Transtheoretical Model

The transtheoretical model of change in health psychology explains or predicts a person's success or failure in achieving a proposed behavior change, such as developing different habits. It attempts to answer why the change "stuck" or alternatively why the change was not made.

The transtheoretical model of change (TTM) — currently, the most popular stage model in health psychology (Horwath, 1999) — has proven successful with a wide variety of simple and complex health behaviors, including smoking cessation, weight control, sunscreen use, reduction of dietary fat, exercise acquisition, quitting cocaine, mammography screening, and condom use (Prochaska, et al., 1994). Based on more than 15 years of research, the TTM has found that individuals move through a series of five stages (precontemplation, contemplation, preparation, action, maintenance) in the adoption of healthy behaviors or cessation of unhealthy ones. TTM research on a variety of different problem behaviors has also shown that there are certain predictors of progression through the stages of change (e.g., Prochaska & DiClemente, 1983), including decisional balance (Prochaska, 1994); self-efficacy (e.g., DiClemente, Prochaska, & Gibertini, 1985); and the processes of change (Prochaska & DiClemente, 1983).

The Stages of Change The TTM (for review, see Prochaska & Velicer, 1997) explains intentional behavior change along a temporal dimension that utilizes both cognitive and performance-based components. Based on more than two decades of research, the TTM has found that individuals move through a series of stages—precontemplation (PC), contemplation (C), preparation (PR), action (A), and maintenance (M)—in the adoption of healthy behaviors or cessation of unhealthy ones (Prochaska & Velicer, 1997).

Pre-Contemplation is the stage in which an individual has no intent to change behavior in the near future,usually measured as the next 6 months. Precontemplators are often characterized as resistant or unmotivated and tend to avoid information, discussion, or thought with regard to the targeted health behavior (Prochaska et al., 1992). Contemplation stage. Individuals in this stage openly state their intent to change within the next 6 months. They are more aware of the benefits of changing, but remain keenly aware of the costs (Prochaska, Redding, & Evers, 1997). Contemplators are often seen as ambivalent to change or as procrastinators (Prochaska & DiClemente, 1984). Preparation is the stage in which individuals intend to take steps to change, usually within the next month (DiClemente et al., 1991). PR is viewed as a transition rather than stable stage, with individuals intending progress to A in the next 30 days (Grimley, Prochaska, Velicer, Blais, & DiClemente, 1994). Action stage is one in which an individual has made overt, perceptible lifestyle modifications for fewer than 6 months (Prochaska et al., 1997). Maintenance: these are working to prevent relapse and consolidate gains secured during A (Prochaska et al., 1992). Maintainers are distinguishable from those in the A stage in that they report the highest levels of self-efficacy and are less frequently tempted to relapse (Prochaska & DiClemente, 1984).

The TTM uses the stages of change to integrate cognitive and behavioral processes and principles of change,including 10 processes of change (i.e., how one changes; Prochaska, 1979; Prochaska,Velicer, DiClemente, & Fava, 1988), pros and cons (i.e., the benefits and costs of changing; Janis & Mann, 1977; Prochaska, Redding, Harlow, Rossi, & Velicer, 1994; Prochaska, Velicer, et al., 1994), and self-efficacy (i.e., confidence in one’s ability to change; Bandura,1977; DiClemente, Prochaska, & Gibertini, 1985)—all of which have demonstrated reliability and consistency in describing and predicting movement through the stages (Prochaska & Velicer, 1997).

Prochaska's Model Prochaska's model stipulates six stages:
 * 1) Precontemplation - lack of awareness that life can be improved by a change in behavior;
 * 2) Contemplation - recognition of the problem, initial consideration of behavior change, and information gathering about possible solutions and actions;
 * 3) Preparation - introspection about the decision, reaffirmation of the need and desire to change behavior, and completion of final pre-action steps;
 * 4) Action - implementation of the practices needed for successful behavior change (e.g. exercise class attendance);
 * 5) Maintenance - consolidation of the behaviors initiated during the action stage;
 * 6) Termination - former problem behaviors are no longer perceived as desirable (e.g. skipping a run results in frustration rather than pleasure).

Application to addiction and other health-related behaviors
Though addiction has long been a significant problem across the world, only recently have studies investigated how individuals are able to make the changes necessary to overcome it. Prochaska, DiClemente, and Norcross (1992) have developed a paradigm to approach this problem, known as the transtheoretical model (TTM) of behavior change. Individuals are able to achieve lasting behavior change without treatment as well as with professional help and it is theorized that there is a similar structure underlying behavior change in general. A wide range of health behaviors have been investigated using this paradigm, including smoking, drinking, eating disorders, and illicit drug use (Belding, Iguchi, & Lamb, 1996; DiClemente, 1990; Etter & Perneger, 1999; Pantalon, Nich, Frankforter, & Carroll, 2002; Prochaska, DiClemente, Velicer, Ginpil, & Norcross, 1985; Prochaska, Norcross, Fowler, Follick, & Abrams, 1992; Prochaska, Velicer, DiClemente, & Fava, 1988; Willoughby and Edens, 1996). There is evidence of a systematic series of phenomena behind successful change of these behaviors.

Progress, relapse, and the spiral model
It should be noted, however, that these phases do not follow a simple linear progression. Relapse is a common and expected occurrence in addiction recovery (Gerwe, 2000; Hunt, Barnett, & Branch, 1971; Milkman, Weiner, & Sunderwirth, 1983). Therefore, the stages are seen as a set of dynamically interacting components through which the individual will likely cycle a number of times before achieving sustained behavior change (DiClemente et al., 1991). This is known as the spiral model of the stages of change, which suggests that when an individual regresses to previous stages, he or she does not typically completely fall back to where they started. The individual advances through the stages, making progress and losing ground, learning from mistakes made over time, and using those gains to move forward.

Progress is made through the stages by implementing a series of 10 processes of change, as first identified by Prochaska (1979) in an analysis of different methods of psychotherapy. However, these processes appear to occur in successful change whether it is change aided by professional therapy or not. The advancement through each stage is facilitated by engaging in a particular set of processes; i. e., movement through the stages is facilitated by different processes depending on the given stage (Prochaska, DiClemente, & Norcross, 1992). Therefore, it has been proposed that treatment is most effective when it is tailored to the particular stage of the individual.

For example, a study of a smoking cessation program for cardiac patients found that an intensive action- and maintenance-oriented approach was highly successful for patients in the action stage, but failed with those in the precontemplation and contemplation stages (Ockene, Ockene, & Kristellar, 1988). The amount of progress made in a treatment program tends to be correlated with the patient’s pretreatment state of change (Prochaska & DiClemente, 1992; Prochaska et al., 1992). Unfortunately, treatment programs tend to be action-oriented (Orleans et al., 1988; Schmid, Jeffrey, & Hellerstedt, 1989), even though most addicts are not in the action stage (Abrams, Follick, & Biener, 1988; Gottleib, Galvotti, McCuan, & McAlister, 1990; Prochaska & DiClemente, 1992).