DiClemente, Ph.D. is Chair and Professor of Psychology at the University of
Maryland Baltimore County since 8/95. He is the co-developer of the
Transtheoretical Model Dr. Prochaska started. He received his Ph.D. in Clinical
Psychology from the University of Rhode Island in 1978. He had his Postdoctoral
Fellowship in Houston. Texas in 1979. He has been a research specialist, the Chief of
Alcoholism Treatment Centre, Chief of Addictive Behaviour and Psychosocial
Research at the Texas Research Institute of Mental Sciences, Associate Professor of
the Dept. of Psychiatry and Behavioural Sciences at the Univ. of Texas Medical
School, and Professor of the Dept. of Psychology at the Univ. of Houston. Despite
moving to Maryland, he is still a Consultant at the Sid W. Richardson Institute for
Preventive Medicine of the Methodist Hospital at Houston, and Faculty Associate of
the School of Public Health at the Univ. of Texas Centre for Health Promotion.
The Transtheoretical Model is a psychological health promotion model about the
Intention of change. It is a model of choice that focuses on the decision making
capabilities of individuals. This model is different to alternative approaches to health
promotion in that its primarily focus is not on social and biological behavioural
influences.
The Transtheoretical Model; developed by Prochaska & DiClemente in 1983; Prochaska,
DiClemente, & Norcross in 1992 and Prochaska & Velicer in 1997; represents an
integration of many theories of behavioural change. It helps health practitioners to
describe how people modify or acquire a problem or positive behaviour. The central
organising construct of the model is the Stages of Change.
The stages of change construct represents ordered categories along a continuum of
motivational readiness for individual change.
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What stage are you at in your own health promotion process of change? Using the
construct you can become aware of your own change management processes.
The Stages of Change are listed as containing the following:
1. Pre-contemplative - Has no intention of taking action within the next 6 months;
this is where you are not aware of any problems with the performance of your health or
do not associate health related issues to your personal management style
2. Contemplative - intends to take action within the next 6 months;
Where you see performance and motivation linked to health promotion activities, but
cannot decide how best to react.
3. Preparation - Intends to take action within the next 30 days and has taken some
behavioural steps in this direction;
this is where you start learning about different health management styles and begin to
make decisions about what might work for you through the development of health
management skills.
4. Action - has changed behaviour for less than 6 months;
this is where you are looking for situations to develop your new health management
behaviours with improved health performances
5. Maintenance - Has changed behaviour for more than 6 months;
this is where you begin to seek social feedback about the value of your improved health
activities. Should you meet negative feedback about the changes that you have made,
the chances of you reverting back to your old ways of health management are high. A
health professional should be able to offer moral and ethical support for the positive
achievement of your health improvement goals.
Health professionals using this approach will more than likely focus on choice as
representing the primary motivator of individual overcoming adversity by working
through the Transtheoretical Model’s Stage of Change.
People have the ability to change their behaviour despite their attitude about change. In
this way, the Transtheoretical Model of Change has shown itself to be a most effective
intervention in securing real and lasting change in behaviour.
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A 'Stages of Change' Approach to Helping Patients
Change Behaviour
GRETCHEN L. ZIMMERMAN, PSY.D.,
CYNTHIA G. OLSEN, M.D., and
MICHAEL F. BOSWORTH, D.O.
Wright State University School of Medicine, Dayton, Ohio
Helping patients change behaviour is an important role for family physicians. Change interventions
are especially useful in addressing lifestyle modification for disease prevention, long-term disease
management and addictions. The concepts of "patient noncompliance" and motivation often focus on
patient failure. Understanding patient readiness to make change, appreciating barriers to change and
helping patients anticipate relapse can improve patient satisfaction and lower physician frustration
during the change process. In this article, we review the Transtheoretical Model of Change, also
known as the Stages of Change model, and discuss its application to the family practice setting. The
Readiness to Change Ruler and the Agenda-Setting Chart are two simple tools that can be used in the
office to promote discussion. (AFPhysician 2000;61:1409-16.)
One role of family physicians is to assist patients in understanding their health and
to help them make the changes necessary for health improvement. Exercise
programs, stress management techniques and dietary restrictions represent some
common interventions that require patient motivation. A change in patient lifestyle
is necessary for successful management of long-term illness, and relapse can often be
attributed to lapses in healthy behaviour by the patient. Patients easily understand
lifestyle modifications (i.e., "I need to reduce the fat in my diet in order to control my
weight.") but consistent, life-long behaviour changes are difficult.
Much has been written about success and failure rates in helping patients change,
about barriers to change and about the role of physicians in improving patient
outcomes. Recommendations for physicians helping patients to change have ranged
from the "just do it" approach to suggesting extended office visits, often
incorporating behaviour modification, record-keeping suggestions and follow-up
telephone calls. Repeatedly educating the patient is not always successful and can
become frustrating for the physician and patient. Furthermore, promising patients
an improved outcome does not guarantee their motivation for long-term change.
Patients may view physicians who use a confrontational approach as being critical
rather than supportive. Relapse during any treatment program is sometimes viewed
as a failure by the patient and the physician. A feeling of failure, especially when
repeated, may cause patients to give up and avoid contact with their physician or
avoid treatment altogether. After physicians invest time and energy in promoting
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change, patients who fail are often labelled "noncompliant" or "unmotivated."
Labelling a patient in this way places responsibility for failure on the patient's
character and ignores the complexity of the behaviour change process.
Lessons Learned from Smoking and Alcohol Cessation
Research into smoking cessation and alcohol abuse has advanced our understanding
of the change process, giving us new directions for health promotion. Current views
depict patients as being in a process of change; when physicians choose a mode of
intervention, "one size doesn't fit all." Two important developments include the
Stages of Change model and motivational interviewing strategies. The developers of
the Stages of Change model used factor and cluster analytic methods in
retrospective, prospective and cross-sectional studies of the ways people quit
smoking. The model has been validated and applied to a variety of behaviours that
include smoking cessation, exercise behaviour, contraceptive use and dietary
behavior. Simple and effective "stage-based" approaches derived from the Stages of
Change model demonstrate widespread utility. In addition, brief counselling
sessions (lasting five to 15 minutes) have been as effective as longer visits.
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Understanding Change
Physicians should remember that behaviour change is rarely a discrete, single event.
Physicians sometimes see patients who, after experiencing a medical crisis and being
advised to change the contributing behaviour, readily comply. More often,
physicians encounter patients who seem unable or unwilling to change. During the
past decade, behaviour change has come to be understood as a process of
identifiable stages through which patients pass. Physicians can enhance those stages
by taking specific action. Understanding this process provides physicians with
additional tools to assist patients, who are often as discouraged as their physicians
with their lack of change.
