13.7: Transtheoretical Model (Stages of Change)

Unlike the previous theories which mostly describe why a person engages in a particular behavior, or antecedents (prerequisites) to behavioral change, the Transtheoretical Model (TTM) instead describes the process of changing behavior. Drawing from several different behavioral theories (hence the name), psychologists James Prochaska and Carlo DiClemente developed the TTM in the late 1970’s. The TTM makes the (perhaps obvious) assertion that behavioral change is not immediate: people do not wake up one morning and start exercising and eating a healthy diet, nor does someone quit smoking overnight. Instead, behavior change is a process, and not even a linear process - people usually enter for the first time at the first stage but then may exit or re-enter the process at any stage in a somewhat circular fashion. Each stage in the TTM is based on the person’s individual readiness to change their behavior. (LaMorte, 2022a, McKenzie et al., 2017). Below are the 5 stages with a description of each, followed by a diagram in Figure 13.6.

• Precontemplation. Before a person decides to make any change to their behavior, they may be unaware of the risks of not changing behavior, or they may be resistant to change. In this stage, a person has no intention of changing their behavior in the next 6 months.
• Contemplation. At this stage, a person is considering changing their behavior in the next 6 months, and they may be thinking about all of the pros and cons to making this change. Barriers can be perceived as enormous, and it may be difficult to see the path forward, especially if the person lacks self-efficacy in this area.
• Preparation. This stage begins when the person intends to change their behavior in the near future, usually within the next month. They may have already started to make a few small changes, are in the process of planning how they will change their behavior, and believe that this is an important thing to do.
• Action. A person in the action stage has begun to change their behavior recently (within the last 6 months). The risk of relapse is high in this stage.
• Maintenance. This stage is reached when the new behavior has been relatively consistent for 6 months or more. A person in the maintenance stage intends to continue this behavior, and the longer they do so the more a part of their lifestyle it becomes.

Relapse, or exiting the stages of change and reverting back to old behavior patterns can occur at any stage, but is less likely the longer a person stays in maintenance. A sixth stage, called termination, occurs when the new behavior is so ingrained in the person’s lifestyle that they have no risk of relapse. For many health behaviors, termination is impossible since the temptation to go back to old behaviors still lingers, or since barriers to the behavior must still be planned for and overcome. Most public health practitioners will therefore not use the termination stage (LaMorte, 2022a, McKenzie et al., 2017). See Fig. \(\PageIndex{1}\) for a diagram of the TTM.

Figure \(\PageIndex{1}\): Diagram of the Transtheoretical Model. *Relapse can occur at any stage of the model, as can re-entry. **Termination does not occur for all behaviors, and so is not always used by public health practitioners.

There are also 10 processes that people can use to move from one stage to the next. Some processes work better for earlier stages and others for later stages. These processes include the following (adapted from LaMorte, 2022a):

• Consciousness raising. Learning information about the behavior change, the risks of not changing, and the benefits of changing can help in the decision-making process, particularly in early stages.
• Dramatic relief. Many decisions to change behavior are emotional decisions. Experiencing a significant event can often bring this on (such as a diagnosis, or loss of a loved one), but so can taking the time to consider what a person’s dreams and desires are. When a person experiences this emotional response - whether positive toward the new behavior, or negative toward the consequences of not changing - it can spur motivation to take action.
• Self re-evaluation. This involves creating a discrepancy between where the person is now and where they want to be, as well as the realization that the desired behavior is part of who they want to be.
• Environmental re-evaluation. Other people are affected by an individual’s behavior, often those that are close to them. Knowing how their behavior affects others can become a significant motivator as well.
• Social liberation. There need to be opportunities that demonstrate the new, healthy behavior as being socially accepted. This helps to “normalize” the healthy behavior.
• Self liberation. When a person has self-efficacy, and believes that change is possible for them, they can make a commitment to the new behavior.
• Helping relationships. Identifying social support is key to both starting and maintaining a new behavior.
• Counter conditioning. This involves substituting negative behaviors and thoughts for change-inducing behaviors and thoughts. For example, a person might have had negative thoughts like “I’ll never be able to change, it’s too hard”, and will need to reframe those thoughts to more positive statements such as “I’ve had challenges in the past, and I will learn from them moving forward”. If a specific behavior happens to be a trigger to relapse into old habits, a similar but healthier behavior can be substituted. For example, driving is often a trigger for former smokers. Other behaviors like snacking on sunflower seeds or carrots can be a substitute.
• Reinforcement management. Rewards can still be helpful to reinforcing behaviors, especially if the person chooses the reward themselves. They can also reduce the “rewards” from the undesired behavior, by making it less pleasant.
• Stimulus control. This involves changing the environment to remove triggers for the undesired behavior and instead place conspicuous cues for the desired behavior. For example, if someone wants to stop snacking while watching TV at night, they can avoid purchasing common snack foods. If a person wants to exercise in the morning, they might lay out their workout clothes the night before.

Figure \(\PageIndex{2}\): For many smokers, driving is an activity that triggers cigarette cravings. Counter conditioning (i.e. substituting sunflower seeds or another snack while driving) and stimulus control (i.e. removing lighters from the car, keeping windows rolled up, etc.) are processes that can be used in the TTM to assist behavior change. . (Copyright; Photo by Elsa Olofsson on Unsplash.).

Any and all of the aforementioned behavioral change models can be potentially useful in helping people change their behavior. They might be used by medical professionals, addiction specialists, counselors and therapists, or nutrition and fitness practitioners as helpful tools. However, some of them may have slight conflicts with public health goals. For example; SDT values autonomy in decision-making. Therefore, if a person decides that they do not want to quit smoking, that choice should be affirmed by practitioners (Sheeran et al., 2020). This obviously conflicts with a public health interest of reducing smoking behaviors! Another potential problem with these models is that they focus exclusively on the individual - their experiences, motivations and/or sense of behavioral control (aka self-efficacy, or competence). Social influences are recognized in several of the models, yet other influences such as environment, politics and public policy, health literacy, access, and economic variables are not. These models describe how an individual may change their own behaviors, but not necessarily how to nudge a group, community, or larger population in the direction of health-behaviors. Therefore, we need to “zoom out” and take a look at human behavior in the larger context of the community.