Stages of Change/Trans-theoretical Model
by Alyssa Stetson (Fall 2016) & Natalie Sanfratello (Spring 2015)
The Trans-theoretical Model (TTM) is a method of visualizing and describing someone’s readiness to change an unhealthy behavior, constructed in 1977 by James O. Prochaska and colleagues. The group used a psychotherapy perspective to develop this model after collecting empirical evidence from smokers who had attempted to quit (1, 2). The model has four construct: Stages of Change, Processes of Change, Decisional Balance, and Self-Efficacy (3). The Stages of Change construct is the most widely used, and so will be the focus of this entry.
Stages of Change:
The Stages of Change is a framework for thinking about behavioral change that can be used to understand someone’s current mindset and suggest strategies for altering an unhealthy behavior. There are five stages that can vary in duration. Although each stage builds from the previous stage, at any point people can advance to the next stage or return to the previous stage. The table below describes each stage and provides an example, using a hypothetical person, named “B.”
Table 1. Stages of Change with definition and example (3, 4).
B. drinks alcohol excessively. He refuses to acknowledge that he skips work when hungover or the concern of his family. He occasionally talks about “cutting back,” but doubts he will be successful.
B. is realizing he cannot control drinking. He sees the cost when his daughter starts avoiding him. He is unsure that abstinence will improve his life. He reaches out to a friend who used AA successfully.
B. promises his daughter he will be sober by her birthday in 2 weeks and asks his friend to accompany him to an AA meeting.
B. stops drinking and begins AA. He forbids alcohol in the house. After a rough day, he longs for a beer.
B. can have liquor in the house and attends fewer A.A. meetings. He knows to be mindful after a rough day.
After an argument at work, B. relapses (resumes drinking) to the Contemplation Stage. He weighs feeling better when sober against the task of “starting over.”
Figure 1: Stages of Change Model for alcohol addiction. Adapted (2, 5).
As explained above, Stages of Change is TTM’s most widely used construct, but there are three others which can also be used to describe someone’s intention to change. They are defined below with examples.
Processes of change are mindsets that occur as someone moves through the stages of change. They can be subconscious, or used as tools to achieve progress.
Example: B. moves past the contemplation stage using “Environmental Reevaluation”. He lists how his hangovers felt and the impact on daughter.
Decisional balance: To progress through the stages, the personal pros of ceasing the behavior (for example quitting drinking) must outweigh the cons. Creating a pro/con list can assist someone with convincing themselves that the change is overall beneficial (2).
Example: B. decided that the relationship with his daughter and dependability at work outweighed the effort it took to remain abstinent.
Self-efficacy is the degree of confidence someone has in his/her ability to maintain change, acting in opposition with the temptation to continue the behavior. In the earlier stages temptation outweighs self-efficacy but this balance changes as someone progresses (6). Self-efficacy is built through performance accomplishment, vicarious experiences, verbal persuasion, and physiological states (7).
Example: When B. relapsed, the temptation to drink outweighed his belief that he could remain abstinent. Knowing that he controlled his drinking before increased his confidence so he returned to the contemplation not the pre-contemplation stage.
Figure 2. Processes of change with example. Adapted (1, 4).
Applications and Limitations:
Behavioral modification programs are crucial to improve global health. In 2012 the worldwide leading causes of death included many with a preventable component such as ischemic heart disease, stroke, COPD, HIV, diabetes, road injury, and hypertension; these alone comprise 22.6 million deaths, a number that could be reduced through changes in modifiable behavior (8). A meta-analysis in 2007 found that ‘tailored’ behavioral change programs (with individual messages) are more effective; there was an odds ratio of 1.21 when compared to programs with a generic or targeted message (9) Although the physical nature of substance addiction makes
behavioral change harder, it seems likely that tailored programs are still more effective than the alternatives. In addition to providing a framework for a tailored program, the TTM is unique in including relapse. This gives people warning, removes the stigma of ‘failure’, and creates space for open discussion about strategies to re-enter the cyclem (5).
TTM has several conceptual limitations: it does not explicitly include determinants, provides no validated or standardized way to determine someone’s current stage, and has no clear delineations between stages (4) These conceptual limitations also matter in practice because they diminish the usefulness of the model. Outside determinants can play a huge role in someone’s success at behavior change, and so people using the model would have to work to define and understand how external factors were shaping their path. The latter two limitations hinder the degree to which TTM can be used to tailor a program.
1. "Transtheoretical Model: Detailed Overview." Cancer Prevention Research Center. University of Rhode Island, 2016. Web. 1 Dec. 2016. http://web.uri.edu/cprc/detailed-overview/.
2. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395.
3. Prochaska, James O., and Wayne F. Velicer. "The Transtheoretical Model of Health Behavior Change." American Journal of Health Promotion 12.1 (1997): 38-48. Web.
4. Shinitzky, Harold E., and Joan Kub. "The Art of Motivating Behavior Change: The Use of Motivational Interviewing to Promote Health." Public Health Nursing 18.3 (2001): 178-85. https://www.ncbi.nlm.nih.gov/pubmed/10170434.
5. "The Transtheoretical Model (Stages of Change)." The Transtheoretical Model (Stages of Change). Boston University, 28 Apr. 2016. Web. 1 Dec. 2016. http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories6.html
6. Pro-Change Behavior Systems, Inc. The Transtheoretical Model. http://www.prochange.com/transtheoretical-model-of-behavior-change (accessed 10 March 2015).
7. Bandura, Albert. "Self-efficacy: Toward a Unifying Theory of Behavioral Change."Psychological Review 84.2 (1977): 191-215. Web.
8. "The Top 10 Causes of Death." World Health Organization. World Health Organization, May 2014. Web. 20 Dec. 2016. http://www.who.int/mediacentre/factsheets/fs310/en/.
9. Noar, S.M., Benac, C.N., and Harris, M.S. (2007) Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychological Bulletin, 4, 673-693.