The Stages of Change model shows that, for most persons, a change in behaviour
occurs gradually, with the patient moving from being uninterested, unaware or
unwilling to make a change (pre-contemplation), to considering a change
(contemplation), to deciding and preparing to make a change. Genuine, determined
action is then taken and, over time, attempts to maintain the new behaviour occur.
Relapses are almost inevitable and become part of the process of working toward
life-long change.
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Pre-contemplation Stage
During the pre-contemplation stage, patients do not even consider changing.
Smokers who are "in denial" may not see that the advice applies to them personally.
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Patients with high cholesterol levels may feel "immune" to the health problems that
strike others. Obese patients may have tried unsuccessfully so many times to lose
weight that they have simply given up.
Contemplation Stage
During the contemplation stage, patients are ambivalent about changing. Giving up
an enjoyed behaviour causes them to feel a sense of loss despite the perceived gain.
During this stage, patients assess barriers (e.g., time, expense, hassle, fear, "I know I
need to, doc, but ...") as well as the benefits of change.
Preparation Stage
During the preparation stage, patients prepare to make a specific change. They may
experiment with small changes as their determination to change increases. For
example, sampling low-fat foods may be an experimentation with or a move toward
greater dietary modification. Switching to a different brand of cigarettes or
decreasing their drinking signals that they have decided a change is needed.
Action Stage
The action stage is the one that most physicians are eager to see their patients reach.
Many failed New Year's resolutions provide evidence that if the prior stages have
been glossed over, action itself is often not enough. Any action taken by patients
should be praised because it demonstrates the desire for lifestyle change.
Maintenance and Relapse Prevention
Maintenance and relapse prevention involve incorporating the new behaviour "over
the long haul." Discouragement over occasional "slips" may halt the change process
and result in the patient giving up. However, most patients find themselves
"recycling" through the stages of change several times before the change becomes
truly established.
The Stages of Change model encompasses many concepts from previously
developed models. The Health Belief model, the Locus of Control model and
behavioural models fit together well within this framework. During the precontemplation stage, patients do not consider change. They may not believe that
their behaviour is a problem or that it will negatively affect them (Health Belief
Model ), or they may be resigned to their unhealthy behaviour because of previous
failed efforts and no longer believe that they have control (external Locus of
Control ). During the contemplation stage, patients struggle with ambivalence,
weighing the pros and cons of their current behaviour and the benefits of and
barriers to change (Health Belief model ). Cognitive-behavioural models of change
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(e.g., focusing on coping skills or environmental manipulation) and 12-Step
programs fit well in the preparation, action and maintenance stages (Table 1).
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TABLE 1
Stages of Change Model
Stage in Transtheoretical
Incorporating other
model of change
Patient stage
explanatory/treatment models
Pre-contemplation
Not thinking about change
Locus of Control
May be resigned
Health Belief Model
Feeling of no control
Motivational interviewing
Denial: does not believe it applies
to self
Believes consequences are not
serious
Contemplation
Weighing benefits and costs of
Health Belief Model
behaviour, proposed change
Motivational interviewing
Preparation
Experimenting with small changes Cognitive-behavioural therapy
Action
Taking a definitive action to
Cognitive-behavioural therapy
change
12-Step program
Maintaining new behaviour over
Cognitive-behavioural therapy
time
12-Step program
Experiencing normal part of
Motivational interviewing
process of change
12-Step program
Maintenance
Relapse
Usually feels demoralized
Information from Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Am
Psychol 1992;47:1102-4, and Miller WR, Rollnick S. Motivational interviewing: preparing people to
change addictive behaviour. New York: Guilford, 1991:191-202.
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Interventions
The Stages of Change model is useful for selecting appropriate interventions. By
identifying a patient's position in the change process, physicians can tailor the
intervention, usually with skills they already possess. Thus, the focus of the office
visit is not to convince the patient to change behaviour but to help the patient move
along the stages of change. Using the framework of the Stages of Change model, the
goal for a single encounter is a shift from the grandiose ("Get patient to change
unhealthy behaviour.") to the realistic ("Identify the stage of change and engage
patient in a process to move to the next stage.").
Starting with brief and simple advice makes sense
because some patients will indeed change their behaviour at the directive of their
physician. (This step also prevents pre-contemplators from rationalizing that, "My
doctor never told me to quit."). Rather than viewing this step as the intervention,
physicians should view this as the opening assessment of where patients are in the
behaviour change process. A patient's response to this direct advice will provide
helpful information on which physicians can base the next step in the physicianpatient dialog. Rather than continue merely to educate and admonish, interventions
based on the Stages of Change model can be appropriately tailored to each patient to
enhance success. A physician who provides concrete advice about smoking cessation
when a patient remarks that family members who smoke have not died from lung
cancer, has not matched the intervention to the patient's stage of change. A few
minutes spent listening to the patient and then appropriately matching physician
intervention to patient readiness to change can improve communication and
outcome.
Patients at the pre-contemplation and contemplation stages can be especially
challenging for physicians. Motivational interviewing techniques have been found to
be most effective. Miller and colleagues replicated studies with "problem drinkers,"
demonstrating that an empathetic therapist style was predictive of decreased
drinking while a confrontational style predicted increased drinking. Motivational
interviewing incorporates empathy and reflective listening with key questions so
that physicians are simultaneously patient-centred and directive. Controlled studies
have shown motivational interviewing techniques to be at least as effective as
cognitive-behavioural techniques and 12-step facilitation interventions, and they are
easily adaptable for use by family physicians.
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Helping the 'Stuck' Patient
The goal for patients at the pre-contemplation stage is to begin to think about
changing a behaviour. The task for physicians is to empathetically engage patients in
contemplating change (Table 2). During this stage, patients appear argumentative,
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hopeless or in "denial," and the natural tendency is for physicians to try to "convince"
them, which usually engenders resistance.
Patient resistance is evidence that the physician has moved too far ahead of the
patient in the change process, and a shift back to empathy and thought-provoking
questions is required. Physicians can engage patients in the contemplation process
by developing and maintaining a positive relationship, personalizing risk factors
and posing questions that provoke thoughts about patient risk factors and the
perceived "bottom line."
The wording of questions and the patient's style of "not thinking about changing" are
also important. As pre-contemplators respond to questions, rather than jumping in
and providing advice or appearing judgmental, the task for physicians is to reflect
with empathy, instill hope and gently point out discrepancies between goals and
statements. Asking argumentative patients, "Do you want to die from this?" may be
perceived as a threat and can elicit more resistance and hostility. On the other hand,
asking patients, "How will you know that it's time to quit?" allows patients to be
their "own expert" and can help them begin a thought process that extends beyond
the examination room. Well-phrased questions will leave patients pondering the
answers that are right for them and will move them along the process of change
TABLE 3
Questions for Patients in the Pre-contemplation and Contemplation Stages*
Pre-contemplation stage
Goal: patient will begin thinking about change.
