It was Dean Karnazes’s 30th birthday, and he felt trapped. Despite a successful career and a happy marriage, he was lost and disillusioned. Show
That evening, he was drunk and out with friends at a night club in San Francisco when a beautiful young woman approached him. They hit it off instantly. One way or another, what he decided next would determine his future. Perhaps unexpectedly, he made his excuses and left. Once home, he rooted through boxes, took out an old pair of sneakers, and did something he hadn’t done since college: he started running (Karnazes, 2006). And he carried on, and on, becoming famous for winning several ultra-marathons and running across America. He has since been named as one of the “Top 100 Most Influential People in the World” by Time magazine. Change can take many forms. Sometimes we choose it, and sometimes it just happens. The Transtheoretical Model of Change explains the stages we pass through when we change our behavior and provides the insights we need to intervene and move on in life. In this article, we look at the model, explore the stages and multiple factors involved in change, and identify worksheets that can help you or your client. Before you continue, we thought you might like to download our three Goal Achievement Exercises for free. These detailed, science-based exercises will help you or your clients create actionable goals and master techniques to create lasting behavior change. This Article Contains:
What Are the Stages of Change?The Transtheoretical Model of Change (TTM) – the result of the analysis of more than 300 psychotherapy theories – was initially developed in 1977 by James Prochaska of the University of Rhode Island and Carlo Di Clemente (Prochaska & Velicer, 1997). The TTM offers a theory of healthy behavior adoption and its progression through six different stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. TTM is a model, rather than a single method for change, combining four key constructs and a temporal dimension – not present in other theories at that time – that can help a client understand behavioral transformation.
How do we progress through change?Our perception of change – for example, altering our diet or increasing exercise –transforms over time. In earlier stages, we see more cons than pros, but over time, in later stages, the balance shifts, and we start to see increased benefits to behavioral change. The model helps us understand not only the process by which clients make an intentional change, but also the support from themselves and others that can help. As such, it provides a useful tool for therapists, counselors, and health professionals working with clients and patients. TTM identifies six stages of readiness experienced by an individual attempting to change (Prochaska & Velicer, 1997; Liu, Kueh, Arifin, Kim, & Kuan, 2018):
The final stage, termination, is perhaps more of a destination – an end state. At this point, even if bored or depressed, the client will not return to their former way of coping (Prochaska & Velicer, 1997). However, it is essential to note that the client’s behavior through earlier stages may not be linear. Instead, it occurs in cycles; they may revisit – or relapse – to prior stages before moving on to the next. An individual may maintain their diet for months, but then on vacation, return to their old ways. After several weeks, they may start re-considering returning to their new diet or seek out other options. What influences change?Many factors impact – strengthening or weakening – the client’s ability to change. TTM lists 10 processes that assist the progression between these stages; important ones include self-efficacy, decisional balance, and temptations. Indeed, self-efficacy – the belief in our ability to change – is crucial to planning and executing the actions required to meet the goals we set and fight the temptation to relapse (Luszczynska, Diehl, Gutiérrez-Dona, Kuusinen, & Schwarzer, 2004). As a result, clients high in self-efficacy are better at accepting challenges and persisting in overcoming obstacles. The individual’s perception of the positive and negative aspects of modifying their behavior is also crucial to success. They must balance the pros and cons to decide whether to continue the journey, fall back, or give in.
