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M7D1: Stages of Change
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SOCIAL COGNITIVE MODELS and: TRANSTHEORETICAL MODEL OF BEHAVIOUR CHANGE
in SOCIAL COGNITIVE MODELS
from Key Concepts in Health Psychology
MEANING
The transtheoretical model of behaviour change (the TTM; also known as the stages of change model) is a stage-based model (see the health action process approach and the precaution adoption process model concepts as other examples of stage-based models in this chapter). Stage-based models view behaviour change as the progress of an individual from a starting point in which they may not be thinking about changing their maladaptive behaviour to a state in which they have changed their behaviour in the desired direction. On the journey of behaviour change a person is thought to pass through a number of distinct stages in which their behaviour, or psychological state, can be well defined. The stages are ordered in a particular way and it is assumed that people will pass through these in that order, with every stage visited in sequence. In addition, to progress from one stage to the next requires different processes. For instance, a stage model would predict that motivational factors, such as weighing up the pros and cons of an action, will be important for describing the conditions under which a person will move from stage X to stage Y, but not for explaining the movement from stage Y to stage Z.

ORIGINS
The TTM was originally developed by Prochaska, DiClemente and colleagues during the 1980s (e.g. DiClemente and Prochaska, 1982; Prochaska and DiClemente, 1983) to provide an analysis of how people change their behaviour. Their early work was based on observing factors that were important when a person appears to change their behaviour without any external sources of help (called ‘spontaneous remission’). These analyses led to the suggestion that people seem to pass through a series of distinct and predictable stages in a specified order during the process of behaviour change (see Sutton, 2005 for a recent review of TTM research).

This reliance on the concept of stages has led to the use of an alternative name for this approach, namely the stages of change model. However, it should be emphasized that the stages of change is but one characteristic of the TTM model. As the name suggests the TTM is an amalgamation of a number of key psychological and psychotherapeutic theories, constructs and concepts that together describe the processes that are important for understanding the psychology of behavioural change. In addition to the stages, the TTM emphasizes the role of evaluating the perceived pros and cons of changing behaviour (known as decisional balance), confidence and temptation and the (so-called) processes of change (Prochaska and Velicer, 1997). These core factors were developed and applied from psychotherapy and behaviour change approaches, then amalgamated and integrated to create an approach that was truly transtheoretcial in nature.

These stages of change are the fundamental organizing standard of the TTM. Five stages have been proposed to describe those people who have no intention of changing behaviour up to those who have changed their behaviour and have maintained this behaviour change for a period of time. Figure 3.8 shows the stages of change in the TTM.

The first three stages of the TTM are pre-actional in that they involve different levels of goal intention without any actual behavioural modification having taken place. The stages in this pre-actional phase are precontemplation, contemplation and preparation. Precontemplation is characterized by no current thoughts about the problems associated with a maladaptive behaviour and any necessary changes that may be necessary to decrease the chances of experiencing a negative outcome in the future. There is no intention to change a behaviour within the next six months. Contemplation is characterized by a behavioural intention to make a change within the next six months. At this stage people are thought to consider the changes that may be necessary if they are to avoid negative outcomes and maximize health-related benefit. For instance, they may become aware of risk factors associated with their current behaviour. The third pre-actional stage is called ‘preparation’ in which the individual has made action plans (processes in intention implementation) to make a change in the next 30 days. Effectively, the stages describe people in different motivational stages of readiness to change a specific behaviour.

Action and maintenance are post-actional in that they describe stages in which people have made the desired behavioural modification. In the action stage the change has occurred for less than six months, whereas a person is said to be in the maintenance stage when their change in behaviour has lasted for more than six months. While this five stage model has been the most commonly cited interpretation of the TTM, other authors have identified two further stages called ‘termination’ and ‘relapse’. The former describes a stage in which an individual has overcome all temptation to reinstate a previously undesirable behaviour – they are high in behavioural self-efficacy. The latter is viewed as the state which results when a person returns to a previous way of acting (e.g. having a cigarette when in a social situation one night). This return to a previous behavioural or thinking pattern may not be long lasting and can occur at any stage in the sequence, that is, preactional or post-actional (Prochaska and Velicer, 1997).

Stages of change in the transtheoretical model

(Source: Prochaska et al., 1992)

Note: This version of the stages of change model is called the spiral model. Prochaska et al. (1992) proposed that the spiral pattern more effectively describes how a person progresses through each of the stages. It recognizes that people may well relapse after they have attempted to change a behaviour. For example, it is argued that the vast majority of people do not revert to the precontemplation stage but are more likely to find themselves in the contemplation or preparation stages. This spiral model proposes that people do not go round in an endless circle of precontemplation, contemplation, preparation, action and maintenance, and that after a relapse do not end up back where they started the change process. People learn from relapse episodes and make action plans accordingly.

