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Kolundija K. et al.



Ksenija Kolundija1, Zoran Gaji1, Gordana Mii-Pavkov1, Jelena Srdanovi Mara1
Abstract: Based on the integration of the leading theories of psychotherapy, Prochaska and colleagues postulated the Transtheoretical Model of Behavior Change in the late eighties of the last century. The model
represents a new framework for understanding intentional human change. The core constructs of the model are processes of change, stages of change, decisional balance and self-efficacy. The processes of change
are defined as cognitive, emotional and behavioral activities used to explain changes of a problem behavior, feeling or thinking. The stages of change represent a temporal dimension of the model and refer to ones
readiness to act on a new behavior. Motivational constructs (i.e. decisional balance and self-efficacy) have
been defined within the frameworks of other psychological theories and are used by the authors of the Transtheoretical Model for better understanding and characterizing change.
Key words: Transtheoretical Model of Behavior Change, processes of change, stages of change, decisional
balance, self-efficacy
Saetak: Na osnovu integracije vodeih psihoterapijskih sistema, krajem osamdesetih godina prolog veka,
Prochaska sa saradnicima postulira Transteorijski model koji predstavlja novi okvir za razumevanje intencionalne ljudske promene. Osnovni konstrukti modela su procesi promene, stadijumi promene, balans odluke i self-efikasnost. Procesi promene koncipirani su kao kognitivne, emocionalne i bihejvioralne aktivnosti kojima se objanjava promena nekog problemskog ponaanja, oseanja ili miljenja. Stadijumi promene
predstavljaju vremensku dimenziju modela i odnose se na spremnost pojedinca u ciklusu promene. Motivacioni konstrukti (balans odluke i self-efikasnost) definisani u okvirima drugih psiholokih teorija, posluili
su autorima Transteorijskog modela za bolje razumevanje i opisivanje promene.
Kljune rei: Transteorijski model promene, procesi promene, stadijumi promene, balans odluke, selfefikasnost

1 Clinic for Psychiatry, Clinical Centre of Vojvodina, Novi Sad, Serbia

Correspondence to: Ksenija Kolundija, MPsy, Clinic for Psychiatry, Clinical Centre of Vojvodina, Hajduk
Veljkova 1, 21000 Novi Sad, Serbia; E-mail:
* Received February 23, 2011; Accepted March 25, 2011.


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Kolundija K. et al..

The Transtheoretical Model of Behavior Change
is an integrative and multidimensional framework
for understanding how people decide to change
and how they act on and maintain change. The
model was developed in the late eighties of the
last century as a result of integration of the leading psychotherapeutic systems. Authors credited
with the development of the model are Prochaska,
DiClemente, Norcross, and Velicer. The core constructs of the model include processes of change,
stages of change, decisional balance and self-efficacy, and resistance to temptation. Change is defined as the relationship between the core constructs (1, 2, 3).

Processes of change are covert or overt activities or experience that help people change their
thoughts, feelings, behaviors, or relationships (1,
3, 4). Each of the processes is a wide category that
encompasses various techniques, methods and interventions used to make a change in a counseling session, in between the sessions, as well as outside the counseling process. On the basis of a great
number of empirical tests and factorial analyses,
the following list of ten basic processes has been
Consciousness raising encompasses interventions or activities aimed at raising the clients consciousness about the problem, its causes, consequences and possible ways of overcoming it. It includes interventions such as interpretation, clarification, confrontation, education, feedback, bibliotherapy, media campaigns, etc.
Dramatic relief refers to techniques that enable
the client to feel and express emotions associated
with the problem and its solution, which leads to
lightening the emotional load. It includes psychodrama, visualization, role-playing, and grieving.
Self-reevaluation combines cognitive and affective assessments of ones self-image in relation to
both the problem behavior and the new behavior.
It includes various rational emotive behavior ther-

apeutic techniques, gestalt techniques, visualization, decontamination techniques, etc.