But there is help at hand. Indeed, interventions based on the TTM have resulted in substantial improvements when applied across multiple disciplines, including the workplace and health settings (Liu et al., 2018; Freitas et al., 2020). Next, we review the six stages of change to understand what it means to be in each, its goal, and the tasks that, when completed, help a person move to the next (guided by Prochaska & Velicer, 1997). Stage 1: Precontemplation
Client statusChange is not wanted, needed, or possible. Client goalSeriously consider the need for behavioral change. DescriptionThe Precontemplation stage occurs when the client has no intention, now, or in the future (typically seen as six months), to change their behavior. For example, “I have no intention of taking up a sport or going running.” Most likely, they are either under-informed or uninformed. The client is either completely unaware or lacking details regarding the health benefits of changing their behavior and taking up physical exercise. Perhaps they tried previously, with little apparent success, and have become demoralized or despondent. Tasks
Stage 2: Contemplation
Client statusProcrastination. The client intends to make the change within six months. Client goalCommit to change in the immediate future. DescriptionThe client has become acutely aware of the pros of making the change, but they are also keenly aware of the cons. For example, “I know I need to lose weight for my health, but I enjoy fast food.” Balancing the costs versus the benefits can lead to ambivalence – mixed and contradictory feelings – that cause the client to become stuck, often for an extended period. Tasks
Stage 3: Preparation
Client statusCommitted to changing their behavior. Client goalDevelop an action plan to organize resources and develop strategies to make the changes happen. DescriptionThe client intends to move to the action stage soon – typically within the next month – but they are not there yet. For example, “I need to understand what support is available and put it in place before I stop smoking.” The client typically begins to put actions in place, for example, starting a gym membership, joining a class, or engaging with a personal trainer. Tasks
Stage 4: Action
Client statusThe plan has taken effect, actions are underway, and a new pattern of behavior is forming. Client goalThe new behavioral pattern has remained in place for a reasonable length of time (typically six months). DescriptionThe client has made good progress; they have modified their lifestyle over the last six months. For example, “I go to the gym on Mondays, Wednesdays, and Fridays every week, and I am following a plan set out by my trainer.” Their new behavior is observable by other people, whether it’s exercising, eating more healthily, or no longer smoking. Tasks
Stage 5: Maintenance
Client statusA new pattern of behavior has been sustained for a reasonable amount of time and is now part of the client’s lifestyle. Client goalSustain the new behavior for the long term. DescriptionWithin the maintenance stage, the client becomes confident they can continue their new lifestyle, and the behavioral change is embedded in their lives. Perhaps equally important, they are less likely to relapse – to fall or slip back into their old selves. For example, “I am confident I can make healthy eating choices at home, work, or when I go out.” Based on data from both self-efficacy and temptation studies, maintenance can last between six months and five years (Prochaska & Velicer, 1997). Tasks
Stage 6: Relapse
Client statusReturned to an earlier stage. Client goalReaffirm commitment and begin progressing through each stage again. DescriptionA relapse is a form of regression to an earlier stage. It is not a stage in itself, but a failure to maintain the existing position in behavioral change, either as a result of inaction (e.g., stopping physical activity) or the wrong activity (e.g., beginning smoking again.) Unfortunately, relapse is typical for many health-related behavioral changes. But it is not inevitable. For example, “I was out the other night and started smoking. I’ve continued since.” The smoker begins smoking, the new runner gives up, the diet is over, fast food is back on the menu. Tasks
Stage 7: Termination“ I am changed forever.” Client statusThe temptation to return to old ways of behavior is no longer present. Client goalNone required; behavioral change is part of who the client is. DescriptionSuccess. The client has zero temptation, and their self-efficacy is 100%. They will not return to their old ways, for example, if they argue with their partner, are unhappy with work, or dent their car. The unhealthy habit is no longer a part of their way of coping. Instead, the new behavior is part of the person’s identity and lifestyle and has persisted for a long time. For example, “I have been keeping up with physical exercise for some years now, and even after recovering from a long-term injury, I continue to do so.” Tasks
Note that an alternative view is that termination is never reached. There is always a risk of relapse into prior unhealthy ways, even several years down the line. In this picture, the individual only ever remains in the maintenance stage. 5 Worksheets to Aid Your Clients’ ProcessThe following worksheets support the client in planning, implementing, and maintaining behavioral change: The five A modelThe five A framework was created to help smoking cessation but has since been successful in the management of other negative health habits (e.g., excessive drinking, lack of exercise, and substance abuse).