"What would have to happen for you to know that this is a problem?"
"What warning signs would let you know that this is a problem?"
"Have you tried to change in the past?"
Contemplation stage
Goal: patient will examine benefits and barriers to change.
"Why do you want to change at this time?"
"What were the reasons for not changing?"
"What would keep you from changing at this time?"
"What are the barriers today that keep you from change?"
"What might help you with that aspect?"
"What things (people, programs and behaviours) have helped in the past?"
"What would help you at this time?"
"What do you think you need to learn about changing?"
*--The change can be applied to any desirable behaviour (e.g., smoking or drinking cessation, losing
weight, exercise).
Information from Miller WR, Rollnick S. Motivational interviewing: preparing people to change
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addictive behavior. New York: Guilford, 1991:191-202.
It is not unusual for some patients to spend years in the contemplation stage, which
physicians can easily recognize by their "yes, but" statements. Empathy, validation,
praise and encouragement are necessary during all stages but especially when
patients struggle with ambivalence and doubt their ability to accomplish the change.
Physicians may find statements such as the following to be useful: "Yes, it is difficult.
What difficult things have you accomplished in the past?" or "I've seen you handle
some tough stuff, I know you'll be able to conquer this." A successful approach calls
for physicians to ask patients about possible strategies to overcome barriers and then
arrive at a commitment to pursue one strategy before the next visit. It is also
productive to ask patients about their previous methods and attempts to change
behaviour. Barriers and gaps in patients' knowledge can then surface for further
discussion.
When patients experiment with changing a behaviour (preparation stage) such as
cutting down on smoking or starting to exercise, they are shifting into more decisive
action. Physicians should encourage them to address the barriers to full-fledged
action. While continuing to explore patient ambivalence, strategies should shift from
motivational to behavioural skills. During the action and maintenance stages,
physicians should continue to ask about successes and difficulties--and be generous
with praise and admiration.
Relapse from Changed Behaviour
Relapse is common during lifestyle changes. Physicians can help by explaining to
patients that even though a relapse has occurred, they have learned something new
about themselves and about the process of changing behaviour. For example,
patients who previously stopped smoking may have learned that it is best to avoid
smoke-filled environments. Patients with diabetes who are on a restricted diet may
learn that they can be successful in adhering to the diet if they order from a menu
rather than choose the all-you-can-eat buffet. Focusing on the successful part of the
plan ("You did it for six days; what made that work?") shifts the focus from failure,
promotes problem solving and offers encouragement. The goal here is to support
patients and re-engage their efforts in the change process. They should be left with a
sense of realistic goals to prevent discouragement, and their positive steps toward
behaviour change should be acknowledged.
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Additional Tools
Two techniques useful in the primary care setting are the Readiness to Change Ruler
and the Agenda-Setting Chart. The Readiness to Change Ruler, which is
incorporated in Figure 1, is a simple, straight line drawn on a paper that represents
a continuum from the left "not prepared to change" to the right "ready to change."
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Patients are asked to mark on the line their current position in the change process.
Physicians should then question patients about why they did not place the mark
further to the left (which elicits motivational statements) and what it would take to
move the line further to the right (which elicits perceived barriers). Physicians can
ask patients for suggestions about ways to overcome an identified barrier and
actions that might be taken before the next visit.
The Agenda-Setting Chart is useful when multiple lifestyle changes are
recommended for long-term disease management (e.g., diabetes or prevention of
heart disease). The physician draws multiple circles on a paper, filling in behaviour
changes that have been shown to affect the disease in question and adding a few
blank circles. For example, "lose weight," "stop smoking" and "exercise" may each
occupy a circle--all of them representing behaviour changes that are known to
reduce the risk of heart disease. The physician begins the patient session with, "Let's
spend a few minutes talking about some of the ways we can work together to
improve your health. In the circles are some factors we can tackle to improve your
health. Are there other factors that you know would be important to address that we
should add to the blank circles?" Discussion then revolves around the patient's
priority area and identifies a goal that might be achievable before the next office
visit.
Changing Behaviour for Your Health
1. On the line below, mark where you are now on this line that measures change in behaviour. Are
you not prepared to change, already changing or someplace in the middle?
Not prepared to change / Already changing
2. Answer the questions below that apply to you.

If your mark is on the left side of the line:
How will you know when it's time to think about changing?
What signals will tell you to start thinking about changing?
What qualities in yourself are important to you?
What connection is there between those qualities and "not considering a change"?

If your mark is somewhere in the middle:
Why did you put your mark there and not further to the left?
What might make you put your mark a little further to the right?
What are the good things about the way you're currently trying to change?
What are the not-so-good things?
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What would be the good result of changing?
What are the barriers to changing?

If your mark is on the right side of the line:
Pick one of the barriers to change and list some things that could help you overcome this barrier.
Pick one of those things that could help and decide to do it by _______________________ (write in
a specific date).

If you've taken a serious step in making a change:
What made you decide on that particular step?
What has worked in taking this step?
What helped it work?
What could help it work even better?
What else would help?
Can you break that helpful step down into smaller pieces?
Pick one of those pieces and decide to do it by _______________________ (write in a specific date).

If you're changing and trying to maintain that change:
Congratulations! What's helping you?
What else would help?
What are your high-risk situations?

If you've "fallen off the wagon":
What worked for a while?
Don't kick yourself--long-term change almost always takes a few cycles.
What did you learn from the experience that will help you when you give it another try?

3. The following are stages people go through in making important changes in their health
behaviours. All the stages are important. We learn from each stage.
We go from "not thinking about it" to "weighing the pros and cons" to "making little changes and
figuring out how to deal with the real hard parts" to "doing it!" to "making it part of our lives. "
Many people "fall off the wagon" and go through all the stages several times before the change really
lasts.
FIGURE 1.The Readiness to Change Ruler can be used with patients contemplating any desirable
behaviour, such as smoking cessation, losing weight, exercise or substance-abuse cessation.
Information from references 4, 26 and 27.
Involving Others
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While no research is available that uses the Stages of Change model in teaching
families how to intervene with their loved one's health-risk behaviour, training
about this model may help family members view the situation differently.
Physicians can enlist the help of other health care professionals (e.g., nutritionists,
nurses, mental health personnel) to reinforce the message that a change in behaviour
is needed and to provide additional education and skill information to the patient.
Referral can also reduce some patient care burden for physicians. Physicians should
document the content and outcome of patient conversations, including specific tasks
and plans for follow-up.