Environmental reevaluation refers to affective
and cognitive assessments of the problem in relation to ones social environment. Systemic therapy techniques, reframing techniques and empathy
training can lead to such re-assessments.
Self-liberation encompasses interventions that
strengthen the clients belief that he or she can
change. This process increases the number of possible alternative responses to external and internal
stimuli. Interventions that enhance self-liberation
include various existential and humanistic techniques, such as logotherapy, changing early decisions, behavioral contracting, homework techniques, etc.
Social liberation refers to interventions that encourage the client to participate in broader social
actions, promoting the clients sensibility for the
broader social context and the populations at risk.
It includes the techniques used in social and clinical psychology and psychiatry, structural therapy techniques, culturally sensitive therapy, as well
as participation in various civil and humanitarian
initiatives and primary prevention.
Counter-conditioning refers to various ways of
learning healthier behaviors that can substitute for
problem behaviors. It includes behavioral therapy
techniques, such as systemic desensitization, relaxation, assertive training, etc.
Stimulus control refers to interventions that encourage the client to change his or her environment in order to control the triggers of problem
behavior. The interventions include various avoidance techniques, environmental re-engineering
techniques, self-help groups that support ones
change, etc.
Reinforcement management comprises techniques that overtly or covertly reinforce the alternative behavior, thus modifying the problem behavior. This process includes behavioral and cognitive-behavioral techniques, such as rewarding,
self-rewarding, group recognition, as well as procedures used in humanistic group treatment and
systemic therapy.

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Kolundija K. et al.

Helping relationship encompasses activities that

pertain to seeking and getting support for the
healthy behavior change. It includes interventions
that rely on the power of empathy, a therapeutic
alliance, creating the atmosphere of acceptance
and belonging, developing a support network, etc.
The processes of change, conceptualized as cognitive, emotional and behavioral activities that
explain a change, can be described through two
higher constructs derived from factorial analyses
- experiential (cognitive) and behavioral processes (5, 6, 7). Experiential processes comprise consciousness raising, dramatic relief, self-reevaluation, social reevaluation and social liberation. Behavioral processes encompass stimulus control,
counter-conditioning, contingency management,
self-liberation and helping relationship. In the early stages of change, clients rely more on the experiential processes, whereas behavioral processes are
more predominant in the late stages (5, 6, 7). The
authors of the model emphasize that the processes
of change have been shown to be good predictors
of treatment outcome, regardless of whether their
application is institutional or independent (8, 9).

By postulating the processes of change, the authors of the Transtheoretical Model answered the
question how a change in thinking, feeling or behavior is encouraged and carried out. However, it
was early recognized that in order to discover the
structure of behavior change it is necessary to answer when the change takes place, which resulted in the conceptualization of the stages of change
as a temporal dimension of the model. Time is
the very construct that makes the Transtheoretical Model unique, since no other relevant therapeutic system includes a construct that represents time. In contrast to the previous definitions
of change as an event, the Transtheoretical Model defines change as a process, a phenomenon that
takes place in a period of time and involves progress through a series of five stages. The stages of
change entail a specific constellation of attitudes,
intentions and behaviors related to ones readiness
to change, change being a phenomenon that develops over time (1). Each of the stages is not only
a period, but also a set of specific tasks necessary

