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Researchers in the 1970s created a “model of change” to help people stop harmful behaviors. Today, the model is useful for preventing habits from worsening.
When the transtheoretical model (TTM) was developed in the 1970s and early 1980s by researchers James O. Prochaska and Carlo DiClemente, it was revolutionary in its explanation of how behavioral change can take root and how it’s maintained over time. TTM became popular in substance use disorder treatment. But research from the early 2000s questioned whether TTM was helpful in this way, because of the difficulty in pinpointing a person’s readiness to change. Another criticism was that TTM excluded people who succeeded in quitting an addiction cold turkey. Yet another criticism noted that TTM may oversimplify substance use disorder and recovery. Recent research indicates that TTM may be best suited for people who need to take preventive action to better their health, rather than rewiring entrenched behaviors. Here’s how. The TTM gauges a person’s readiness to change and the likelihood they will continue that change forward. There are six stages of change in this framework. It begins with no desire to change and ends with maintaining new behavior and the completion of treatment. There’s evidence that TTM works by changing behaviors preemptively in people at risk of developing chronic diseases and before negative thought patterns can contribute to the development of mental health issues. The stages of change may be most effective by defining what each level means to you, how your experience fits into a stage, and whether you can preemptively adopt a behavior change. I need to change my behavior. How can TTM help?To make a long-term behavioral change using TTM, first identify your present stage. A therapist or psychologist may be best able to help identify which stage you’re in:
Once you’ve done that, you can speak with a professional who specializes in the type of change you want to make. You can learn about behavior-changing programs and which one will assist you in your particular path, and you might be motivated to commit to following it. Like G.I. Joe says, “Knowing is half the battle.” TTM helps you know where you are, and what stages you can look forward to next. What are the stages of change?The stages of change identify a person’s readiness to make behavioral changes in their life. The stages range from denial to acceptance. Going back to the behavior, or relapse, may occur. A person may cycle through the stages of change more than once on their journey, too. Share on PinterestPrint Design and Illustrations by Maya Chastain There are six stages of change in the TTM: PrecontemplationThis stage is marked by denial. Folks at this juncture have not acknowledged that there’s problematic behavior. Someone, like a therapist, friend, or family member, may have hinted at there being an issue or cause for concern, but you don’t believe them yet. ContemplationThe indecision is real at this stage. You might be wavering if you can or should try to change the behavior, and what losing it may mean for everyday life. You could be making a pros and cons list. Maybe you’re speaking with a therapist, family member, or friends about what might change in your life. When considering changing a behavior, visualizing yourself having made the change — or not — in the future can help you decide next steps. PreparationWhen you’ve decided to make a behavior change and are ready to take action, you’re in the prep stage. You might still be gathering facts about the exact method you will use to make your change, such as finding a support group. ActionYou’re actively changing in this stage! You’ve put the pedal to the metal. You may be attending a support group, openly discussing your new behaviors with family and friends, referencing the negative behavior in the past tense, and keeping track of your progress. MaintenanceIn the maintenance stage, you’re focused on keeping the changes you’ve made for the long term. You’ll be working to keep your forward momentum so you don’t regress to old habits. Your focus may shift from making changes and reinforcing them to changing your environment and enlisting support. At this point, you likely understand that life stressors may make adhering to the changes you’ve made more difficult, and so you may create action plans to help you manage stress. In this stage, you might, after a length of time, stop active treatment. TerminationIn this stage, the old behavior is fossilized in your past. The habit may have lost its appeal entirely. You’re certain you won’t go back to it. Not all TTM programs agree that termination is the final stage, as lapses are understood to be part of the journey in ongoing recovery. The processes of change in the TTM is the work a person does to progress through the stages of change. These are where a person’s motivations to change become actions. Some research indicates that people have more success with these processes than the stages of change themselves. Processes within TTM include: CommitmentsMaking a commitment to change is a public acknowledgment of your willingness to switch up your behavior. But it also represents a