Definition/Introduction
The factors that influence behavior change have been widely studied, yet one model continues to serve as the benchmark. The transtheoretical model (TTM), with its clear, stepwise approach, provides a straightforward framework for understanding human behavior and the process of change.
TTM stages include:
Precontemplation
Contemplation
Preparation
Action
TTM has become 1 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, and preventative measures such as medical screens like mammography and cancer screening.[1] This topic explains the key concepts of TTM and its application.[1][2][3][6]
Precontemplation, the first stage, involves unmotivated individuals who see no need to seek a solution to a problem because they typically do not believe a problem 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's response is atypical, as most people acknowledge their adverse behaviors. It is important to recognize that a person at this stage is in complete denial and may even defend their actions. People in this stage often present as resistant, unmotivated, unready, and unwilling to change. Furthermore, this individual often fixates on the negative aspects of change rather than recognizing the benefits they would gain. In other words, the cons outweigh the pros. Should a precontemplator present for therapy, it is likely due to constant pressure from others in their life, who are pushing them to seek help. At times, they may even exhibit elements of change, provided that external pressure remains constant. If that pressure to change is no longer present, Precontemplators 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 life, they tend to critically evaluate their behaviors and consider whether those behaviors serve them and those around them positively. Until they gain such insight, an individual remains in the precontemplation stage and continues to engage in harmful behaviors. People in this stage have no intention of making a change in the next 6 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 whether the problem behavior warrants correction. Therefore, this internal approach-avoidance conflict results in a lack of commitment to taking the necessary steps toward change. In contemplation, the problem sits “center stage,” but the actor never moves. The ambivalence and indecisiveness characteristic of this stage lead individuals to remain in “contemplation” for at least 6 months. In general, people at this stage are more open to receiving information about their behavior and to finding solutions to address it. 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 readily acknowledge that a behavior is problematic and commit to correcting it. There is now an acknowledgment that the benefits of changing behavior outweigh the drawbacks. People begin gathering information from various sources, such as self-help books, counseling, and change-oriented programs, as they 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 of the change on their lives. As such, they may stumble when challenges arise, and relapse often becomes inevitable. Often, appropriate planning is completed; people intend to act within the next 30 days and have typically taken behavioral steps toward that end 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 from the adverse behavior is the expectation for a period of fewer than 6 months. At this stage, people gain confidence because they believe they have the willpower to continue the process 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. Providing short-term positive reinforcement, such as rewards, sustains motivation. Considering potential hurdles and developing plans to counteract triggers that may lead to relapse is essential. 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 with the only components of change. Often, people mistakenly associate change solely with action, thereby forgoing the prerequisite work required to effect a behavioral change. Prematurely advancing to this stage without adequate preparation leads to difficulties.[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 4 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 6 months. As people progress through this stage, they become more confident in their ability to sustain positive lifestyle changes and are less tempted or fearful of relapse. They can maintain a new status quo and remind themselves of their progress. 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, individuals remain in this stage for between 6 months and 5 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 to avoid relapse.
The ultimate goal of TTM is to develop an action plan that helps prevent relapse and maintain sobriety. The concept of relapse is a common factor in changing behavior and, as such, should be discussed and normalized. Often, behavior change follows a spiral or a recycling of stages rather than a linear progression.[1][2][7] For example, smokers can take an average of 3 to 4 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 reevaluate 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 to acknowledge it as a potential source of 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 or preparation stage rather than the precontemplation stage.[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 no temptation to relapse and the attainment 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-efficacy.[1][2][7]
The processes of change explain how change occurs. The ten processes illustrate both the external and internal requirements needed to transition through the stages.
Decisional balance considers the pros and cons of change. The further one progresses through the stages, the greater the perceived benefits of change are valued over its perceived costs.
Self-efficacy refers to the degree of confidence one has in executing and maintaining positive change despite the temptation to relapse.
Issues of Concern
It is important to note that much TTM research has focused on demonstrating high success rates in changing a single 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 behavior change across multiple adverse behaviors showed that only 1 of 39 studies achieved significant change on at least 3 of the 3 or more adverse behaviors.[8]
There is limited research and even less evidence regarding the efficacy of this theory in changing multiple adverse behaviors simultaneously, although it is possible that research methods don’t capture change. One challenge in developing such successful research trials is that individuals may not acknowledge all targeted adverse behaviors as equally important 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 on how to address relapse in a behavior while maintaining other behaviors is limited. TTM, also known as the Stages of Change Theory, does not address the complexity of multiple change behaviors at this time and, as such, warrants further research.
Clinical Significance
Developing a reliable framework for self-change or professionally assisted change is beneficial for both those seeking change and those in the health care system who are assisting with it. When using this model of change, “changers” are not coerced but rather supported and accepted at the stage at which they present. Treatment becomes personalized based on the individual and the stage at which they reside. With this method, “change behavior” is conceived as a fluid, dynamic process, with the possibility of recycling stages, rather than as a focus on the end goal of change. Discussing the common and potential risks of relapse allows the focus to shift from a failure mindset to the successes achieved up to 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 improves compliance and motivates individuals to 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) have been seen in a wide variety of problematic behaviors. The numerous applications of this model have ranged from stress management, medication adherence, exercise participation, weight control, and condom use to preventive measures such as medical screening tests.[1]
Using TTM to support preventive medicine is another area of significance. One way to promote healthy lifestyle behaviors is to support 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. Failure to maintain regular medical care may lead to a complex clinical presentation when care is eventually sought. With this in mind, the concept of offering financial incentives from payers to patients who seek routine medical care was proposed to promote healthy lifestyle behaviors and advance patients to the planning or action stage.
Nursing, Allied Health, and Interprofessional Team Interventions
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 most "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, the 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 6 months. Conversely, 76% of individuals in the action stage were not smoking after 6 months.[5] Furthermore, a study by Velicer et al reports that 40% of individuals are in the precontemplation stage, 40% in contemplation, and 20% in preparation. This suggests that for every behavioral change, 40% of individuals are not ready for change.[2][7][12]
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 in behavior change. The type, duration, and intensity of therapy should be tailored to the individual's current stage.[3][13]
Studies show that moving from 1 stage to the next within 1 month doubles the likelihood of acting on behavior change in the next 6 months of treatment.[1] Among pre-contemplators who remained at this stage by the end of the first month, only 3% progressed to action by 6 months. However, among pre-contemplators who transitioned to contemplation at 1 month, 7% advanced to action by 6 months.[1] Similarly, among contemplators remaining at this stage for 1 month, only 20% acted within 6 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 6 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 assume different roles depending on the stage their client is at. During the precontemplation stage, the therapist must assume the role of a nurturing parent, demonstrating empathy, using active listening, and accommodating the client's resistance rather than opposing it.[2][5] During the contemplation stage, the therapist must adopt the role of a Socratic teacher, aiming to challenge the client's beliefs to elicit new insights into their behavior.[2][5] During the preparation stage, the therapist adopts the role of an experienced coach as they work with the client to develop a plan that is executable when the client is ready.[2][5] Lastly, during the action and maintenance stages, the therapist serves as a consultant, providing guidance, advice, and support as needed.[2][5]