for advancing through and transition to the next

stage. Time required for progressing to the next
stage is variable, whereas the set of tasks and the
order of the stages tend to be constant.
Precontemplation is a stage in which people
do not intend to change a problem behavior in
the foreseeable future, at least within the next 6
months. At this stage people are unaware of the
problem, underinformed about the consequences
of the unhealthy behavior, or they may have tried
to change a number of times and become demoralized about their ability to change. The main characteristic of precontemplaitors is their resistance
to acknowledge and modify the problem. Defense
mechanisms characteristic for the stage are negation, minimizing, rationalization, intellectualization, projection, and displacement. In order to
progress to the next stage, clients should become
more conscious of their own resistance, as well as
of the problem behavior, through clarification and
education about the negative consequences of the
behavior. In addition, their resources and capacities for change should be adequately assessed.
Contemplation is the stage in which the client
recognizes the problem and intends to change it,
but is still unprepared to take any concrete actions. The ambivalence that is characteristic for the
stage develops due to weighing positive and negative aspects of both the problem and its solution.
Longitudinal studies have shown that people can
stay chronically stuck in this stage (8). The clients
tasks that enable progress to the next stage are explicit weighing of the pros and cons of change, and
shifting the balance towards the positive aspects,
which leads to the decision making.
Preparation is the stage in which people are intending to take action in the immediate future.
Work with clients in this stage involves increasing
their sense of freedom and control over their own
decisions and actions. In addition, making a detailed plan and taking small, i.e. probative, actions
are also important.
Action is the stage in which the client changes his
or her behavior, way of thinking and environment
in order to overcome the problem behavior. This
stage involves observable behavioral changes and
demands significant dedication as regards, time,

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Kolundija K. et al.

resources, and personal involvement. The main

tasks for the client in this stage are developing a
strategy for overcoming usual behavioral patterns,
developing plans for avoiding risk situations, and
finding alternative reinforcement and alternative
ways of satisfying needs.
Maintenance is the last stage of change, in which
people are working to prevent relapse and continue their change. In contrast to the traditional views of the maintenance stage as a static one,
the authors of the Transtheoretical Model consider the stage an active stage in which the client continues to use the processes of change in order to
avoid relapse. For this purpose, the client should
be educated about new mechanisms, work on recognition of potential risk situations, as well as encouraged to continue the change.
It has been established that some processes of
change are more efficient in certain stages of readiness. Integration of the two constructs thus suggests that people apply cognitive, affective and
evaluative (experiential) processes as they progress through the early stages of change, whereas behavioral processes are predominantly used
at later stages. According to the Transtheoretical
Model, an efficient change depends on whether
the right thing (process) is done at the right time
(stage) (1).

Decisional balance is a concept originally developed within the conflict model of decision-making by Janis and Mann (10). According to the
model, decision making involves constant and
careful weighing of the pros and cons of a new behavior (10, 11)
By analyzing the association between decisional
balance and the stages of change, researchers have
concluded that the two constructs have a characteristic relationship (10). Anticipated benefits related to changing a problem behavior or adopting
a new one are low in the early stages and as they
increase, progress to the next stage is made. Conversely, the cons are high in the early stages and
decrease in the later stages.

The self-efficacy construct, adapted from Banduras self-efficacy theory (12), is frequently used in
the Transtheoretical Model, either independently or together with the temptation measure, in order to better describe a behavioral change. The
self-efficacy measure represents the situation-specific confidence that people have that they can
cope with high-risk situations without relapsing
to their old, unhealthy or high-risk habit. The situational temptation measure reflects the intensity of urges to engage in the problem behavior that
is being changed. Self-efficacy and temptations are
usually negatively correlated. However, this is not
a rule, since these two are not mirror images (5).
During therapy, the client may be strongly tempted to relapse in certain situations and simultaneously be convinced in own ability to avoid relapse.
Their relationship with the stages of change shows
a specific pattern, with self-efficacy being the lowest in the early stages and increasing as the client
progresses toward the maintenance stage, whereas
with temptations the converse applies (13).

The Transtheoretical Model of Behavior Change
provides a new perspective on human motivation,
facilitates assessment of ones readiness to change,
and harmonizes therapeutic interventions with
the clients stage of change. The latter is important
since people seeking professional help present in
various stages of change. Action-oriented treatments may be efficient for people in the preparation and action stages, whereas the same programs
may be harmful for those in the precontemplation
and contemplation stages. The Transtheoretical
Model offers a global concept of change and encourages creation of new approaches in the treatment of various problem behaviors.

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