The transtheoretical model of change is a theory introduced by psychologist James Prochaska in the 1980s. Sometimes called the “readiness-to-change” model, this theory identifies five stages through which people progress. Clinicians can use the transtheoretical model to meet clients where they are and help them move forward at any stage.
What are the stages of change?
Prochaska developed this theory after observing a problem with behavior change programs. Participants were expected to adopt healthy behaviors immediately – and blamed for lack of willpower if they failed to change promptly.
Instead, Prochaska suggested the existing model was broken. Even if people were not ready to change, they could still move forward. “Successful self-changing individuals follow a powerful and, perhaps more important, controllable and predictable course,” Prochaska writes with fellow psychologists John Norcross and Carlo DiClemente in Changing for Good. “No one stage is any more or less important than another.”
The transtheoretical model includes key concepts from other theories to form a comprehensive theory of change. This broader model can be applied to a wide range of people and behaviors. It identifies helpful actions that build forward momentum, no matter where individuals are in the change process.
The transtheoretical approach has proved useful in tailoring individual treatments for smoking cessation, weight management, depression prevention, stress management and medication adherence. It has been used by the Centers for Disease Control and Prevention (CDC) and National Health Service of Great Britain to support health promotion programs like addiction treatment and HIV/AIDS prevention.
The model’s influence prompted the American Psychological Society to name Prochaska the Most Influential Author in Clinical and Health Psychology, and one of the Top Five Most Cited Authors in Psychology.
Here’s a deeper look at the stages of change – and techniques you can use with clients:
Stage One: Precontemplation
In the precontemplation stage, people do not intend to change (definition: not within the next six months). They may be unaware of the consequences of unhealthy behaviors – or at least, they overestimate the cost of rethinking their choices.
A key component of the transtheoretical model is an individual’s evaluation of pros and cons for changing their behavior. In precontemplation, people have a low assessment of the benefits and high assessment of the cost.
How to encourage progress: Don’t underestimate the value of “just thinking about it.” Individuals in precontemplation can benefit from thinking objectively about what they could gain from taking action.
Questions to explore:
- Are clients open to discussing their behavior patterns?
People in precontemplation are often defensive about unhealthy behaviors. They may have tried to change and failed.
- Are they willing to think about the possibility of changing?
Don’t push your clients to move further into the process – but do encourage them to entertain the idea of changing. Consider an assignment to explore possible benefits from changing their behavior.
- Is your client approaching a milestone? Do social situations support your client changing a behavior?
For some clients, a recent event – their marriage, illness or 40th birthday – may support new motivation to change. External influences, like no-smoking spaces, may also make it easier for your clients to change.
Stage Two: Contemplation
In the contemplation stage, people intend to adopt healthy behaviors in the near future (definition: within the next six months). They are more aware of benefits of changing, although they usually see pros and cons as equal.
How to encourage progress: Help individuals find opportunities to learn from people with healthy behaviors. At this stage, a person is open to new information. People in contemplation can work through ambivalence by gaining a better picture of the kind of people they could be.
Questions to explore:
- How do your clients picture their future selves?
In contemplation, your clients can begin to overcome fear of change and focus on positive motivation. Encourage clients to visualize their lives if they change: How will I feel when I’ve made this change?
- How can your clients keep building knowledge and enthusiasm?
Are your clients now seeking out advice and information? It’s important they don’t feel pressured to act prematurely. Help them build an informed foundation to fuel next steps.
- Which great movies, songs or real-life events relate to your clients’ journeys?
In contemplation, your clients can use emotional arousal to their advantage. Help them find a dramatic story they can relate to.
Stage Three: Preparation
In the preparation stage, people intend to take action (definition: within the next 30 days). They are ready to tell friends and family about their plans to change. They may have taken a few small steps, and they believe changing the problem behavior will improve their life.
How to encourage progress: preparation is about building confidence and commitment. Individuals are likely to welcome support from others. They will also benefit from changing their environment, choosing a start date and planning if-then strategies for challenges ahead.
Questions to explore:
- Are your clients preparing to face obstacles?