belief in yourself — that you will change and maintain that change. Counter-conditioningThis is swapping unhealthy behaviors for healthy ones. For example, if you’re committed to stop smoking, you may call a friend instead of smoking a cigarette when you go for a stroll. RewardsTreat yourself for following through with healthy habits. For example, each day you don’t engage in negative self-talk, you might snap a happy selfie or buy a refreshing beverage at the local coffee shop. Environmental controlsYou might try to avoid places that will trigger the behavior you’re trying to change, and find places that encourage your new, healthy behaviors. For example, if you’re trying to stop drinking, that could mean not going to a favorite neighborhood bar or restaurant that serves alcohol, and trying a new juice bar or coffee shop instead. To set yourself up for success, you can also consider making adjustments to your home environment so it’s full of foods and items that can contribute to your mental health and well-being. SupportYou can surround yourself with people who support the changes you’re making as well. You may want to observe how the modifications you’re making affect the people around you. Embrace the people who react positively to your behavior changes. The transtheoretical model (TTM) of change, introduced in the 1970s, was based on its creators’ observations of people trying to change substance use behaviors. The TTM combined different psychological theories to present a new way of treating substance use disorders. But ultimately, it’s been shown to be more effective at preventing habits before they solidify into a condition. Depending on your readiness to change a behavior, you could fall into one of six stages of change, and treatment can be tailored to your openness for change. Last medically reviewed on August 23, 2021 The factors that influence “change behavior” have been significantly researched, yet one model is the standard-bearer for change. The transtheoretical model (TTM), and its easy-to-follow steps toward change, make understanding human behavior one of the easiest filters to follow. TTM stages include[1][2][3][4][5]:
TTM has become one of the most commonly applied theoretical and clinical frameworks in mental health and is effective across a broad spectrum of problems, including smoking, alcohol abuse, addiction, weight control and exercise acquisition, sunscreen use, condom use, school bullying, to preventative measures such as medical screens like mammography and cancer screening.[1] This article explains the important concepts of TTM and how to use it.[1][2][3][6] Pre-contemplation, the first stage, reveals unmotivated people who see no need to find a solution to a problem because they usually do not believe that one exists. Individuals in this stage are unaware of or have limited awareness of the problem or lack insight into the consequences of their negative/addictive behavior. This patient response is atypical since the majority of people acknowledge their adverse behaviors. It is important to understand that a person in this stage is in complete denial and even tends to defend their actions. People in this stage often present as resistant, unmotivated, and unready, and unwilling to change. Furthermore, this individual often obsesses about the negative side of change rather than recognizing the benefits that they would gain. In other words, the cons outweigh the pros. Should a pre-contemplator present to therapy, it is likely to be due to the constant pressure of others in their life, who are likely pushing them to seek help. At times, they may even exhibit elements of change as long as the pressure from others remains present and constant. If that pressure to change is no longer present, Precontemplators will quickly return to their old habits. How does one progress to the next stage of change when there is no consideration of recognizing a problem in the first place? Consciousness-raising therapy, in addition to changes in life circumstances, may help. When people enter a new stage of their life, they tend to critically evaluate their behaviors and consider if those behaviors are serving them and those around them in a positive way. Until they gain such insight, an individual remains in this pre-contemplation stage and will continue to engage in adverse behaviors. People in this stage have no intention of making a change in the next six months and often make comments like, “I don’t see a problem with what I’m doing, so there’s no reason to change anything.” The second stage is contemplation. This stage is marked by awareness and acknowledgment of the problematic behavior with serious consideration to change. However, the person is uncertain if the problem behavior is worthy of correcting. Therefore, this internal approach-avoidance conflict results in no commitment to taking the necessary steps toward change. In contemplation, the problem sits “center stage,” but the actor never moves. The ambivalence and indecisiveness that occur in this stage cause people to remain stuck in “contemplation” for at least six months. In general, people in this stage are more open to receiving information regarding their behaviors and finding solutions to