4
Final Comment
Family physicians need to develop techniques to assist patients who will benefit
from behaviour change. Traditional advice and patient education does not work
with all patients. Understanding the stages through which patients pass during the
process of successfully changing a behaviour enables physicians to tailor
interventions individually. These methods can be applied to many areas of health
changing behaviour.
Members of various medical faculties develop articles for "Practical Therapeutics." This article is one
in a series coordinated by the Department of Family Medicine at Wright State University School of
Medicine, Dayton, Ohio. Guest editors of this series are Cynthia G. Olsen, M.D., and Gordon
S.Walbroehl, M.D.
The Authors
GRETCHEN L. ZIMMERMAN, PSY.D.,
is an assistant professor in the Department of Family Medicine at Wright State
University School of Medicine, Dayton, Ohio. She is also a faculty member in the
Dayton Community Family Practice Residency Program. She received a doctorate in
psychology at Wright State University School of Professional Psychology in Dayton.
CYNTHIA G. OLSEN, M.D.,
is a professor and executive vice-chair in the Department of Family Medicine,
Wright State University School of Medicine, where she obtained her medical degree.
She completed a family practice residency at Good Samaritan Hospital in Dayton.
MICHAEL F. BOSWORTH, D.O.,
is an associate professor in the Department of Family Medicine, Wright State
University School of Medicine, and residency director of the Dayton Community
Family Practice Residency. A graduate of the College of Osteopathic Medicine and
Surgery, Des Moines, he completed a family practice residency at Wright Patterson
Air Force Base in Dayton.
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Address correspondence to Gretchen L. Zimmerman, Psy.D., Dayton Community Family Practice
Residency Program, 2345 Philadelphia Dr., Dayton, OH 45406. Reprints are not available from the
authors.
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The following is from Wikipedia
Transtheoretical model
The Transtheoretical model in health psychology 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 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."
History and core constructs of the model
James O. Prochaska 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." The original model
consisted of four variables: "preconditions for therapy," "processes of change,"
"content to be changed," and "therapeutic relationship."
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Prochaska and colleagues later refined the model on the basis of research that they
published in peer-reviewed journals and books. By 1997, the model consisted of five
"core constructs": "stages of change," "processes of change," "decisional balance,"
"self-efficacy," and "temptation."
Factors which mediate the change process
Factors which mediate the change process are as follows:
Stages of change
In the Transtheoretical model as of 1997, change is a "process involving progress
through a series of six stages"
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Pre-contemplation – "people are not intending to take action in the foreseeable
future, usually measured as the next 6 months"
Contemplation – "people are intending to change in the next 6 months"
Preparation – "people are intending to take action in the immediate future,
usually measured as the next month
Action – "people have made specific overt modifications in their life styles
within the past 6 months"
Maintenance – "people are working to prevent relapse," a stage which is
estimated to last "from 6 months to about 5 years"
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 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.
Processes of change
The 10 processes of change are "covert and overt activities that people use to
progress through the stages." These processes are most emphasized at different
transitions between stages of change:
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For movement from pre-contemplation to contemplation, the processes of
"consciousness raising," "dramatic relief," and "environmental reevaluation"
are emphasized.
Between contemplation and preparation, "self-reevaluation" is emphasized.
Between preparation and action, "self-liberation" is emphasized.
Between action and maintenance, "contingency management, "helping
relationship," "counter conditioning," and "stimulus control" are emphasized.
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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 must be "stage-matched," that
is, "matched to each individual's stage of change.
Decisional balance
This core construct "reflects the individual's relative weighing of the pros and cons of
changing.
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.
Temptation
This core construct "reflects the intensity of urges to engage in a specific habit when
in the midst of difficult situations.
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.
o In a systematic review published in 2003 of 23 randomized controlled
trials, the authors determined that "stage based interventions are no
more effective than non-stage based interventions or no intervention in
changing smoking behaviour.”
o 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 pregnancy
and sexually transmitted disease.
o 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."
o According to a randomized controlled trial published in 2006, a stagematched intervention for smoking cessation in pregnancy was more
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
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effective than a non-stage-matched intervention, but this finding could
have resulted from the "greater intensity" of the stage-matched
intervention.
o 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.
o 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 diabetes.
"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-sectional,
but longitudinal study 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." A 2007 meta-analysis of tailored print health behavior
change interventions found that the "number and type of theoretical concepts
tailored on," including stage of change and processes of change, were
associated with behavior change. 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 activity; only 7 of the
24 interventions addressed all four dimensions "stages of change," "processes
of change," "decisional balance," and "self-efficacy."
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
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cholesterol levels depending on the discrete category the cholesterol level is
placed into.
Notes
The following notes summarize major differences between the well-known 1983,
1992, and 1997 versions of the model. Other published versions may contain other
differences. For example, Prochaska, Prochaska, and Levesque (2001) do not mention
the Termination stage, Self-efficacy, or Temptation.
1. In the 1983 version of the model, the Preparation stage is absent.
2. 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.
3. In the 1983 version of the model, Relapse is considered one of the five stages of
change.
4. In the 1983 version of the model, the processes of change were said to be emphasized
in only the Contemplation, Action, and Maintenance stages.
5. In the 1983 and 1992 versions of the model, Prochaska et al. called this process
"reinforcement management," not "contingency management."
6. 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."
7. 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."
8. In the 1983 and 1992 versions of the model, "temptation" is absent.
References
1. Prochaska, JO; Butterworth, S; Redding, CA; Burden, V; Perrin, N; Leo, M; FlahertyRobb, M; Prochaska, JM. Initial efficacy of MI, TTM tailoring and HRI's with multiple
behaviors for employee health promotion. Prev Med 2008 Mar;46(3):226–31.
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2. Greene, GW; Rossi, SR; Rossi, JS; Velicer, WF; Fava, JL; Prochaska, JO. Dietary
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Accessed 2009 Mar 21.
3. Pro-Change Behavior Systems. About us. Transtheoretical model. 2008 Mar.
Accessed 2009 Mar 21.
4. Prochaska, JO; Norcross, JC; DiClemente, CC. Changing for good: the revolutionary
program that explains the six stages of change and teaches you how to free yourself
from bad habits. New York: W. Morrow; 1994. ISBN 0688112633.
5. Goleman, Daniel. New addiction approach gets results. New York Times 1993 Sep 1.
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6. Miller, Kay. Revolving resolutions - Year after new year, we vow to lose weight, stop
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7. Stettner, Morey. A methodical way to change bad behavior. Investor's Business Daily
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8. Understanding change: expect a few bumps. Washington Post 2007 Jan 2. Accessed
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9. Carbine, Michael E. Health plans use a variety of strategies to identify and ensure
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10. Armitage, CJ. Is there utility in the transtheoretical model? Br J Health Psychol 2008
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11. Prochaska, JO.; DiClemente, CC. The transtheoretical approach. In: Norcross, JC;
Goldfried, MR. (eds.) Handbook of psychotherapy integration. 2nd ed. New York:
Oxford University Press; 2005. p. 147–171. ISBN 0195165799.
