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Transtheoretical Model of Intentional Behavior Change

Article · January 2012

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Elyse Mireille Charrois

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Objective: This self study module provides an overview of the Transtheoretical Model in
relation to the recovery journey.

James Prochaska’s interest in learning about how people change began when his
attempts to help his father, who suffered from depression and alcoholism, failed and ended with
his death. While alive, James Prochaska’s father did not envision himself as having difficulties
with depression or alcoholism and did not believe in psychotherapy. In an attempt to understand
why his father could not change, Prochaska began reviewing individual methods of
psychotherapy to understand how they encourage change. Prochaska and his colleagues,
John Norcross and Carlo DiClemente, found that there were an overwhelming amount (400 +)
of methods of psychotherapy available. Many therapies had a very restricted approach but none
were clearly better than the others.

The Transtheoretical model came out of Prochaska’s efforts to find familiar elements
within important therapies including psychoanalysis, behaviourism, cognitive therapies,
existential analysis and humanism. He tried to segregate the main beliefs and methods of
change that each psychotherapeutic approach had to offer. What he discovered was that while
each psychotherapeutic approach disagreed on what problems clients have and what they need
to change, there was more agreement about how change is effected (Prochaska et al., 1994, p.
25). Prochaska was able to summarize a very large amount of psychotherapeutic theories by a
few crucial principles he called the “processes of change”, which he defined as any activity that
an individual initiates to help modify thinking, feeling, or behaviour. This prompted Prochaska to
write his first book titled “Systems of Psychotherapy” in 1979.

Prochaska determined that all psychotherapies promote change by applying at least two
processes of change as seen in Table 1. Each theory of psychotherapy has its own sphere of
excellence. For example, psychoanalysis is the preferred approach for raising awareness of
both conscious and unconscious motivations, also referred to as consciousness-raising; while
behaviourism is the most effective approach for modifying discrete problem behaviours. The
Transtheoretical model integrates the best of each approach into a coherent whole.

Table 1: Summary of the Principle Theories of Psychotherapy

Theory Primary Processes of Change

Psychoanalytic Consciousness-raising, Emotional arousal
Humanistic/Existential Social liberation, Commitment, Helping
relationships
Gestalt/Experiential Self-re-evaluation, Emotional arousal
Cognitive Countering, Self-re-evaluation
Behavioural Environment control, Reward, Countering
(Adapted from Prochaska, Norcross, & DiClemente, 1994, p.26)

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 Having identified the processes of change that were inherent in various
psychotherapeutic approaches, Prochaska (1994) now wanted to determine how often
individuals who are self-motivated to change (self-changers) employed each of these
processes. He engaged a doctoral student, Carlo DiClemente to assist him. They began by
interviewing 200 people who were trying to quit smoking on their own. The interviewees came
from a wide socioeconomic stratum. Prochaska credits one woman with helping them to
understand that change occurs through certain stages. She responded to their inquiry about
how often she used each of the different change processes by saying: “That depends on when
you’re talking about, there were times when I used one in particular and times when I didn’t use
it at all” (Prochaska et al.).

Prochaska and DiClemente’s most surprising discovery was that successful self -
changers used certain tools only at specific times and that these specific times were constant
from person to person (Prochaska et al., 1994). This phenomenon has now come to be called
stages of change. Prochaska and DiClemente also found that there were fewer differences
between individuals who use therapy to assist them with change (therapy – changers) and self -
changers than once believed, that successful change was precipitated by individuals identifying
the stage they were in for a particular predicament and matching their challenges to their stage,
that individuals progress through the same stages of change regardless of the problem they are
addressing, that the same processes of change can apply to any problem and to a combination
of problems, that each stage entails a series of tasks that need to be completed before
progressing to the next stage, and that undesirable predicaments seem to occur simultaneously
(eg. smoking and drinking). There is some evidence that it may be more efficient to apply the
processes of change to more than one problem at a time rather than try to change problem
behaviours one by one and that people are more likely to be successful in their change attempts
when they are given two or more choices of how to pursue change rather than one (Prochaska
et al.). Hence, the five stages of change include pre-contemplation, contemplation, preparation,
action, and maintenance. The diagram below illustrates the Transtheoretical model as a spiral
model of change that includes progress and relapses that is inherent in the individual’s journey
toward recovery.

