Evidence-based health and well-being for entire populations.

The Transtheoretical Model

The Transtheoretical Model (TTM):

  • uses the Stages of Change to integrate the most powerful principles and processes of change from leading theories of counseling and behavior change;
  • is based on principles developed from over 35 years of scientific research, intervention development, and scores of empirical studies;
  • applies the results of research funded by over $80 million worth of grants and conducted with over 150,000 research participants; and
  • is currently in use by professionals around the world.

Overview of the Model

The Transtheoretical Model (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992) is an integrative, biopsychosocial model to conceptualize the process of intentional behavior change. Whereas other models of behavior change focus exclusively on certain dimensions of change (e.g. theories focusing mainly on social or biological influences), the TTM seeks to include and integrate key constructs from other theories into a comprehensive theory of change that can be applied to a variety of behaviors, populations, and settings (e.g. treatment settings, prevention and policy-making settings, etc.)—hence, the name Transtheoretical.

The Stages of Change

Stages of Change lie at the heart of the TTM. Studies of change have found that people move through a series of stages when modifying behavior. While the time a person can stay in each stage is variable, the tasks required to move to the next stage are not. Certain principles and processes of change work best at each stage to reduce resistance, facilitate progress, and prevent relapse. Those include decisional balance, self-efficacy, and processes of change. Only a minority (usually less than 20%) of a population at risk is prepared to take action at any given time. Thus, action-oriented guidance misserves individuals in the early stages. Guidance based on the TTM results in increased participation in the change process because it appeals to the whole population rather than the minority ready to take action.

The stage construct represents a temporal dimension. Change implies phenomena occurring over time. Surprisingly, none of the leading theories of therapy contained a core construct representing time. Traditionally, behavior change was often construed as an event, such as quitting smoking, drinking, or overeating. TTM recognizes change as a process that unfolds over time, involving progress through a series of stages. While progression through the Stages of Change can occur in a linear fashion, a nonlinear progression is common. Often, individuals recycle through the stages or regress to earlier stages from later ones.

Stages of Change
The Stages of Change 'curve'
The Stages of Change 'curve'
The Stages of Change 'curve'
The Stages of Change 'curve'
The Stages of Change 'curve'

The Stages of Change 'curve'
The Stages of Change 'curve'
The Stages of Change 'curve'

The Stages of Change 'curve'
The Stages of Change 'curve'
The Stages of Change 'curve'

The Stages of Change 'curve'
The Stages of Change 'curve'
The Stages of Change 'curve'

The Stages of Change 'curve'
The Stages of Change 'curve'
The Stages of Change 'curve'

Precontemplation
Contemplation
Preparation
Action
Maintenance
Not intending to take action in the next six months
Intending to take action in the next six months
Ready to take action in the next 30 days
Have made overt lifestyle changes in the past six months
Doing a new behavior for more than six months

Precontemplation.

People in the Precontemplation stage do not intend to take action in the foreseeable future, usually measured as the next six months. Being uninformed or under informed about the consequences of one’s behavior may cause a person to be in the Precontemplation stage. Multiple unsuccessful attempts at change can lead to demoralization about the ability to change. Both the uninformed and under informed tend to avoid reading, talking, or thinking about their high-risk behaviors. They are often characterized in other theories as resistant, unmotivated, or unready for help. The fact is, traditional programs were not ready for such individuals and were not designed to meet their needs.

Contemplation.

Contemplation is the stage in which people intend to change in the next six months. They are more aware of the pros of changing, but are also acutely aware of the cons. In a meta-analysis across 48 health risk behaviors, the pros and cons of changing were equal (Hall & Rossi, 2008). This weighting between the costs and benefits of changing can produce profound ambivalence that can cause people to remain in this stage for long periods of time. This phenomenon is often characterized as chronic contemplation or behavioral procrastination. Individuals in the Contemplation stage are not ready for traditional action-oriented programs that expect participants to act immediately.

Preparation.

Preparation is the stage in which people intend to take action in the immediate future, usually measured as the next month. Typically, they have already taken some significant action in the past year. These individuals have a plan of action, 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 are the people who should be recruited for action-oriented programs.

Action.

