Transtheoretical Model

transtheoretical model theory of change

Overview of The Transtheoretical Model (TTM)

TTM (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992) is an integrative, biopsychosocial model to conceptualize the process of intentional behavior change. It seeks to integrate key constructs from other theories into a comprehensive theory of change that can be applied to a variety of behaviors, populations, and settings—hence, the name Transtheoretical.

TTM also is known as the “Stages of Change” and assumes that health behavior change involves progress through 5 stages of change:

  1. Precontemplation: tailor only to the stage, not to decisional balance. Focus on increasing the Pros of changing & experiential processes. Provide consciousness-raising, incorporate dramatic relief (anxiety, fear)
  2. Contemplation: tailor to both stages of change & decisional balance. Focus on overcoming the cons of changing as determined by a decisional balance scale. Focus on experiential processes. Use consciousness-raising, dramatic relief, environmental reevaluation, and if possible self reevaluation.
  3. Preparation: same as “contemplation tailor” plus the following. Focus on experiential processes but begin behavior processes with self-liberation. Increase emphasis on self reevaluation and self-liberation. Provide guidelines for preparatory steps (i.e. see MD before exercising)
  4. Action: focus on decreasing cons and behavioral processes especially contingency management and stimulus control.
  5. Maintenance: Focus on behavioral processes, especially contingency management, stimulus control, and counter-conditioning.

Ten processes of change have been identified for producing progress along with decisional balance, self-efficacy, and temptations:

Processes of Change

  1. Consciousness-raising: finding and learning new facts, ideas, and tips that support the healthy behavioral changes.
  2. Dramatic relief: experiencing the negative emotions (fear, anxiety, worry) that go along with unhealthy behavioral risks.
  3. Self reevaluation: realizing that the behavioral change is an important part of one’s identity as a person.
  4. Environmental reevaluation: realizing the negative impact of the unhealthy behavior or the positive impact of the healthy behavior on one’s proximal social and physical environment.
  5. Self-liberation: making a firm commitment to change.
  6. Helping relationships: seeking and using social support for the healthy behavioral change.
  7. Counter conditioning: substituting healthier alternative behaviors and cognitions for the unhealthy behaviors.
  8. Contingency management: increasing the rewards for the positive behavioral change and decreasing the rewards of the unhealthy behavior.
  9. Stimulus control: removing reminders or cues to engage in the unhealthy behavior and adding cues or reminders to engage in the healthy behavior.
  10. Social liberation: realizing that the social norms are changing in the direction of supporting the healthy behavioral change.

An Example of the Change Process with Smoking Cessation

I. Processes of Change: Experiential

  • Consciousness Raising [Increasing awareness]: I recall information people had given me on how to stop smoking.
  • Dramatic Relief [Emotional arousal]: I react emotionally to warnings about smoking cigarettes.
  • Environmental Reevaluation [Social reappraisal]: I consider the view that smoking can be harmful to the environment.
  • Social Liberation [Environmental opportunities]: I find society changing in ways that make it easier for the nonsmoker.
  • Self Reevaluation [Self reappraisal]: My dependency on cigarettes makes me feel disappointed in myself.

II. Processes of Change: Behavioral

  • Stimulus Control [Re-engineering]: I remove things from my home that remind me of smoking.
  • Helping Relationship [Supporting]: I have someone who listens when I need to talk about my smoking.
  • Counter Conditioning [Substituting]: I find that doing other things with my hands is a good substitute for smoking.
  • Reinforcement Management [Rewarding]: I reward myself when I don’t smoke.
    Self Liberation [Committing]: I make commitments not to smoke.

–Stages of Change

Transtheoretical Model Limitations 

There are several limitations of TTM, which should be considered when using this theory in public health. Limitations of the model include the following:

  • The theory ignores the social context in which change occurs, such as SES and income.
  • The lines between the stages can be arbitrary with no set criteria of how to determine a person’s stage of change. The questionnaires that have been developed to assign a person to a stage of change are not always standardized or validated.
  • There is no clear sense of how much time is needed for each stage, or how long a person can remain in a stage.
  • The model assumes that individuals make coherent and logical plans in their decision-making process when this is not always true.

The Transtheoretical Model provides strategies for public health interventions to address people at various stages of the decision-making process. This can result in interventions that are tailored (i.e., a message or program component has been specifically created for a target population’s level of knowledge and motivation) and effective. The TTM encourages an assessment of an individual’s current stage of change and accounts for relapse in people’s decision-making processes.

–Boston University School of Public Health

A Simplified Version of TTM

Stages of Change 

  • Precontemplation: Has no intention to take action within the next 6 months.
  • Contemplation: Intends to take action within the next 6 months.
  • Preparation: Intends to take action within the next 30 days and has taken some behavioral steps in this direction.
  • Action: Has changed overt behavior for less than 6 months.
  • Maintenance: Has changed overt behavior for more than 6 months.

Cognitive and Affective Experiential Processes
1. Consciousness Raising (Get the Facts)
2. Dramatic Relief (Pay Attention to Feelings)
3. Environmental Reevaluation (Notice Your Effect on Others)
4. Self-Reevaluation (Create a New Self-Image)
5. Social Liberation (Notice Public Support) Processes

Behavioral Processes
6. Self-Liberation (Make a Commitment)
7. Counter Conditioning (Use Substitutes)
8. Helping Relationships (Get Support)
9. Reinforcement Management (Use Rewards)
10. Stimulus Control (Manage Your Environment)

–ProChange

Additional Information & References

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