The Stages of Change Model/Transtheoretical Model (TTM)

The Stages of Change Model/Transtheoretical Model (TTM)

The stages of change model, also known as the transtheoretical model (TTM), describes an individual’s readiness or willingness to change and breaks down the change process. It holds that individuals move through six stages of change in making changes in their behavior.¹

1. Pre-contemplation – occurs when the individual does not intend to change
2. Contemplation – occurs when the individual intends to change and has a plan to do so
3. Preparation – occurs when the individual prepares to act and takes some initial steps
4. Action – occurs when the individual has initiated changes for a short time
5. Maintenance – occurs when the individual has changed their behavior and continues to maintain the change for an extended period
6. Termination – occurs when the individual no longer wants to return to the previous negative behaviors

Pre-contemplation Stage

In the pre-contemplation stage (not ready stage), the individual doesn’t intend to do anything to change their behavior. They might be unaware that their behavior is harmful or leads to unwelcome consequences. Individuals in the pre-contemplation stage might overemphasize the negatives of making behavioral changes and underestimate the benefits of doing so.

Contemplation Stage

An individual in the contemplation stage (getting ready stage) intends to make a positive behavioral change within the next six months. They understand that their current behavior is undesirable and begin considering the advantages and disadvantages of changing more thoughtfully. However, individuals in this stage might still need to be made about making desired behavioral changes.

Preparation Stage

In the preparation stage (ready stage), individuals are prepared to begin taking action to change their behavior in the immediate future. They might start to make small changes to change undesirable behavior. Individuals in the preparation stage understand that making the behavioral change will lead to healthier outcomes.

Action Stage

In the action stage, individuals have changed the problematic behavior recently, which means within the past six months. They intend to continue with the change in behavior and work to acquire newer, healthier behaviors.

Maintenance Stage

Individuals in the maintenance stage have continued and maintained their behavior change for over six months. They also intend to continue with the behavioral change for the foreseeable future. People who are in maintenance must work to prevent relapses. If a relapse occurs, the individual will move back to an earlier stage and need to go through the process again.

Termination

The termination stage occurs when the individual no longer wants to return to their previous undesirable behaviors. At this stage, the individual is confident that they will not relapse. Achieving the termination stage is rare. Most people who make positive behavioral changes reach and remain in the maintenance stage and never progress to the termination stage.

Background/History of the Stages of Change Model

James Prochaska and Carlo DiClemente developed the stages of change model through their work during the late 1970s and early 1980s, studying behavioral changes during a smoking cessation study.³ They wanted to learn why some smokers could quit independently while others needed additional treatment. They found that people who quit smoking independently were ready to do so.

Prochanska and DiClemente developed the transtheoretical model to describe how individuals make decisions to make intentional changes. Under this model, behavioral changes are viewed as occurring in a cyclical process. Since it is a behavioral model instead of a theory, different approaches that might be the most effective can be used in varying stages.

People are believed to use ten evaluative processes to facilitate their movement through the stages of change:³

1. Consciousness-raising: increasing their awareness of the desirable behavior.
2. Emotional Arousal: positive or negative arousal about the desirable behavior.
3. Self-reevaluation: reappraising healthy behavior to understand it is what the individual wants.
4. Environmental Reevaluation: reappraising the harmful behavior to recognize how it affects others and the surrounding environment.
5. Social Liberation: recognizing that society supports the desirable behavior.
6. Stimulus Control: avoiding triggering and stressing cues and situations.
7. Counterconditioning: substituting healthy behaviors for unhealthy ones.
8. Reinforcement Management: using positive reinforcement to reward the desirable behavior.
9. Self-liberation: commitment to making a positive change while believing that doing so is possible.
10. Helping Relationships: finding supportive relationships with others who encourage positive change.

Applications and Implications of the Stages of Change Model

The transtheoretical model can be applied in various programs to address multiple behaviors in different settings. It has been used to help people achieve better health outcomes by addressing the following challenges:

• Use of tobacco
• Drug addiction
• Alcohol overuse
• Sedentary lifestyles
• Weight management
• Screening and preventative measures for chronic disease
• Medication adherence
• Psychotherapeutic outcomes
• Organizational change and entrepreneurship

The stages of change/transtheoretical model may also be applied in various therapeutic and/or coaching modalities, such as motivational interviewing. Counselors are to meet clients where they are in the change process. “When using this model of change, “changers” are not coerced, but rather supported and accepted at the stage they present.”²

Scientific Support for the Stages of Change Model

Significant research, in the form of 4,000 academic studies, has been completed using the stages of change model.⁴

A systematic review of the research on the transtheoretical model was conducted in 2019 on articles published between 2009 and 2015. The researchers found that the stages of change model was effective when used to facilitate behavioral change to prevent the development of chronic diseases and to manage them, including obesity, diabetes, breast cancer, and others.⁵

A study of the effectiveness of a TTM-based program for smoking cessation among high school smokers was conducted by researchers in 2018. The researchers found that the stages of change model effectively facilitated smoking cessation among the participants, with 26.4% successfully quitting smoking.⁶

Another study evaluated the integration of TTM with the theory of planned behavior in developing a program to reduce underage drinking among Thai youth. The researchers found that interventions should identify the stages in which underage drinkers are and utilize strategies at different stages to facilitate the reduction or cessation of underage drinking.⁷

A 2020 study conducted in Brazil with overweight and obese women evaluated the effectiveness of incorporating the transtheoretical model in facilitating weight management. The researchers found that the stages of change model was effective when combined with traditional care.⁸

In a meta‐analysis of 76 studies reviewing the relationship between the stages of change and psychotherapeutic outcomes, researchers concluded that the further along a client on the stages of change, the better the treatment outcomes.⁴

Challenges and Criticisms of the Stages of Change Model

There are several criticisms of the stages of change model, including the following:

• The model doesn’t consider several potentially impactful factors, including the individual’s socioeconomic background and income, that could affect behavior and readiness to change.
• The questionnaires that might be used to assess an individual’s stage are arbitrary and may need validation.
• People do not always make logical decisions as the model assumes.
• The transtheoretical model is helpful in changing a single behavior but less successful when targeting multiple behaviors.

Summary/Key Takeaways

The stages of change model might help identify whether an individual is ready to change unhealthy behaviors. By identifying a person’s current stage, a therapist can use different intervention strategies that might be more effective in facilitating positive behavioral change. Since the stages of change is a model rather than a theory of behavior, many different types of intervention can be applied at different stages.

TTM has been considered “the standard-bearer” for change.² Practitioners might use the stages of change model to pinpoint whether an individual is ready for change and choose interventions based on their stage.

Quotes on Change