Action is the stage in which people have made specific overt modifications in their lifestyles within the past six months. Because action is observable, the overall process of behavior change often has been equated with action. But in the TTM, Action is only one of six stages. Typically, not all modifications of behavior count as Action in this Model. In most applications, people have to attain a criterion that scientists and professionals agree is sufficient to reduce risk of disease. For example, reduction in the number of cigarettes or switching to low-tar and low-nicotine cigarettes were formerly considered acceptable actions. Now the consensus is clear—only total abstinence counts.

Maintenance.

Maintenance is the stage in which people have made specific overt modifications in their lifestyles and are working to prevent relapse; however, they do not apply change processes as frequently as do people in Action. While in the Maintenance stage, people are less tempted to relapse and grow increasingly more confident that they can continue their changes. Based on self-efficacy data, researchers have estimated that Maintenance lasts from six months to about five years. While this estimate may seem somewhat pessimistic, longitudinal data in the 1990 Surgeon General’s report support this temporal estimate. After 12 months of continuous abstinence, 43% of individuals returned to regular smoking. It was not until 5 years of continuous abstinence that the risk for relapse dropped to 7% (USDHHS).

Termination.

Termination is the stage in which individuals are not tempted; they have 100% self-efficacy. Whether depressed, anxious, bored, lonely, angry, or stressed, individuals in this stage are sure they will not return to unhealthy habits as a way of coping. It is as if their new behavior has become an automatic habit. Examples include adults who have developed automatic seatbelt use or who automatically take their antihypertensive medication at the same time and place each day. In a study of former smokers and alcoholics, researchers found that less than 20% of each group had reached the criteria of zero temptation and total self-efficacy (Snow, Prochaska & Rossi, (1992). The criterion of 100% self-efficacy may be too strict or it may be that this stage is an ideal goal for population health efforts. In other areas, like exercise, consistent condom use, and weight control, the realistic goal may be a lifetime of maintenance.

Decisional Balance

Decision making was conceptualized by Janis and Mann (1977) as a decisional “balance sheet” of comparative potential gains and losses. Two components of decisional balance, the pros and the cons, have become critical constructs in the Transtheoretical Model. As individuals progress through the Stages of Change, decisional balance shifts in critical ways. When an individual is in the Precontemplation stage, the pros in favor of behavior change are outweighed by the relative cons for change and in favour of maintaining the existing behavior. In the Precontemplation stage, the pros and cons tend to carry equal weight, leaving the individual ambivalent toward change. If the decisional balance is tipped however, such that the pros in favor of changing outweigh the cons for maintaining the unhealthy behavior, many individuals move to the Preparation or even Action stage. As individuals enter the Maintenance stage, the pros in favor of maintaining the behavior change should outweigh the cons of maintaining the change in order to decrease the risk of relapse.

Self-Efficacy

The TTM integrates elements of Bandura’s self-efficacy theory (Bandura, 1977, 1982). This construct reflects the degree of confidence individuals have in maintaining their desired behavior change in situations that often trigger relapse. It is also measured by the degree to which individuals feel tempted to return to their problem behavior in high-risk situations. In the Precontemplation and Contemplation stages, temptation to engage in the problem behavior is far greater than self-efficacy to abstain. As individuals move from Preparation to Action, the disparity between feelings of self-efficacy and temptation closes, and behavior change is attained. Relapse often occurs in situations where feelings of temptation trump individuals’ sense of self-efficacy to maintain the desired behavior change.

Processes of Change

While the Stages of Change are useful in explaining when changes in cognition, emotion, and behavior take place, the processes of change help to explain how those changes occur. These ten covert and overt processes need to be implemented to successfully progress through the stages of change and attain the desired behavior change. These ten processes can be divided into two groups: cognitive and affective experiential processes and behavioral processes.

Experiential Processes

Consciousness Raising (Get the Facts).

Consciousness raising involves increased awareness about the causes, consequences, and cures for a particular problem behavior. Interventions that can increase awareness include feedback, interpretations, and bibliotherapy. Sedentary people, for example, may not be aware that their inactivity can have the same risk as smoking a pack of cigarettes a day.

Dramatic Relief (Pay Attention to Feelings).