12. Prochaska, JO. Systems of psychotherapy: a transtheoretical analysis. Homewood, IL:
Dorsey Press; 1979.
13. Prochaska, JO; DiClemente, CC. Trans-theoretical therapy - toward a more
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14. McConnaughy, EA; Prochaska, JO; Velicer, WF. Stages of change in psychotherapy measurement and sample profiles. Psychotherapy: Theory, Research and Practice
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15. Prochaska, JO; DiClemente, CC. Stages and processes of self-change of smoking:
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16. DiClemente, CC; Prochaska, JO; Gibertini, M. Self-efficacy and the stages of selfchange of smoking. Cognit Ther Res 1985;9(2):181–200. Accessed 2009 Mar 22.
17. Velicer, WF; DiClemente, CC; Prochaska, JO; Brandenburg, N. Decisional balance
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18. Prochaska, JO; DiClemente, CC. Toward a comprehensive model of change. In:
Miller, WR; Heather, N. (eds.) Treating addictive behaviors: processes of change.
New York: Plenum Press; 1986. p. 3–27. ISBN 0306422484. Accessed 2009 Mar 18.
19. Prochaska, JO; Velicer, WF; DiClemente, CC; Fava, J. Measuring processes of change:
applications to the cessation of smoking. J Consult Clin Psychol 1988 Aug;56(4):520–
8. PMID 3198809.
20. DiClemente, CC; Prochaska, JO; Fairhurst, SK; Velicer, WF; Velasquez, MM; Rossi,
JS. The process of smoking cessation: an analysis of precontemplation,
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Apr;59(2):295–304. Accessed 2009 Mar 18.
21. Velicer, WF; Prochaska, JO; Rossi, JS; Snow, MG. Assessing outcome in smoking
cessation studies. Psychol Bull 1992 Jan;111(1):23–41. PMID 1539088.
22. Prochaska, JO; DiClemente, CC. Stages of change in the modification of problem
behaviors. Prog Behav Modif 1992;28:183–218. PMID 1620663.
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23. Prochaska, JO; DiClemente, CC; Norcross, JC. In search of how people change.
Applications to addictive behaviors. Am Psychol 1992 Sep;47(9):1102–14. Accessed
2009 Mar 16.
24. Prochaska, JO; DiClemente, CC; Velicer, WF; Rossi, JS. Standardized, individualized,
interactive, and personalized self-help programs for smoking cessation. Health
Psychol 1993 Sep;12(5):399–405. Accessed 2009 Mar 18.
25. Prochaska, JO; Velicer, WF; Rossi, JS; Goldstein, MG; Marcus, BH; et al. Stages of
change and decisional balance for 12 problem behaviors. Health Psychol 1994
Jan;13(1):39–46. Accessed 2009 Mar 18.
26. Prochaska, JO; Velicer, WF. The transtheoretical model of health behavior change.
Am J Health Promot 1997 Sep–Oct;12(1):38–48. Accessed 2009 Mar 18.
27. Prochaska, JM; Prochaska, JO; Levesque, DA. A transtheoretical approach to
changing organizations. Adm Policy Ment Health 2001 Mar;28(4):247–61. Accessed
2009 Mar 20.
28. 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. ISBN 9780787996147.
29. Riemsma, RP; Pattenden, J; Bridle, C; Sowden, AJ; Mather, L; Watt, IS; Walker, A.
Systematic review of the effectiveness of stage based interventions to promote
smoking cessation. BMJ 2003 May 31;326(7400):1175–7. Accessed 2009 Mar 18.
30. Horowitz, SM. Applying the transtheoretical model to pregnancy and STD
prevention: a review of the literature. Am J Health Promot 2003 May–Jun;17(5):304–
28. Accessed 2009 Mar 18.
31. Bridle, C; Riemsma, RP; Pattenden, J; Sowden, AJ; Mather, L; Watt, IS; Walker, A.
Systematic review of the effectiveness of health behavior interventions based on the
transtheoretical model. Psychol Health 2005;20:283–301. Accessed 2009 Mar 18.
32. Aveyard, P; Lawrence, T; Cheng, KK; Griffin, C; Croghan, E; Johnson, C. A
randomized controlled trial of smoking cessation for pregnant women to test the
effect of a transtheoretical model-based intervention on movement in stage and
interaction with baseline stage. Br J Health Psychol 2006 May;11(Pt 2):263–78.
Accessed 2009 Mar 18.
33. Aveyard, P; Massey, L; Parsons, A; Manaseki, S; Griffin, C. The effect of
Transtheoretical Model based interventions on smoking cessation. Soc Sci Med 2009
Feb;68(3):397–403. Accessed 2009 Mar 18.
34. Salmela, S; Poskiparta, M; Kasila, K; Vähäsarja, K; Vanhala, M. Transtheoretical
model-based dietary interventions in primary care: a review of the evidence in
diabetes. Health Educ Res 2009 Apr;24(2):237–52. Accessed 2009 Mar 19.
35. West, R. Time for a change: putting the Transtheoretical (Stages of Change) Model to
rest. Addiction 2005 Aug;100(8):1036–9. Accessed 2009 Mar 19.
36. Sutton, S. Back to the drawing board? A review of applications of the transtheoretical
model to substance use. Addiction 2001 Jan;96(1):175–86. Accessed 2009 Mar 19.
37. Adams, J; White, M. Why don't stage-based activity promotion interventions work?
Health Educ Res 2005 Apr;20(2):237–43. Accessed 2009 Mar 22.
38. Littell, JH; Girvin, H. Stages of change. A critique. Behav Modif 2002 Apr;26(2):223–
73. Accessed 2009 Mar 19.
39. Prochaska, JO. Moving beyond the transtheoretical model. Addiction 2006
Jun;101(6):768–74. Accessed 2009 Mar 20.
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40. Noar, SM; Benac, CN; Harris, MS. Does tailoring matter? Meta-analytic review of
tailored print health behavior change interventions. Psychol Bull 2007 Jul;133(4):673–
93. Accessed 2009 Mar 21.
41. Hutchison, AJ; Breckon, JD; Johnston, LH. Physical activity behavior change
interventions based on the Transtheoretical Model: a systematic review. Health Educ
Behav 2008 Jul 7 [Epub ahead of print]. Accessed 2009 Mar 20.
42. Spencer, L; Pagell, F; Hallion, ME; Adams, TB. Applying the transtheoretical model
to tobacco cessation and prevention: a review of literature. Am J Health Promot 2002
Sep–Oct;17(1):7–71. Accessed 2009 Mar 22.