Diagram 1: Spiral Model of Change

(http://hamsnetwork.org/images/spiral.gif)

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 Precontemplation
The first stage of the Transtheoretical model is the precontemplation stage. Prochaska
et al. (1994) describe precontemplators as having no intention of changing their behaviour as
they typically deny having a problem. Precontemplators usually attend therapy only as a result
of pressures being placed on them by others. In this situation, the precontemplator may express
the most interest in finding a way to relieve the demands being placed on them, on having
others change their ways, and have no intention of attending therapy as a result of their own
motivation. Because after all, they think they do not have a problem regardless of the fact that
everyone else thinks so. Change for precontemplators may occur as long as external demands
or pressures are maintained, but when external demands are quieted, the individual may
promptly assume the self-defeating behaviour once again. Denial and blame are characteristic
of precontemplators, they often see things as outside their control and may be demoralized as
well because they feel the situation is hopeless (Prochaska et al.).

Table 2: Stages and Processes of Change

Stages of Change Processes of Change

Precontemplation Consciousness-raising, Social liberation
Contemplation Consciousness-raising, Social liberation, Self-
re-evaluation, Emotional Arousal
Preparation Social Liberation, Self-re-evaluation, Emotional
Arousal, Committing
Action Social Liberation, Committing, Helping
Relationships, Environment Control, Rewarding
Countering
Maintenance Helping Relationships, Environmental Control,
Rewarding, Countering
(Adapted from Prochaska et al., 1994)

The primary processes of change common to the precontemplative stage include

consciousness raising and social liberation. Consciousness-raising includes increasing
awareness about the self, and gathering information about the predicament at hand that will
enable the individual to think about necessary alterations. The first step in fostering intentional
change is to become conscious of the self-defeating defenses used to deflect the predicament
(Prochaska et al., 1994). Self-defeating defenses may include denial and minimization,
rationalization, projection and displacement, or internalization. The following conversation
illustrates rationalization and displacement:

Emily: Hey Isabella, I notice that you have been smoking more often lately.
Isabella: Yeah, I have been under a lot of stress, plus I have been very busy writing. But
enough talk about me, what about you’re atrocious eating habits of late?

In this example, the response does not address the smoking, but instead displaces the
blame on writing and stress; in addition the focus quickly shifts from one person to the other.
Precontemplators actively resist consciousness-raising by utilizing well-placed defense
mechanisms. Social liberation involves any element in the external environment that supports
the change effort being made by the individual which in tandem can increase self-esteem. This
process may involve creating more alternatives and choices for individuals, providing more
information about problem behaviours, and offering public support for individuals who want to
change (Prochaska et al., 1994). Social liberation may be actualized by no smoking signs,

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seatbelt reminders in cars, bicycle helmet laws, self-help groups, Operation Red Nose, Safe
Grad initiatives, crisis centers’ and others. Techniques that reflect social liberation may include
determining who is on that individual’s side, whose side the individual is on, and seeking and
welcoming outside influences (Prochaska et al.). For example, new friends with healthy living
habits may have a positive influence on someone who is trying to quit smoking. The
motivational strategies that health care professionals may use with individuals who are in the
precontemplative stage of change may include establishing contact with the client, listening to
their story in a reflective manner, and affirming the validity and value of their experience.

Box 1: Motivational Strategies for the Precontemplative Stage

• Establish contact
• Actively listen
• Affirm

Contemplation
The next stage of change is the contemplative stage. In this stage many contemplators
have indefinite plans to take action in the next 6 months or so, but may also be far from making
a commitment to action (Prochaska et al., 1994). Sometimes individuals move quickly into the
next stage of change and other times individuals remain in the contemplative stage for a very
long time, even years. Though individuals may know their goal and how to achieve it, the time
spent in contemplation may be a result of a fear of failure and individuals may conduct a search
with no end for the latest information on their predicament but never engage in the change
process. Individuals who eternally substitute thinking for action can be called chronic
contemplators (Prochaska et al.).

Besides consciousness-raising and social liberation, the processes of change involved in

the contemplative stage also include self-re-evaluation, and emotional arousal. Emotional
arousal refers to an abrupt emotional response to a predicament that empowers the individual
toward the action of changing the predicament. It is the energy that allows individuals to
supersede procrastination, and determine what is really in their best interest (Prochaska et al.,
1994). Techniques to rouse the emotions may include using provocative movies to stimulate
emotions, using your imagination to create hypothetical situations that produce feelings of
aversion or misery, or thinking of real life circumstances that encountered losses as a negative
result of the problem behavior.