The TTM suggests that although people move through these stages in the defined sequence, there may be occasions when some move backwards from one stage to the previous one (e.g. from preparation to contemplation, and so on), staying at that stage for a while before making the onward journey to the stage which they had originally visited. In effect, the TTM allows a kind of recycling effect in which people can move between stages in a more cyclical manner. The best known example of this conceptualization is the spiral model of the stages of change (Prochaska et al., 1992).

Factors that influence the transition from one stage to the adjacent stage are also outlined in the TTM. The first is called ‘decisional balance’ which describes the weighing up of the pros and cons or benefits and barriers in behaviour change (see the health belief model for another use of the benefits/barriers principle). Transitions between different stages are predicted by differences in decisional balance characteristics. For instance, in comparison to the contemplation stage, thinking in the preparation stage may comprise greater emphasis on benefits of change over barriers.

Consistent with almost every social cognitive account of health behaviour and behaviour change, Prochaska, DiClemente and colleagues propose self-efficacy to be a very important factor in understanding stage transitions. They conceptualized self-efficacy as the balance between a confidence in one’s ability to undertake health protective behaviour against the temptation to behave in an unhealthy manner. Think of these processes as the independent variables in predicting stage transitions. In other words, advocates of the TTM propose that these processes are the causes of movement between adjacent stages. The final set of proposals for describing factors important in predicting movement through the stages in the pre-defined sequence is called the ‘processes of change’. These 10 processes of change include five experiential processes, or cognitive-affective factors, as well as five behavioural processes. They are listed and described in Box 3.3.

Box 3.3 Processes of change in the transtheoretical model

Consciousness-raising – identifying new facts, information sources and suggestions in support of a behavioural change (e.g. through health promotion campaigns, social interaction with significant others). Incorporating this information as part of the learning process.

Dramatic relief – experiencing negative emotions about related issues (e.g. worry or fear) and expressing these with significant others (e.g. with a friend, partner, or counsellor).

Self re-evaluation – realizing that there is a link between the behavioural change and one’s own identity (e.g. viewing oneself as a non smoker, fit person or a healthy eater).

Environmental re-evaluation – appraising how the behavioural problem influences the physical environment and the experience of others in that environment (e.g. recognition of the bad effects on other important people of one’s behaviour, such as in the case of passive smoking).

Self liberation – making a decision and committing oneself to act on the belief that changing a behaviour is possible and accepting personal responsibility for the change.

Social liberation – an understanding of societal support for the need for healthy behaviours as being fundamental in influencing social communities.

Counter-conditioning – identifying healthier behaviours and substituting them for the maladaptive behaviours (e.g. utilizing relaxation techniques or nicotine replacement as a means of overcoming the link between feeling ‘stressed’ and having a cigarette).

Stimulus control – identifying and avoiding triggers or cues to the problem behaviour.

Contingency management – increasing the rewards associated with positive behaviour change, as well as decreasing the rewards associated with unhealthy behaviours (e.g. putting aside the money saved as a result of not smoking for a month and buying something new with that money).

Helping relationships – identifying personal social support systems and networks (e.g. family, friends and professionals) to provide reassurance and reinforcement of the positive aspects of behaviour change and the negative aspects of not changing.

CURRENT USAGE
The TTM has been applied and studied in a vast array of health behaviours including smoking (e.g. Aveyard et al., 2003), exercise (e.g. Cox et al., 2003), condom use (e.g. Brown-Peterside et al., 2000) and drinking (e.g. Budd and Rollnick, 1996). In a number of meta-analyses studying the validity of TTM as a stage model, and the various processes of change factors identified by the model, there is some support for the utility of the model and its constructs (e.g. Marshall and Biddle, 2001). However, critics have suggested that behaviour change is not necessarily reflected in differences in processes between distinct stages, but is more likely to be about the same processes varying across the whole change-related span (e.g. Rosen, 2000).

Other work has tested the TTM components by incorporating stage matched and stage mismatched interventions to test the applicability of the model. For instance, only interventions matched to the factors thought to move a person from contemplation to preparation, and so on, should show such an effect. The manipulation of other factors relevant for later or earlier stage transition should not affect the focus transition. Evidence from such intervention studies has not been conclusive in their support of the TTM (e.g. Cox et al., 2003), nor has it been wholly supported by relevant meta-analyses (e.g. Bridle et al., 2005). Sutton (2005) argues that the inconclusive nature of these findings is not aided by researchers not directly testing the tenets of the TTM in the first place, and this leads him to conclude that ‘ … there have been no process analyses published to date demonstrating that TTM-based interventions do indeed influence the variables they target in particular stages and that forward stage movement can be explained by these variables’ (p. 247) (see also Sutton, 1996).