correct them. They may make comments such as, “I know I have a problem, and I think I should do something about it.” This behavior is also known as chronic contemplation or behavioral procrastination. The next stage along the continuum is the preparation stage. At this point in the change process, the person can easily acknowledge that a behavior is problematic and can make a commitment to correcting it. Now, there is an acknowledgment that the pros of change behavior outweigh the cons. People begin gathering information from various sources; self-help books, counseling, change-oriented programs as they start to develop a plan of action. Gathering information is a vital step in preparation. If bypassed, individuals tend to plan insufficiently, without thoughtfully considering the impact the change will play in their lives. As such, they may stumble when challenges arise, and relapse often becomes inevitable. Often appropriate planning is completed; people intend to act in the next thirty days and have usually taken behavioral steps towards that direction over the past year. It is common for people in this stage to make comments such as, “Smoking is such a bad habit. I’ve been reading about different ways to quit, and even though I haven’t totally quit yet, I am smoking less than I did before.” During the action stage, change happens. Total abstinence of the adverse behavior is the expectation for a period of fewer than six months. While in this stage, people gain confidence as they believe they have the willpower to continue on the journey of change. They continue to review the importance of the behavioral change while evaluating their commitment to themselves. People in this stage are willing to receive assistance and support. Developing short-term positive reinforcement in the form of rewards sustains motivation. Considering potential hurdles to overcome and then developing plans to counteract potential triggers that may lead to relapse is prominent. During this stage, the most overt behavioral changes are acknowledged by the individual and by others. However, the visible changes found in this stage should not be mistakenly equated as the only components of change. Often, people mistakenly associate change solely with action, thereby forgoing all the prerequisite work required to act on changing a behavior. Prematurely jumping to this stage without adequately preparing will lead to difficulty.[2][3] An example of a statement made by an individual in the action stage would be, “It’s easy to say you’ll quit smoking, but I’m doing something about it. I haven’t smoked a cigarette in four months.” Continuing the new behavior change is the focus of the maintenance stage. Here, individuals have maintained total abstinence from the adverse behavior for more than six months. As people progress through this stage, the more confident they become in their ability to sustain the positive lifestyle changes and the less tempted/fearful they feel of relapsing. They can maintain a new status quo and can remind themselves of the progress they have made. At times, they may have thoughts of returning to old habits; however, they resist the temptation and remain on track because of the positive strides they have made. People become skilled at anticipating potential triggers that may result in relapse and have constructed coping strategies to combat these situations in advance. Typically, people remain in this stage anywhere between six months to five years.[7] A longitudinal study from the 1990 Surgeon General’s Report showed that after 12 months of abstinence, 43% of people returned to their smoking habit. However, it was not until reaching the 5-year mark of abstinence that the risk for relapse dropped to 7%.[7] Individuals in this stage require support as they re-evaluate their reasons for change, acknowledge the success they’ve made thus far, consider the potential triggers for relapse, and subsequently create contingency plans to try and avoid relapse. The ultimate goal of TTM is to create an action plan that will assist in preventing relapse and maintaining sobriety. The concept of relapse is a common factor in change behavior and, as such, should be discussed and normalized. Often, change behavior will take a spiral or recycling of stages rather than a linear progression.[1][2][7] For example, smokers can take an average of three to four action attempts before achieving long-term maintenance.[1] At the risk of demeaning one’s achievement up to that point, relapse should not be viewed as a failure. It should be considered an excellent opportunity to revaluate one’s triggers, reassess one’s motivation for change, reassess old/new barriers to achieving the goal, and plan for stronger contingency plans. It is essential to recognize the possibility of relapse and acknowledge it as a potential for growth and improvement. Approximately fifteen percent of people who relapse regress to the pre-contemplation stage and often try to suppress the memory of the unsuccessful trial and thoughts of the negative behavior.[1] Eighty-five percent of individuals return to the contemplation stage or preparation stage rather than pre-contemplation.[1] Individuals require constant active maintenance in the first 3 to 6 months of abstinence since this period is considered the most tempting time for relapse.[1] Termination, the final stage, is not often included in the stages of change (TTM) because it is difficult to achieve. It describes a period with zero temptation for relapse and the achievement of 100% self-efficacy. Although this level of success rarely accompanies addictive behaviors, examples of this can be seen in everyday life, when individuals buckle their seat belts as soon as they enter a car or when individuals take their medications at the same time every day. Certain factors are required to assist with stage progression. These factors include the processes of change, decisional balance, and self-efficiency.[1][2][7]