43. Prochaska, JO. Flaws in the theory or flaws in the study: a commentary on "The effect
of Transtheoretical Model based interventions on smoking cessation". Soc Sci Med
2009 Feb;68(3):404–6. Accessed 2009 Mar 21.
Further reading

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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
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Cancer Prevention Research Center, University of Rhode Island. Summary
overview of the Transtheoretical model.
Pro-Change Behavior Systems, Inc Company Website Company founded by
James O. Prochaska. Mission is to apply the Transtheoretical Model to
behavior change programs for organizations.
HABITS [Health and Addictive Behaviors: Investigating Transtheoretical
Solutions] Lab, Psychology Department, University of Maryland Baltimore
County. The transtheoretical model of behavior change.
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

Lenio, James A. Analysis of the transtheoretical model of behavior change.
University of Wisconsin – Stout, Journal of Student Research, Fifth Edition,
2006.
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.
Retrieved from "http://en.wikipedia.org/wiki/Transtheoretical_model"
Categories: Behavior | Health promotion | Psychotherapy | Public health | Public
health education
The Cancer Prevention Research Center is an American Health organisation
dedicated to helping people change their behaviour for living longer and healthier
lives.
The following is a detailed overview of the Transtheoretical Model as adapted and
updated for the CPRC Website.
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Detailed Overview of theTranstheoretical Model
Material adapted and updated from:
Velicer, W. F, Prochaska, J. O., Fava, J. L.,
Norman, G. J., & Redding, C. A. (1998)
Smoking cessation and stress management:
Applications of the Transtheoretical Model
of behaviour change. Homeostasis, 38, 216-233.
This is an overview of the Transtheoretical Model of Change, a
theoretical model of behaviour change, which has been the basis for
developing effective interventions to promote health behaviour
change. The Transtheoretical Model (Prochaska & DiClemente, 1983;
Prochaska, DiClemente, & Norcross, 1992; Prochaska & Velicer, 1997)
is an integrative model of behaviour change. Key constructs from
other theories are integrated. The model describes how people
modify a problem behaviour or acquire a positive behaviour. The
central organizing construct of the model is the Stages of Change. The
model also includes a series of independent variables, the Processes
of Change, and a series of outcome measures, including the
Decisional Balance and the Temptation scales. The Processes of
Change are ten cognitive and behaviour activities that facilitate
change. This model will be described in greater detail below.
The Transtheoretical Model is a model of intentional change. It is a
model that focuses on the decision making of the individual. Other
approaches to health promotion have focused primarily on social
influences on behaviour or on biological influences on behaviour. For
smoking, an example of social influences would be peer influence
models (Flay, 1985) or policy changes (Velicer, Laforge, Levesque, &
Fava, 1994). An example of biological influences would be nicotine
regulation models (Leventhal & Cleary, 1980; Velicer, Redding,
Richmond, Greeley, & Swift, 1992) and replacement therapy (Fiore.
Smith, Jorenby, & Baker, 1994). Within the context of the
Transtheoretical Model, these are viewed as external influences,
impacting through the individual.
The model involves emotions, cognitions, and behaviour. This
involves a reliance on self-report. For example, in smoking cessation,
self-report has been demonstrated to be very accurate (Velicer,
Prochaska, Rossi, & Snow 1992). Accurate measurement requires a
series of unambiguous items that the individual can respond to
accurately with little opportunity for distortion. Measurement issues
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are very important and one of the critical steps for the application of
the model involves the development of short, reliable, and valid
measures of the key constructs.
This paper will demonstrate applications of the Transtheoretical
Model. The model has previously been applied to a wide variety of
problem behaviours. These include smoking cessation, exercise, low
fat diet, radon testing, alcohol abuse, weight control, condom use for
HIV protection, organizational change, use of sunscreens to prevent
skin cancer, drug abuse, medical compliance, mammography
screening, and stress management. Two of these applications will be
described in detail, smoking cessation and stress management. The
former represents a well-researched area where multiple tests of the
model are available and effective interventions based on the model
have been developed and evaluated in multiple clinical trials. The
latter represents a problem area where research based on the
Transtheoretical Model is in the formative stages.
Stages of Change: The Temporal Dimension
The stage construct is the key organizing construct of the model. It is
important in part because it represents a temporal dimension. Change
implies phenomena occurring over time. However, this aspect was
largely ignored by alternative theories of change. Behaviour change
was often construed as an event, such as quitting smoking, drinking,
or over-eating. The Transtheoretical Model construes change as a
process involving progress through a series of five stages.
Pre-contemplation is the stage in which people are not intending to
take action in the foreseeable future, usually measured as the next six
months. People may be in this stage because they are uninformed or
under-informed about the consequences of their behaviour. Or they
may have tried to change a number of times and become demoralized
about their ability to change. Both groups tend to avoid reading,
talking or thinking about their high risk behaviours. They are often
characterized in other theories as resistant or unmotivated or as not
ready for health promotion programs. The fact is traditional health
promotion programs are often not designed for such individuals and
are not matched to their needs.
Contemplation is the stage in which people are intending to change in
the next six months. They are more aware of the pros of changing but
are also acutely aware of the cons. This balance between the costs and
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benefits of changing can produce profound ambivalence that can
keep people stuck in this stage for long periods of time. We often
characterize this phenomenon as chronic contemplation or
behavioural procrastination. These people are also not ready for
traditional action oriented programs.
Preparation is the stage in which people are intending to take action
in the immediate future, usually measured as the next month. They
have typically taken some significant action in the past year. These
individuals have a plan of action, such as joining a health education
class, consulting a counsellor, talking to their physician, buying a selfhelp book or relying on a self-change approach. These are the people
that should be recruited for action- oriented smoking cessation,
weight loss, or exercise programs.
Action is the stage in which people have made specific overt
modifications in their life-styles within the past six months. Since
action is observable, behaviour change often has been equated with
action. But in the Transtheoretical Model, Action is only one of five
stages. Not all modifications of behaviour count as action in this
model. People must attain a criterion that scientists and professionals
agree is sufficient to reduce risks for disease. In smoking, for example,
the field used to count reduction in the number of cigarettes as action,
or switching to low tar and nicotine cigarettes. Now the consensus is
clear--only total abstinence counts. In the diet area, there is some
consensus that less than 30% of calories should be consumed from fat.
The Action stage is also the stage where vigilance against relapse is
critical.
Maintenance is the stage in which people are working to prevent
relapse but they do not apply change processes as frequently as do
people in action. They are less tempted to relapse and increasingly
more confident that they can continue their change.
Figure 1 illustrates how the temporal dimension is represented in the
model. Two different concepts are employed. Before the target
behaviour change occurs, the temporal dimension is conceptualized
in terms of behavioural intention. After the behaviour change has
occurred, the temporal dimension is conceptualized in terms of
duration of behaviour.