Dramatic relief initially produces increased emotional experiences followed by reduced affect or anticipated relief if appropriate action is taken. Interventions can provide fear arousing feedback on health risks or success stories to move people emotionally.

Environmental Reevaluation (Notice Your Effect on Others).

Environmental reevaluation combines both affective and cognitive assessments of how the presence or absence of a personal habit affects one’s social environment, such as the effect of smoking on others. It can also include the awareness that one can serve as a positive or negative role model for others.

Self-Reevaluation (Create a New Self-Image).

Self-reevaluation combines both cognitive and affective assessments of one’s self-image with and without a particular unhealthy habit, such as one’s image as a couch potato versus an active person. Values clarification, identifying healthy role models, and imagery are techniques that programs can use to move people toward self-reevaluation. During interaction with a TTM intervention, the program might ask, “Imagine you were free from smoking. How would you feel about yourself?”

Social Liberation (Notice Social Trends).

Social liberation requires an increase in social opportunities or alternatives, especially for people who are relatively deprived or oppressed. For example, advocacy, empowerment procedures, and appropriate policies can produce increased opportunities for mental health promotion, gay health promotion, and health promotion for impoverished segments of the population. These same procedures can also be used to help populations change; examples include smoke-free zones, healthy food at schools and work, and easy access to condoms and other contraceptives.

Behavioral Processes

Self-Liberation (Make a Commitment).

Self-liberation is both the belief that one can change and the commitment, as well as the recommitment, to act on that belief. Encouraging people to make New Year’s resolutions, public testimonies, or a contract are ways of enhancing willpower. A TTM program might say, “Telling others about your commitment to take action can strengthen your willpower. Who are you going to tell?”

Counter Conditioning (Use Substitutes).

Counter conditioning requires learning healthy behaviors as substitutes for problem behaviors. Examples of counter conditioning include recommendations for use of nicotine replacement as a safe substitute for smoking or walking as a healthier alternative than “comfort foods” as a way to cope with stress.

Helping Relationships (Get Support).

Helping relationships combine caring, trust, openness, and acceptance, as well as support for healthy behavior change. Rapport building, a therapeutic alliance, supportive calls, and buddy systems can be sources of social support.

Reinforcement Management (Use Rewards).

Reinforcement management provides consequences for taking steps in a positive direction. While reinforcement management can include the use of punishment, self-changers rely on reward much more than punishment. So, the TTM recommends an emphasis on reinforcement so as to work in harmony with how people change naturally. People expect to be reinforced by others more frequently than occurs, so they should be encouraged to reinforce themselves through self-statements like “Nice going—you handled that temptation.” They also need to treat themselves at milestones as a way to provide reinforcement and to increase the probability that healthy responses will be repeated.

Stimulus Control (Manage Your Environment).

Stimulus control removes cues for unhealthy habits and adds prompts for healthier alternatives. In this process TTM programs can recommend removing all the ashtrays from the house and car or removing high-fat foods that are tempting cues for unhealthy eating.

Different strategies are most effective at different Stages of Change. For example, counter conditioning and stimulus control can really help people in the Action and Maintenance stages. But these processes are not helpful for someone who is not intending to take action. Consciousness raising and dramatic relief work better for someone in that stage—Precontemplation.

Principles and Processes of Change

Critical Assumptions of the TTM

The Transtheoretical Model is also based on critical assumptions about the nature of behavior change and population health interventions that can best facilitate such change. The following set of assumptions drives Transtheoretical Model theory, research, and practice:

  • Behavior change is a process that unfolds over time through a sequence of stages. Health population programs need to assist people as they progress over time.
  • Stages are both stable and open to change, just as chronic behavior risk factors are both stable and open to change.
  • Population health initiatives can motivate change by enhancing the understanding of the pros and diminishing the value of the cons.
  • The majority of at-risk populations are not prepared for action and will not be served by traditional action-oriented prevention programs. Helping people set realistic goals, like progressing to the next stage, will facilitate the change process.
  • Specific principles and processes of change need to be emphasized at specific stages for progress through the stages to occur. Table 1 outlines which principles and processes to apply at each stage.