Part of the preparation stage is helping your clients troubleshoot their plans in advance. Consider an assignment to help clients anticipate likely obstacles and plan how they will overcome them.
- When will they move to the next step?
Are your clients now well-informed? Suggest they schedule a specific day to begin changing their behavior.
- Are your clients ready to announce their plans?
Can your clients gain support by telling friends or joining a support group? Once they are well-prepared, it’s important to move forward with confidence.
Stage Four: Action
In the action stage, people have changed their behavior (definition: within the last six months). To keep moving forward, they need external support, self-confidence and strategies to replace old habits.
How to encourage progress: Every small action helps build momentum. Individuals in action need to keep acquiring healthy behaviors. It’s important to reward small steps toward change, substitute positive new behaviors and avoid opportunities to slip back to earlier stages.
Questions to explore:
- What seemingly unimportant decisions will help your clients?
Everyday choices can make all the difference. Help your clients recognize and celebrate small steps that lead to meaningful change.
- What new habits are clients building?
Your clients will encounter situations that could trigger old, problem behaviors. What new behaviors are replacing them?
- Are your clients leaning on a support system?
External support can help clients keep their commitment strong. Are they building social circles that support their new, healthy actions?
Stage Five: Maintenance
In the maintenance stage, people have successfully sustained their behavior change (definition: more than six months). They have gained confidence with practice in the action stage and have overcome obstacles.
How to encourage progress: New behaviors must become part of a person’s identity. At this stage, it’s important for an individual to integrate healthy actions with their social life. This helps set them up for long-term success.
Questions to explore:
- Are your clients facing stressful situations or major life events?
An unexpected crisis can trigger old behaviors. Have your clients clearly defined what it would mean to lapse out of the maintenance stage? Help them identify strategies to recover quickly.
- What new challenges can keep your clients engaged?
Boredom is a real risk for clients in the maintenance stage. Their changed behaviors have become routine, but it’s important to maintain commitment. What keeps them in touch with motivations for healthy behaviors?
- What can support your clients’ long-term success?
Do your clients spend time with support systems that reinforce positive attitudes and behaviors? Do they continue to set goals and celebrate small successes? Help them continue to find opportunities to master healthy behaviors.
Sometimes, a sixth stage is identified: termination. People in this stage maintain healthy behaviors with no effort – and never return to old habits. As Prochaska, Norcross and DiClemente write in Changing for Good:
“There is a lively debate about termination. Some experts believe that certain problems cannot be terminated but only kept at bay through a life of decreasingly wary maintenance.”
It’s important to remember that progress through the stages is not linear. Individuals often move back to earlier stages and repeat the cycle as needed while addressing setbacks. At any turn, the stages of change model helps find opportunities for progress. “The only real mistake you can make,” Prochaska argues, “is to give up on your ability to change.”
The Transtheoretical Model Meets Interactive Journaling®
For more than a decade, Prochaska has collaborated with The Change Companies® to create behavioral health resources incorporating the transtheoretical model. Interactive Journaling® is an evidence-based practice that motivates and guides participants toward positive life change. Prochaska works with The Change Companies® to develop Interactive Journals focused on practical applications of the transtheoretical model for meaningful transformation. Prochaska’s oversight of behavior change curriculum development ensures fidelity of the transtheoretical model. Speaking on the efficacy of Interactive Journaling®, Prochaska said:
“The Change Companies®’ Interactive Journals are truly transtheoretical. First, they apply all of the constructs of the transtheoretical model to facilitate behavior change, including the pros and cons of changing, self-efficacy and temptation, the processes of change and those of resistance. Then they use four of the most important theories for treating addictive disorders: 12-step, motivational interviewing, cognitive-behavioral therapy and the transtheoretical model. Each of these approaches has been found to be effective in rigorous scientific evaluations.”
Prochaska is one of many leading researchers and subject matter experts The Change Companies® collaborates with to stay on the cutting edge of behavior change science and application models. The Interactive Journaling® process has been refined in collaboration with single state agencies, clinical treatment programs, correctional facilities, university research institutes and individual feedback provided by more than 5,000 clients. Each Interactive Journaling® curriculum also incorporates research on motivational interviewing and cognitive-behavioral therapy.