SIGNIFICANCE TO HEALTH PSYCHOLOGY
The TTM was the first stage-based model presented in an attempt to understand the processes involved in how people change their behaviour and in particular their health behaviour. In this way it is similar to other stage theories including the precaution adoption process model and the health action process approach. The TTM proposes not only the stages through which a person travels in sequence while changing behaviour, but also identifies a number of core processes that instigate and motivate the change processes. In other words, these processes identify how people change and are important because they imply that change is a predictable behavioural process grounded in observable and measurable psychological factors. If this is the case, then theoretically interventions, based on knowledge about which factors are fundamental in ensuring the transition of a person in stage X to stage Y, could be designed. As the literature stands there is both support and contradictory evidence for the TTM as being a stage-based model at all, and also as to how valid each of the change processes are in describing and predicting stage transitions.

Further reading
A useful statistically based review of a large number of studies that have utilized the transtheoretical model in understanding changes in behaviour related to exercise.

A detailed account of the key theoretical characteristics, components and predictions inherent in the transtheoretical model.

A useful review of the key components of any stage-based model and includes a detailed analysis of the transtheoretical model in these terms.

A useful critique of stage-based approaches in the study and treatment of addictive behaviours, including a detailed critical account of the transtheoretical model.

Marshall, S. J. and Biddle, S. (2001) The transtheoretical model of behaviour change: a meta-analysis of applications to physical activity and exercise. Annals of Behavioral Medicine, 23, 229-246.
Prochaska, J. O. and Velicer, W. F. (1997) The transtheoretical model of health behavior change. American Journal of Health Promotion, 12, 38-48.
Sutton, S. (2005) Stage theories of health behaviour. In Conner, M. and Norman, P. (eds), Predicting Health Behaviour (2nd edition). Buckingham: Open University Press. pp. 223-275.
Sutton, S. R. (1996) Can ‘stages of change’ provide guidance in the treatment of addictions? A critical examination of Prochaska and DiClemente’s model. In Edwards, G. and Dare, C. (eds), Psychotheraphy, Psychological Treatments and the Addictions. Cambridge: Cambridge University Press. pp. 189-205.
See also social cognitive models and social cognitive theory; social cognitive models and precaution adoption process model

The stages of change model is a commonly used model of treatment that can be applied to the field of addiction. In this module, you discussed how this model applies to the field of addiction and offered some examples. In this activity, you will apply the stage of change model to a behavioral addiction.

Choose a behavior (such as overeating, shopping, Internet use, etc.)
Identify examples of each of the stages of change—pre-contemplation through maintenance—using the behavior you selected as the focus.
Review at least two of your classmates’ postings, identifying at least one possible strategy to assist the individual to move forward to the next level in each of the stages described.

Evaluation Criteria

Your initial post should be at least 250 words and must substantively integrate the assigned readings in the instructions with proper APA (Links to an external site.) style formatting.

For assistance with APA style formatting, visit the Library (Links to an external site.) or the Excelsior OWL (Links to an external site.).

After you have posted, read through the postings of your peers. Choose (at least) two of your peers’ posts to respond to. The posts you choose to respond to do not necessarily have to be classmates’ initial posts.

Each response to a peer should be (at least) approximately 100 words in length and should contribute to the discussion in progress. All responses to classmates should be substantive. That is, they should go beyond simple agreement or disagreement with classmates’ posts. Also, be sure that your responses are respectful, substantive, and consistent with the expectations for discussion, as stated by the prompt. Be sure to monitor and respond to feedback to your major thread post throughout the module. Be sure also to reply to your classmates’ postings and that your responses are within the designated due dates for this discussion activity. Please direct any questions you may have to your instructor.

See the Course Calendar for due dates for posts and responses.

Consult the Discussion Posting Guide for information about writing your discussion posts. It is recommended that you write your post in a document first. Check your work and correct any spelling or grammatical errors. When you are ready to make your initial post, click on “Reply.” Then copy/paste the text into the message field, and click “Post Reply.”

This is a “post first” discussion forum. You must submit your initial post before you can view other students’ posts.

To respond to a peer, click “Reply” beneath her or his post and continue as with an initial post.

Evaluation

This discussion will be graded using the discussion board rubric. Please review this rubric, located on the Rubrics page within the Start Here module of the course, prior to beginning your work to ensure your participation meets the criteria in place for this discussion. All discussions combined are worth 30% of your final course grade.