Decisional Balance WorksheetsChanges are most effective when there is motivation and ‘buy-in’ from the client. The Decisional Balance Worksheet provides an excellent way of capturing pros versus cons involving a change under discussion. Stages of ChangeThe Stages of Change worksheet is a free download to educate the client about the stages involved in behavioral transformation and relapse. Relapse Prevention PlanThe Relapse Prevention Plan provides a useful resource to capture coping skills and social support, along with the potential impact of relapse in behavior. Goal SettingGoal Setting is crucial to any transformation. It provides focus, tracks progress, and ensures appropriate support and resources are in place for success. Our SMART Goals Worksheet offers a valuable tool for defining and documenting realistic, achievable, and time-bound goals. 4 Ways to Use Motivational InterviewingMotivational interviewing can be used with the client to overcome feelings of ambivalence and find the self-motivation needed to change their behavior (Miller & Rollnick, 2013).The approach has proven successful as an intervention for managing health conditions and overcoming addiction. The OARS acronym offers guidance for a set of basic questions to be used early and on an ongoing basic in an interview: Open questionsInvite someone to tell their story, without leading or directing them. How can I help you with… ? AffirmationsAcknowledge someone’s strengths and behaviors that lead to positive change. That’s a great idea. Reflective listeningListening well is essential to building trust, engagement, and developing the motivation required to change. Focus on the real message being spoken by repeating or rephrasing what has been said. So you feel that… SummariesThis is a particular way of using reflective listening, often at the end of discussing a topic or when the interview is about to finish. So, from what I understand so far … The answers to the above questions feed into the process of planning with the client. PositivePsychology.com ResourcesThe following resources will help your client progress through the six stages, reducing the likelihood of relapse. Basic needs satisfactionMeeting basic psychological needs can help the client avoid becoming stuck and unable to proceed with positive behavioral changes. WDEP questions worksheetUse this list of questions to help a client understand what they Want, what they are Doing, Evaluate if it is working, and follow their Plan to change things for the better. Abstraction worksheetDownload and complete this worksheet to identify the behavior to be changed, understand the steps to get there, and visualize how it will look. Self-Directed Speech WorksheetUse the client’s inner voice to motivate them to make changes in their life, with this Self-Directed Speech Worksheet. Reward Replacement WorksheetIdentify and document the rewards that will arise from a change in behavior to motivate the client. Behavior ContractHelping the client write a Behavior Contract for the changes they wish to make can be an effective way of forming a commitment. If-Then PlanningWe often fail to act on our good intentions. If-Then planning can offer an effective strategy to turn goals into action. Self-validation and Self-respectSelf-efficacy can grow over time as a result of a cycle of achievement and building confidence. This tool helps the client enhance their self-confidence. Breaking out of the Comfort ZoneGrowth mindsets must be translated into action, usually outside of the comfort zone. This tool helps the client identify opportunities to challenge their comfort zone. 17 Motivation & Goal-Achievement ExercisesIf you’re looking for more science-based ways to help others reach their goals, this collection contains 17 validated motivation & goals-achievement tools for practitioners. Use them to help others turn their dreams into reality by applying the latest science-based behavioral change techniques. A Take-Home MessageAt times we lose our way. We don’t always eat well, exercise regularly, drink enough water, take time to learn, put our phone down, and spend time with our friends and family. We need to change. But often we are unaware or ill-informed about what’s wrong or don’t know how to begin the process. Understanding the steps to personal transformation is a great place to start and where the TTM can help. The six stages of the model may not always closely map to our behavioral change, the progression between stages may seem unclear and the reasons for relapse ill-defined, but it can help you achieve your goals. The TTM offers us insights into the journey we must take to move from where we are now, to where we want to be, by describing a useful abstraction of what is going on when we talk about change. The model provides a lens through which we can view ourselves and our clients. Ask yourself: What do I want to change? Am I ready to start? What stage am I at in my journey? Use the answers, along with the TTM, the tools provided, and support from family and friends to push forward with the changes you want in life. We hope you enjoyed reading this article. Don’t forget to download our three Goal Achievement Exercises for free.
What is the preparation stage of change?Preparation is the stage in which individuals intend to take steps to change, usually within the next month (DiClemente et al., 1991). PR is viewed as a transition rather than stable stage, with individuals intending progress to A in the next 30 days (Grimley, Prochaska, Velicer, Blais, & DiClemente, 1994).
What are the stages in the stages of change model?Five stages of change have been conceptualized for a variety of problem behaviors. The five stages of change are precontemplation, contemplation, preparation, action, and maintenance.
Which of the following is a stage in the stages of change health model?The TTM posits that individuals move through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Termination was not part of the original model and is less often used in application of stages of change for health-related behaviors.
What are the 5 stages of Transtheoretical Model of change and describe each?According to the TTM, individuals move through a series of five stages — precontemplation, contemplation, preparation, action, and maintenance — in the adoption of healthy behaviors or the cessation of unhealthy ones.
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