Stages of Change Model/Transtheoretical Model (TTM)

INTRODUCTION

Transtheoretical Model of Change, a theoretical model of behavior change was originally explained by Prochaska & DiClemente, 1983.
Transtheoretical model of change has been the basis for developing effective interventions to promote health behavior change.
The model describes how people modify a problem behavior or acquire a positive behavior.
The TTM is a model of intentional change. This model focuses on the decision making of the individual.
The transtheoretical model may help to explain differences in persons’ success during treatment for a range of psychological and physical health problems.
This model has been widely applied in behaviour modification techniques.

CONCEPTS

The core constructs of the TTM are

the processes of change
decisional balance
self-effi cacy, and
temptation.

Processes of change

Processes of change are the covert and overt activities that people use to progress through the stages.
There are ten such processes as explained by Prochaska:
Consciousness Raising (Increasing awareness)
Dramatic Relief (Emotional arousal)
Environmental Reevaluation (Social reappraisal)
Social Liberation (Environmental opportunities)
Self Reevaluation (Self reappraisal)
Stimulus Control (Re-engineering)
Helping Relationship (Supporting)
Counter Conditioning (Substituting)
Reinforcement Management (Rewarding)
Self Liberation (Committing)
The first five are classified as Experiential Processes and are used primarily for the early stage transitions.
The last five are labeled Behavioral Processes and are used primarily for later stage transitions.

Decisional Balance

Decisional Balance reflects the individual's relative weighing of the pros and cons of changing.
The Decisional Balance scale involves weighting the importance of the Pros and Cons.

Self-efficacy

Self-efficacy represents the situation specific confidence that people have that they can cope with high-risk situations without relapsing to their unhealthy or high-risk habit.
This concept was adapted wfrom Bandura's self-efficacy theory.

Temptation

reflects the intensity of urges to engage in a specific behavior when in the midst of difficult situations.
Temptation is the converse of self-efficacy.
The most common types of tempting situations are;
negative affect or emotional distress
positive social situations, and
craving.

STAGES OF CHANGE

People pass through a series of stages when change occurs.
The stages discussed in their change theory are:
precontempation
contemplation
preparation
action, and
maintenance

PRECONTEMPLATION (Not ready to change)

The individual is not currently considering change: "Ignorance is bliss"
People are not intending to take action in the foreseeable future, usually in the next six months.
Techniques:
Validate lack of readiness
Encourage re-evaluation of current behavior
Encourage self-exploration, not action
Explain and personalize the risk
Traditional health promotion programs are often not designed for such individuals and are not matched to their needs.(Velicer, 1998)

CONTEMPLATION (Thinking of changing)

Ambivalent about change: "Sitting on the fence"
Not considering change within the next month.
Techniques:
Encourage evaluation of pros and cons of behavior change.
Re-evaluation of group image through group activities.
Identify and promote new, positive outcome expectations

PREPARATION (Ready to change)

Some experience with change and are trying to change: "Testing the waters"
Planning to act within 1month.
Techniques:
The individual needs encouragement to evaluate pros and cons of behavior change.
The therapist needs to identify and promote new, positive outcome expectations in the individual.
Encourage small initial steps .
These individuals ahve taken some actions in the past year such as joining a health education class, consulting a counselor, talking to their physician, buying a self-help book or relying on a self-change approach.
These group of individuals ar suitablefor action- oriented programs for smoking cessation, weight loss, or exercise programs.

ACTION (Making change)

The active work toward desired behavioral change including modifi cation of environment, experiences, or behavior have been taken.
At this stage people have made specific overt modifications in their life-styles within the past six months.
At this stage measures should be taken against relapse.
Techniques:
Help the individual on restructuring cues and social support.
Enhance self-efficacy for dealing with obstacles.
Help to guard against feelings of loss and frustration.

MAITANANCE (Staying on track)

Here, the focus is on ongoing, active work to maintain changes made and relapse prevention.
At this stage people are are less tempted to relapse and increasingly more confident that they can continue their change.
Techniques:
lan for follow-up support
Reinforce internal rewards
Discuss coping with relapse

RELAPSE (Fall from grace)

This stage is not explained in the original article. It is a form of regression to previous stages.
It refers to falling back to the old behaviors after going through other stages.
Regression occurs when individuals revert to an earlier stage of change.
Techniques:
Evaluate trigger for relapse
Reassess motivation and barriers
Plan stronger coping strategies

APPLICATION OF THE MODEL

The model has been applied to a wide variety of problem behaviors like;
smoking cessation
exercise
low fat diet
radon testing
alcohol abuse
weight control
condom use for HIV protection
organizational change
use of sunscreens to prevent skin cancer
drug abuse
medical compliance
mammography screening, and
stress management.
Rhode Island Change Assessment Scale (URICA) is a 32-item questionnaire designed to measure the stages of change across diverse problem behaviors.
Motivational Enhancement Therapy (MET) is based on the Prochaska and
DiClemente’s stages of change model, which is applicable in smocking sessation and alcohol abuse.

REFERENCES

Prochaska JO, DiClemente CC, Norcross JC (1992). In search of how people change. Applications to addictive behaviours. Am Psychol 47:1102.
Velicer, W. F, Prochaska, J. O., Fava, J. L., Norman, G. J., & Redding, C. A. (1998) Smoking cessation and stress management: Applications of the Transtheoretical Model of behavior change. Homeostasis, 38, 216-233.
Prochaska JO , Velicer WF , Rossi JS , et al. ( 1994 ) Stages of change and decisional balance for 12 problem behaviors . Health Psychology 13, 39 – 46 .
Prochaska JO and DiClemente CC ( 1984 ) The Transtheoretical Approach: Towards a Systematic Eclectic Framework . Dow Jones Irwin , Homewood, IL, USA .
The web page of UCLA Centre for Human Nutrition. http://www.cellinteractive.com/ucla/physcian_ed/stages_change.html