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Figure 1. The Temporal Dimension as the Basis for the Stages of Change
Regression occurs when individuals revert to an earlier stage of
change. Relapse is one form of regression, involving regression from
Action or Maintenance to an earlier stage. However, people can
regress from any stage to an earlier stage. The bad news is that
relapse tends to be the rule when action is taken for most health
behaviour problems. The good news is that for smoking and exercise
only about 15% of people regress all the way to the Pre-contemplation
stage. The vast majority regress to Contemplating or Preparation.
In a recent study (Velicer, Fava, Prochaska, Abrams, Emmons, &
Pierce, 1995), it was demonstrated that the distribution of smokers
across the first three Stages of Change was approximately identical
across three large representative samples. Approximately 40% of the
smokers were in the Pre-contemplation stage, 40% were in the
Contemplation stage, and 20% were in the Preparation stage.
However, the distributions may be different in different countries. A
recent paper (Etter, Perneger, & Ronchi, 1997) summarized the stage
distributions from four recent samples from different countries in
Europe (one each from Spain and the Netherlands, and two from
Switzerland). The distributions were very similar across the European
samples but very different from the American samples. In the
European samples, approximately 70% of the smokers were in the
Pre-contemplation stage, 20% were in the Contemplation stage, and
10% were in the Preparation stage.
While the stage distributions for smoking cessation have now been
established in multiple samples, the stage distributions for other
problem behaviours are not as well known. This is particularly true
for countries other than the United States.
Intermediate/Dependent Measures: Determining when Change
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Occurs
The Transtheoretical Model also involves a series of
intermediate/outcome measures. Typical theories of change involve
only a unit variable outcome measure of success, often discrete. Point
prevalence smoking cessation (Velicer, Prochaska, Rossi, & Snow,
1992) is an example from smoking cessation research. Such measures
have low power, i.e.: a limited ability to detect change. They are also
not sensitive to change over all the possible stage transitions. For
example, point prevalence for smoking cessation would be unable to
detect an individual who progresses from Pre-contemplation to
Contemplation or from Contemplation to Preparation or from Action
to Maintenance. In contrast, the Transtheoretical Model proposes a set
of constructs that form a multivariate outcome space and includes
measures that are sensitive to progress through all stages. These
constructs include the Pros and Cons from the Decisional Balance
Scale, Self-efficacy or Temptation, and the target behaviour. A more
detailed presentation of this aspect to the model is provided
elsewhere (Velicer, Prochaska, Rossi, & DiClemente, 1996).
Decisional Balance. The Decisional Balance construct reflects the
individual's relative weighing of the pros and cons of changing. It is
derived from the Janis and Mann's model of decision making (Janis
and Mann, 1985) that included four categories of pros (instrumental
gains for self and others and approval for self and others). The four
categories of cons were instrumental costs to self and others and
disapproval from self and others. However, an empirical test of the
model resulted in a much simpler structure. Only two factors, the
Pros and Cons, were found (Velicer, DiClemente, Prochaska, &
Brandenberg, 1985). In a long series of studies (Prochaska, et al. 1994),
this much simpler structure has always been found.
The Decisional Balance scale involves weighting the importance of the
Pros and Cons. A predictable pattern has been observed of how the
Pros and Cons relate to the stages of change. Figure 2 illustrates this
pattern for smoking cessation. In Pre-contemplation, the Pros of
smoking far outweigh the Cons of smoking. In Contemplation, these
two scales are more equal. In the advanced stages, the Cons outweigh
the Pros.
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Figure 2. The Relationship between Stage and the Decisional Balance for an
Unhealthy Behaviour
A different pattern has been observed for the acquisition of healthy
behaviours. Figure 3 illustrates this pattern for exercise. The patterns
are similar across the first three stages. However, for the last two
stages, the Pros of exercising remain high. This probably reflects the
fact that maintaining a program of regular exercise requires a
continual series of decisions while smoking eventually becomes
irrelevant. These two scales capture some of the cognitive changes
that are required for progress in the early stages of change.
Figure 3. The Relationship between Stage and the Decisional Balance for a
Healthy Behaviour
Self-efficacy/Temptations. The Self-efficacy construct represents the
situation specific confidence that people have that they can cope with
high-risk situations without relapsing to their unhealthy or high-risk
habit. This construct was adapted from Bandura's self-efficacy theory
(Bandura, 1977, 1982). This construct is represented either by a
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Temptation measure or a Self-efficacy construct.
The Situational Temptation Measure (DiClemente, 1981, 1986; Velicer,
DiClemente, Rossi, & Prochaska, 1990) reflects the intensity of urges
to engage in a specific behaviour when in the midst of difficult
situations. It is, in effect, the converse of self-efficacy and the same set
of items can be used to measure both, using different response
formats. The Situational Self-efficacy Measure reflects the confidence
of the individual not to engage in a specific behaviour across a series
of difficult situations.
Both the Self-efficacy and Temptation measures have the same
structure (Velicer et al., 1990). In our research we typically find three
factors reflecting the most common types of tempting situations:
negative affect or emotional distress, positive social situations, and
craving. The Temptation/Self-efficacy measures are particularly
sensitive to the changes that are involved in progress in the later
stages and are good predictors of relapse.
Self-efficacy can be represented by a monotonically increasing
function across the five stages. Temptation is represented by a
monotonically decreasing function across the five stages. Figure 4
illustrates the relation between stage and these two constructs.
Figure 4. The Relationship between Stage and both Self-efficacy and
Temptation
Independent Measures: How Change Occurs
Processes of Change are the covert and overt activities that people use
to progress through the stages. Processes of change provide
important guides for intervention programs, since the processes are
the independent variables that people need to apply, or be engaged
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in, to move from stage to stage. Ten processes (Prochaska &
DiClemente, 1983; Prochaska, Velicer, DiClemente, & Fava, 1988)
have received the most empirical support in our research to date. The
first five are classified as Experiential Processes and are used
primarily for the early stage transitions. The last five are labelled
Behavioural Processes and are used primarily for later stage
transitions. Table 1 provides a list of the processes with a sample item
for each process from smoking cessation as well as alternative labels.