It is important to note that a great deal of TTM research has focused on illustrating high success rates when changing one adverse behavior. However, many studies that have attempted to use stage-matched system treatment for multiple behaviors have yielded limited efficacy.[8] A comprehensive literature review of studies attempting to implement change behavior to multiple adverse behaviors showed only 1 out of 39 studies were able to achieve significant change results on each of three or more adverse behaviors.[8] There is limited research and even less evidence towards the efficacy of this theory for changing multiple adverse behaviors at one given time, although it is possible that research methods don’t capture change. One challenge in developing such successful research trials is the possibility that an individual may not acknowledge all targeted adverse behaviors at the same level of importance for change. For example, an individual may be considered by researchers to be in the action stage for smoking cessation, but in the contemplation stage for exercise, while in the pre-contemplation stage for excessive alcohol use. Furthermore, information regarding ways to approach the relapse of one behavior, yet maintenance of other behaviors is limited. TTM, also known as the Stages of Change Theory, does not consider ways to tackle the complexity of multiple change behavior at this time and, as such, requires further research. Developing a reliable framework for self-change, or professionally-assisted-change is beneficial for those seeking change and for those in the health care system who are assisting with change. When using this model of change, “changers” are not coerced, but rather supported and accepted at the stage they present. Treatment becomes personalized based on the individual and the stage in which they reside. With this method, “change behavior” is thought of as a fluid and dynamic evolution, with possible recycling of stages, rather than focusing on the end goal of change. The importance of discussing the common and potential risk of relapse allows for the focus to be shifted from a failure mindset to the success that was achieved up until the point of relapse. Allowing the discussion of relapse in a nonpunitive manner leads to an honest examination of lessons learned regarding the individual, their triggers, and better ways to address those triggers. Overall, TTM assists in improving compliance and motivates people regarding the prospect of change. Although much of the documented research has centered around smoking cessation and other addictive behaviors such as alcohol abuse, and other illicit drug use; applications of the stages of change theory (TTM) has been seen in a wide variety of problematic behaviors. The numerous applications of this model have ranged from stress management, medication compliance, exercise participation, weight control, and condom use, to preventative measures such as medical screening tests.[1] Using TTM to assist with preventative medicine is another category of significance. One way to comply with healthy lifestyle behaviors is to encourage compliance with medical assessments. One study showed that patient-no show rates were not only a financial burden on the U.S. healthcare system but also indirectly affected patient access to medical care.[9][10][11] Per TTM, one would assume that these future patients are either in the pre-contemplation or contemplation stages. Not maintaining regular medical care may lead to complex clinical presentation when care is eventually requested. With this in mind, the concept of offering financial incentives from payers to patients who seek routine medical care was thought of as a way to promote healthy lifestyle behavior and advance a patient into the planning or action stage. TTM provides guidelines for "changers" and assists various health care professionals when helping individuals who are considering a change. Team members must be mindful that the majority of "changers" are not in the action stage. As such, it is reasonable to expect low registration rates and/or high dropout rates when creating and implementing an action-based treatment plan for the collective of "changers."[1] In a study by Krebs et al., results showed that stages of change strongly predicted therapy outcomes. In an action/maintenance-oriented smoking cessation program for cardiac patients, only 22% of pre-contemplators and 43% of contemplators quit smoking after six months. Conversely, 76% of individuals in the action stage were not smoking after six months.