Transtheoretical Model Research Breakthroughs

1980s

  • Discovered the Stages of Change and the dynamic principles and processes of change related to each stage

1990s

  • Developed the first computer-tailored intervention based on the Transtheoretical Model of Behavior Change
  • Demonstrated tailored interventions for smoking cessation effective even when more than 80% were not ready to quit
  • Applied the Transtheoretical Model to a variety of behaviors beyond smoking cessation

2000s

  • Demonstrated that Transtheoretical Model-based interventions for simultaneous multiple behavior change are effective
  • Applied the Transtheoretical Model to a wide variety of new behavior change challenges
    Served entire populations with inclusive proactive and home-based care

2010s

  • Implemented innovative strategies to ensure greater impact on multiple behaviors with fewer demands on patients and providers
  • Designed a more cost-effective delivery for coaching and online programs
  • Gained synergistic insights into how changing one behavior increases the chance of changing other behaviors (coaction)
  • Improved well-being by increasing productivity and thriving
  • Improved well-being resulting in increased productivity
  • Increased the efficacy of our best practices by 31.7% as a result of adding tailored text messages
  • Developed a Clinical Dashboard to provide evidence-based stage matched behavior change messages for clinicians to deliver to patients.

Tailoring Matters

A recent meta-analyses, by Noar et al., of 57 studies demonstrated greater effects in programs that are tailored on each of the Transtheoretical Model constructs. Specifically, programs that tailor on stage do better than those that do not; programs that tailor on pros and cons do better than those that do not; programs that tailor on self-efficacy do better than those that do not, and programs that tailor on processes of change do better than those that do not.

Noar, S.M., Benac, C.N., and Harris, M.S. (2007) Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychological Bulletin, 4, 673-693. abstract
Abstract:
Although there is a large and growing literature on tailored print health behavior change interventions, it is currently not known if or to what extent tailoring works. The current study provides a meta-analytic review of this literature, with a primary focus on the effects of tailoring. A comprehensive search strategy yielded 57 studies that met inclusion criteria. Those studies, which contained a cumulative N = 58,454, were subsequently meta-analyzed. The sample-size weighted mean effect size of the effects of tailoring on health behavior change was found to be r = .074. Variables that were found to significantly moderate the effect included 1) type of comparison condition; 2) health behavior; 3) type of subject population (both type of recruitment and country of sample); 4) type of print material; 5) number of intervention contacts; 6) length of follow-up; 7) number and type-of theoretical concepts tailored on; and 8) whether or not demographics and/or behavior were tailored on. Implications of these results are discussed and future directions for research on tailored health messages and interventions are offered.

To learn about the efficacy of our online programs, see the citations on each of our products pages, or our program effectiveness summary. A 2008 replication study at Oregon Science and Health University also shows program effectiveness; see:

Prochaska, J.O., Butterworth, S., Redding, C.A., Burden, V., Perrin, N., Lea, Michael, Flaherty, Robb M., and Prochaska, J.M. (2008). Initial efficacy of MI, TTM tailoring, and HRI’s in multiple behaviors for employee health promotion. Preventive Medicine, 46, 226-231. abstract
Abstract:
Objective. This study was designed to compare the initial efficacy of Motivational Interviewing (MI), Online Transtheoretical Model (TTM)-tailored communications and a brief Health Risk Intervention (HRI) on four health risk factors (inactivity, BMI, stress and smoking) in a worksite sample.
Method. A randomized clinical trial assigned employees to one of three recruitment strategies and one of the three treatments. The treatment protocol included an HRI session for everyone and in addition either a recommended three TTM online sessions or three MI in person or telephone sessions over 6 months. At the initial post-treatment assessment at 6 months, groups were compared on the percentage who had progressed from at risk to taking effective action on each of the four risks.
Results. Compared to the HRI only group, the MI and TTM groups had significantly more participants in the Action stage for exercise and effective stress management and significantly fewer risk behaviors at 6 months. MI and TTM group outcomes were not different.
Conclusion. This was the first study to demonstrate that MI and online TTM could produce significant multiple behavior changes. Future research will examine the long-term impacts of each treatment, their cost effectiveness, effects on productivity and quality of life and process variables mediating outcomes.
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