Transtheorethical model and stages of change

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TRANSTHEORITICAL MODEL
&
STAGES OF CHANGE
Elham Shakibazadeh
PhD
TUMS

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Introduction
The Transtheoritical Model (TTM)
uses stages of change to integrate
processes and principles of
change from across major theories
of intervention; hence, the name is
trans-theoretical.

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 Originally developed in the late 1970’s
and early 1980’s by James Prochaska
and Carlo DiClemente at the University
of Rhode Island, the TTM views behavior
change as a dynamic process.
 There are three basic, inter-related
factors in the model:
1. Behavior change (Quitting) does not
happen in one step – people progress
through five stages on the way to
successful change.
2. Movement through the stages
occurs as people utilize distinct
processes of change.
3. Initiating and maintaining behavior
(cessation) requires a sufficient sense of
confidence – self-efficacy – in one’s
ability to actually carry out the actions
required to change.

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Readiness , confidence,
importance of change
Not ready unsure ready
1 2 3 4 5
Decided not undecided soon: now:
Not to thinking next taking
Change about 30 days steps
change
Not confident unsure confident
Not important unsure important

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 Intensive clinically-delivered cessation
interventions appear to be most
effective, but fail to reach the majority of
smokers.
 In addition, such programs typically
recruit participants in a reactive manner
– meaning that they wait for smokers
who are ready to quit (who represent
only about 20% of smokers) to come to
them.
 This is a big problem, because it really
means that we are actually providing
interventions to a relatively small
proportion of smokers, and missing
many who would otherwise benefit.

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Critical Assumptions
1. No single theory can account for all of the
complexities of behavior change.
2. Behavior change is a process that unfold over
time through a sequence of stages.
3. Stages are both stable and open to change
just as chronic behavioral risk factors are both
stable and open to change.
4. The majority of at risk populations are no
prepared for action and will not be served by
traditional action-oriented prevention
programs.
5. Specific processes and principles of change
should be applied at specific stages if
progress through the stages is to occur.

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Core Constructs
 Stages of change
 Decisional balance
 Self efficacy
 Processes of change

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Precontemplation
Has no intention to take action
within the next six months
(Hard to reach people)

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Contemplation
Intends to take action within the
next six months
or
24-hr quit attempt in the past year
(Behavioral procrastination)

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Preparation
Intends to take action within the
next thirty days and has taken
some behavioral steps in his/her
direction

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Action
Has changed overt behavior for
less than six months

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Maintenance
Has changed overt behavior for
more than six months

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Termination
Total self-efficacy

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Stages of change:
The Temporal Dimension
 Precontemplation
 Contemplation
 Preparation
 Action
 Maintenance
 Termination/Relapse

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Measuring the stages
 Measurement of stage of change can be accomplished
quite readily with a five-item algorithm that assesses
intentions and current behaviors specific to each stage.
 The five items are as follows:
Question: Have you quit smoking cigarettes? Check one.
. Yes, I have for more than 6 months (defines
maintenance).
. Yes, I have, but for less than 6 months (defines
action).
. No, but I intend to in the next 30 days and have tried
for at least 24 hours in the past year (defines
preparation).
. No, but I intend to in the next 6 months (defines
contemplation).
. No, and I do not intend to in the next 6 months
(defines precontemplation).

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The Temporal Dimension as the
Basis for the Stages of Change


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DECISIONAL BALANCE:
TO CHANGE OR NOT TO CHANGE
Pros: The benefits of changing
Cons: The costs of changing
Considering
change
Reasons not to
change
Reasons to
change
Stay the same
Benefits
What do you like
about…?
Concerns
What concerns
you about…?
Change
Concerns
What concerns
would you have if
you were to
change?
Benefits
What are the
benefits of
change?

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Alcohol: Decisional Balance
 How important to you are the
following statements in your
decisions about how much to drink
or if not to drink at all.
1 = Not at all Important
2 = Not Very Important
3 = Somewhat Important
4 = Very Important
5 = Extremely Important

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Pros of Drinking
1.Drinking gives me a thrilling feeling.
2.Drinking gives me more courage.
3.I feel happier when I drink.
4.I can talk with someone I am attracted to better
after a few drinks.
5.Drinking makes me feel more relaxed and less
tense.
6.Drinking helps me have fun with friends.
7.Events with alcohol are more fun.
8.I am more sure of myself when I am drinking.