[5] Furthermore, a study by Velicer et al. illustrates that 40% of individuals are in the pre-contemplation stage, while 40% are in contemplation, and 20% in preparation. This suggests that for every behavioral change, 40% of individuals will not be ready for change.[2][7][12][7] Therefore, treating every "changer" as if they are in the action stage does not adequately serve those contemplating change and ultimately leads to premature relapse. Once the client's stage of change is determined, health care professionals can better assist with change behavior. The type, duration, and intensity of therapy should be geared towards which stage the individual finds themselves in at the time.[3][13] Studies show that moving from one stage to the next within one month will double one's chances of acting on changing behavior in the next six months of treatment.[1] For pre-contemplators who remain in this stage by the end of the first month, only 3% of them progressed to action by six months. However, for pre-contemplators who transitioned to contemplation at one month, 7% of them advanced to action by six months.[1] Similarly, for contemplators remaining in this stage by one month, only 20% acted by six months. Conversely, and perhaps even more profoundly, for the contemplators who transitioned to the preparation stage by one month, 41% of them took action by six months of treatment.[1] In summary, processes of change, when paired with their appropriate stages of change (TTM) counterparts, provide the best support for change.[1][2] More cognitive and affective processes are required initially, while the later stages require more behavioral processes. Therapists take on different roles based on the stage their client is present at the time. During the pre-contemplation stage, the therapist must take on the role of a nurturing parent, showing empathy, using active listening, and going with the client's resistance rather than against it.[2][5] During the contemplation stage, the therapist must take on the persona of a Socratic teacher, as they aim to challenge the client's beliefs to gain new insights about their behaviors.[2][5] During the preparation stage, the therapist takes on the character of an experienced coach as they work with the client to develop a game plan that is executable when the client is ready.[2][5] Lastly, in the stages of action and maintenance, the therapist takes on the role of a consultant, as they provide guidance, advice, and support when needed.[2][5] Review Questions1. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. Am Psychol. 1992 Sep;47(9):1102-14. [PubMed: 1329589] 2.Norcross JC, Krebs PM, Prochaska JO. Stages of change. J Clin Psychol. 2011 Feb;67(2):143-54. [PubMed: 21157930] 3.Norcross JC, Wampold BE. What works for whom: Tailoring psychotherapy to the person. J Clin Psychol. 2011 Feb;67(2):127-32. [PubMed: 21108312] 4.Zimmerman GL, Olsen CG, Bosworth MF. A 'stages of change' approach to helping patients change behavior. Am Fam Physician. 2000 Mar 01;61(5):1409-16. [PubMed: 10735346] 5.Krebs P, Norcross JC, Nicholson JM, Prochaska JO. Stages of change and psychotherapy outcomes: A review and meta-analysis. J Clin Psychol. 2018 Nov;74(11):1964-1979. [PubMed: 30335193] 6.Prochaska JO, Velicer WF, Redding C, Rossi JS, Goldstein M, DePue J, Greene GW, Rossi SR, Sun X, Fava JL, Laforge R, Rakowski W, Plummer BA. Stage-based expert systems to guide a population of primary care patients to quit smoking, eat healthier, prevent skin cancer, and receive regular mammograms. Prev Med. 2005 Aug;41(2):406-16. [PubMed: 15896835] 7.Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997 Sep-Oct;12(1):38-48. [PubMed: 10170434] 8.Prochaska JO, Velicer WF, Rossi JS, Redding CA, Greene GW, Rossi SR, Sun X, Fava JL, Laforge R, Plummer BA. Multiple risk expert systems interventions: impact of simultaneous stage-matched expert system interventions for smoking, high-fat diet, and sun exposure in a population of parents. Health Psychol. 2004 Sep;23(5):503-16. [PubMed: 15367070] 9.Peterson K, McCleery E, Anderson J, Waldrip K, Helfand M. VA Evidence Synthesis Program Evidence Briefs [Internet]. Department of Veterans Affairs (US); Washington (DC): Jul, 2015. Evidence Brief: Comparative Effectiveness of Appointment Recall Reminder Procedures for Follow-up Appointments. [PubMed: 27606388] 10.Wu J. Rewarding healthy behaviors--pay patients for performance. Ann Fam Med. 2012 May-Jun;10(3):261-3. [PMC free article: PMC3354976] [PubMed: 22585891] 11.Dunnagan T, Haynes G, Smith V. The relationship between the stages of change for exercise and health insurance costs. Am J Health Behav. 2001 Sep-Oct;25(5):447-59. [PubMed: 11518339] 12.Velicer WF, Fava JL, Prochaska JO, Abrams DB, Emmons KM, Pierce JP. Distribution of smokers by stage in three representative samples. Prev Med. 1995 Jul;24(4):401-11. [PubMed: 7479632] 13.DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol. 1991 Apr;59(2):295-304. [PubMed: 2030191] |
What stage of change is a person in if they start to think seriously about planning to make a long term change in the near future?
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