I. Processes of Change: Experiential
1. Consciousness Raising [Increasing awareness]
I recall information people had given me on how to stop
smoking
2. Dramatic Relief [Emotional arousal]
I react emotionally to warnings about smoking cigarettes
3. Environmental Re-evaluation [Social reappraisal]
I consider the view that smoking can be harmful to the
environment
4. Social Liberation [Environmental opportunities]
I find society changing in ways that make it easier for the nonsmoker
5. Self Re-evaluation [Self reappraisal]
My dependency on cigarettes makes me feel disappointed in
myself
II. Processes of Change: Behavioural
6. Stimulus Control [Re-engineering]
I remove things from my home that remind me of smoking
7. Helping Relationship [Supporting]
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I have someone who listens when I need to talk about my
smoking
8. Counter Conditioning [Substituting]
I find that doing other things with my hands is a good
substitute for smoking
9. Reinforcement Management [Rewarding]
I reward myself when I don’t smoke
10. Self Liberation [Committing]
I make commitments not to smoke
Table 1. The processes of change with alternative labels and sample items
from smoking cessation
Consciousness Raising involves increased awareness about the
causes, consequences and cures for a particular problem behaviour.
Interventions that can increase awareness include feedback,
education, confrontation, interpretation, bibliotherapy and media
campaigns.
Dramatic Relief initially produces increased emotional experiences
followed by reduced affect if appropriate action can be taken.
Psychodrama, role playing, grieving, personal testimonies and media
campaigns are examples of techniques that can move people
emotionally.
Environmental Re-evaluation combines both affective and cognitive
assessments of how the presence or absence of a personal habit affects
one's social environment such as the effect of smoking on others. It
can also include the awareness that one can serve as a positive or
negative role model for others. Empathy training, documentaries, and
family interventions can lead to such re-assessments.
Social Liberation requires an increase in social opportunities or
alternatives especially for people who are relatively deprived or
oppressed. Advocacy, empowerment procedures, and appropriate
policies can produce increased opportunities for minority health
promotion, gay health promotion, and health promotion for
impoverished people. These same procedures can also be used to help
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all people change such as smoke-free zones, salad bars in school
lunches, and easy access to condoms and other contraceptives.
Self-re-evaluation combines both cognitive and affective assessments
of one's self-image with and without a particular unhealthy habit,
such as one's image as a couch potato or an active person. Value
clarification, healthy role models, and imagery are techniques that
can move people to be evaluative.
Stimulus Control removes cues for unhealthy habits and adds
prompts for healthier alternatives. Avoidance, environmental reengineering, and self-help groups can provide stimuli that support
change and reduce risks for relapse. Planning parking lots with a
two-minute walk to the office and putting art displays in stairwells
are examples of reengineering that can encourage more exercise.
Helping Relationships combine caring, trust, openness and
acceptance as well as support for the healthy behaviour change.
Rapport building, a therapeutic alliance, counsellor calls and buddy
systems can be sources of social support.
Counter Conditioning requires the learning of healthier behaviours
that can substitute for problem behaviours. Relaxation can counter
stress; assertion can counter peer pressure; nicotine replacement can
substitute for cigarettes, and fat free foods can be safer substitutes.
Reinforcement Management provides consequences for taking steps
in a particular direction. While reinforcement management can
include the use of punishments, we found that self-changers rely on
rewards much more than punishments. So reinforcements are
emphasized, since a philosophy of the stage model is to work in
harmony with how people change naturally. Contingency contracts,
overt and covert reinforcements, positive self-statements and group
recognition are procedures for increasing reinforcement and the
probability that healthier responses will be repeated.
Self-liberation is both the belief that one can change and the
commitment and recommitment to act on that belief. New Year's
resolutions, public testimonies, and multiple rather than single
choices can enhance self-liberation or what the public calls willpower.
Motivation research indicates that people with two choices have
greater commitment than people with one choice; those with three
choices have even greater commitment; four choices does not further
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enhance will power. So with smokers, for example, three excellent
action choices they can be given are cold turkey, nicotine fading and
nicotine replacement.
For smoking cessation, each of the processes is related to the stages of
change by a curvilinear function. Process use is at a minimum in Precontemplation, increases over the middle stages, and then declines
over the last stages. The processes differ in the stage where use
reaches a peak. Typically, the experiential processes reach peak use
early and the behavioural processes reach peak use late. Figure 5
illustrates the relation of process to stage for two processes,
Consciousness Raising and Stimulus Control, exemplars of
experiential and behavioural processes, respectively.
Figure 5. The Relationship between Stage and two sample Processes,
Consciousness Raising and Stimulus Control
Summary
The Transtheoretical Model has general implications for all aspects of
intervention development and implementation. We will briefly
describe how it impacts on five areas: recruitment, retention,
progress, process, and outcome.
The Transtheoretical Model is an appropriate model for the
recruitment of an entire population. Traditional interventions often
assume that individuals are ready for an immediate and permanent
behaviour change. The recruitment strategies reflect that assumption
and, as a result, only a very small proportion of the population
participates. In contrast, the Transtheoretical Model makes no
assumption about how ready individuals are to change. It recognizes
that different individuals will be in different stages and that
appropriate interventions must be developed for everyone. As a
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result, very high participation rates have been achieved.
The Transtheoretical Model can result in high retention rates.
Traditional interventions often have very high dropout rates.
Participants find that there is a mismatch between their needs and
readiness and the intervention program. Since the program is not
fitting their needs, they quickly dropout. In contrast, the
Transtheoretical Model is designed to develop interventions that are
matched to the specific needs of the individual. Since the
interventions are individualized to their needs, people much less
frequently drop out because of inappropriate demand characteristics.
The Transtheoretical Model can provide sensitive measures of
progress. Action oriented programs typically use a single, often
discrete, measure of outcome. Any progress that does not reach
criterion is not recognized. This is particularly a problem in the early
stages where progress typically does not involve easily observed
changes in overt patterns of behaviour. In contrast, the
Transtheoretical Model includes a set of outcome measures that are
sensitive to a full range of cognitive, emotional, and behavioural
changes and recognize and reinforce smaller steps than traditional
action-oriented approaches.
The Transtheoretical Model can facilitate an analysis of the
meditational mechanisms. Interventions are likely to be differentially
effective. Given the multiple constructs and clearly defined
relationships, the model can facilitate a process analysis and guide the
modification and improvement of the intervention. For example, an
analysis of the patterns of transition from one stage to another can
determine if the intervention was more successful with individuals in
one stage and not with individuals in another stage. Likewise, an
analysis of process use can determine if the interventions were more
successful in activating the use of some processes.
The Transtheoretical Model can support a more appropriate
assessment of outcome. Interventions should be evaluated in terms of
their impact, i.e., the recruitment rate times the efficacy. For example,
a smoking cessation intervention could have a very high efficacy rate
but a very low recruitment rate. This otherwise effective intervention
would have very little impact on smoking rates in the population. In
contrast, an intervention that is less effective but has a very high
recruitment rate could have an important impact on smoking rates in
the population. Interventions based on the Transtheoretical Model
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have the potential to have both a high efficacy and a high recruitment
rate, thus dramatically increasing our potential impact on entire
populations of individuals with behavioural health risks.
______________________________________________________________
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