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Cons of Drinking
1- Drinking could get me addicted to alcohol.
2- Drinking could land me in trouble with the law.
3- I can hurt people close to me when I drink too
much.
4- Some people close to me are disappointed in me
because of my drinking.
5- I could accidentally hurt someone because of my
drinking.
6- I am setting a bad example for others with my
drinking.
7- Drinking causes me to fail to do what is normally
expected of me.

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Self efficacy
Self-efficacy is an individuals
confidence in his/her ability to
successfully perform a
particular task“.
Bandura, 1977
The situation-specific
confidence that people have
that they can cope with high-
risk situations without
relapsing to their unhealthy or
high-risk behavior

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The Relationship between Stage and
both Self-efficacy and Temptation


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Processes of change
what people think and do to change
their behavior
1-Experiential Processes
 Consciousness raising
 Dramatic relief
 Self-reevaluation
 Social liberation
 Environmental reevaluation
2- Behavioral processes
 Counter Conditioning
 Self-liberation
 Reinforcement management
 Helping relationships
 Stimulus control

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Finding and learning new facts, ideas,
and tips that support the healthy
behavior change
I recall information given to me
on how smoking is dangerous
observations, confrontations,
interpretations, bibliotherapy.
Consciousness raising

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Dramatic relief
Experiencing the negative emotions
(fear, anxiety, worry) that go along with
unhealthy behavioral risks
I react emotionally to
warnings about smoking
cigarettes
psychodrama, grieving losses,
role playing

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Self-reevaluation [Self reappraisal]
Realizing that the behavior change
is an important part of one’s
identity as a person
My dependency on
cigarettes makes me feel
disappointed in myself
value clarification, imagery

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Social liberation
[Environmental opportunities]
Realizing that the social norms are changing in
the direction of supporting the healthy
behavior change
I find society changing in ways that
make it easier for the nonsmoker
policy interventions.

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Environmental reevaluation
[Social reappraisal]
Realizing the negative impact of the
unhealthy behavior or the positive impact
of the healthy behavior on one’s proximal
social and physical environment
I consider the view that
smoking can be harmful to the
environment
empathy training, documentaries.

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Counter Conditioning
[Substituting]
Substituting healthier alternative
behaviors and cognitions for the
unhealthy behavior
I find that doing other things with my
hands is a good substitute for
smoking
relaxation, desensitization

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Self-liberation
[Committing]
making a firm commitment to
change
I make commitments not to
smoke
decision-making therapy, New Year's
resolutions, logo therapy
techniques, commitment enhancing
techniques.

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Reinforcement management
[Rewarding]
Increasing the rewards for the positive
behavior change and decreasing the
rewards of the unhealthy behavior
I reward myself when I don’t
smoke
overt and covert reinforcement, self-
reward.

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Helping relationships
[Supporting]
Seeking and using social support for he
healthy behavior change
I have someone who listens when I
need to talk about my smoking
Counselor calls

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Stimulus control
[Re-engineering]
Removing reminders or cues to
engage in the unhealthy behavior
and adding cues or reminders to
engage in the healthy behavior
I remove things from my home
that remind me of smoking
restructuring the environment

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The Relationship between Stage and
two sample Processes, Consciousness
Raising and Stimulus Control


 Figure 5. The Relationship
between Stage and two
sample
Figure 5. The Relationship between Stage and two sample

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Processes of change that mediate
progression between the stages of change
Stages of change
Precontemplation contemplation preparation action maintenance
consciousness
raising
dramatic relief
environmental
reevaluation
self- reevaluation
self-liberation
counter conditioning
helping relationships
reinforcement manag.
stimulus control

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Support Studies
 Stage distribution
 Pros and cons structure across 10
behaviors: smoking cessation, quitting
cocaine, weight control, dietary fat reduction,
exercise acquisition, sun screen use, radon
testing, mammography screening, and
physicians practicing preventive medicine
 Integration of pros and cons and
stages of change

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The Relationship between Stage and the
Decisional Balance for a Healthy Behavior


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Support Studies (cont.’)
 Strong principal of progress
PC A=1 SD PROS
 Weak principal of progress
PC A=0.5 SD CONS

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Summary
 Recruitment and retention,
Impact on population=
Participation rate* rate of
efficacy
(30 percent* 5 percent)
versus ( 25 percent* 60
Percent)
 Progress,
 Process

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SO scientific and professional
shifts are required:
 From an action paradigm to a stage
paradigm
 From reactive to proactive recruitment
 From expecting participants to match the
needs of programs to programs that
match their needs
 From clinic-based to community-based
behavioral health programs that apply
the field’s most powerful individualized
and interactive intervention strategies

Transtheorethical model and stages of change

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