Emily: Isabella, wasn’t that smoking video graphic?

Isabella: Yes, it was graphic enough to make me re-consider smoking altogether.

In this example, Isabella seems to have been emotionally affected by the movie that she
watched enough to consider making a change to her habit of smoking.

Self-re-evaluation, which naturally results from consciousness-raising, would include an

individual assessing their feelings and thoughts about themselves with respect to the
predicament. Self-re-evaluation will reveal that an individual’s essential values are in conflict
with their problem behaviours, which contributes to leaving the individual feeling, thinking and
believing that life would improve without the predicament/problem behaviours (Prochaska et al.)
Evaluating the present and evaluating the future including the change are two forms of self-re-
evaluation that work well to motivate individuals toward preparing for change. For example,

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when someone wants to stop smoking they may visualize themselves as a non-smoker and
determine the positive outcomes related to conquering their smoking addiction. The motivational
strategies that health care professionals may use with individuals who are in the contemplative
stage of change may include giving practical assistance for the client’s immediate concerns,
modeling open and honest communication, expressing empathy, aligning with the client’s
struggle, explore the client’s goals, and support the client’s desire to change.
Box 2: Motivational Strategies for the Contemplative Stage
• Give practical help for the client’s immediate concerns
• Model open, honest communication
• Express empathy
• Align with the client’s struggle with mental health and substance use
disorders
• Explore client’s goals
• Support client’s desire to change

Preparation
While an individual is continuing to work through the processes of social liberation,
emotional arousal and self-re-evaluation, they may begin to transition to the stage of preparation
which begins with the process of commitment. During the transition, the individual’s thinking will
begin to focus on the solution to the predicament rather than the predicament itself, and it also
directs attention to the future rather than the past. Commitment is taking the responsibility to
change. It includes not only a willingness to act, but also a belief in the individual’s ability to
change, which in turn reinforces a person’s will (Prochaska et al., 1994). Techniques that might
help consolidate commitment include taking small steps toward the change, setting a date for
which the change may begin, telling others outside of the self about the intended change,
spending the energy that the change will take, and creating a plan of action (Prochaska et al.).
Any lingering ambivalence that undermines the individual’s determination must be resolved for
the preparation stage to transition to the action stage of change. It is important to allow enough
dwelling time in the preparation stage to mitigate the risk of failure. For example, if an individual
makes a private promise to themselves one day that they wish to stop smoking immediately and
spends little time planning how they are going to proceed with making the change, there is a
higher chance that they will not succeed in implementing their change, or that the change will
not last very long.
Emily: Isabella, when did you say you were going to quit smoking?
Isabella: A month ago, I just feel like I don’t know how to go about quitting.
In this example, Isabella is recognizing that she needs to create a plan to assist her in
making the change of quitting her smoking habit.
The motivational strategies that health care professionals may utilize with individuals
who are in the preparation stage of change include exploring the client’s concern about mental
health and substance use, and identifying discrepancies between the client’s goals and their
current behaviors.
Box 3: Motivational Strategies for the Preparation Stage

• Explore the client’s concerns about mental health and substance

use
• Develop discrepancies between the client’s goals and his/her
current behaviors

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 Action
The action stage requires the greatest dedication and is the most visible to others thus
lending to the stage that receives the greatest recognition (Prochaska et al. 1994). Still engaged
with the social liberation and commitment processes of change, individuals may concurrently
focus on the countering, environment control, reward and helping relationship processes as they
move into the action stage of change. The use of these processes continues throughout the
action stage, which usually lasts for months (Prochaska et al.).

Countering is a term that describes when an individual will replace unbeneficial

behaviors with beneficial behaviors. Countering involves changing one’s responses to a given
situation (Prochaska et al.). Effective countering techniques that individuals have used
successfully include active diversion (redirecting attention to engage in another activity),
exercising (since urges are physical sensations, it can be helpful to use physical activity to
overcome urges or cravings), relaxation (sometimes exercise is not feasible because of the
environment an individual is in at the time), counter thinking (replacing negative thoughts with
positive thoughts), and assertiveness (effectively communicating your thoughts, and feelings
when you feel you are not being respected). An example of countering may be evident if
someone who has a craving to drink defies that urge by engaging themselves in meditation and
visualizing that they are lying on a beach. While using meditation as a countering method might
not work for everyone, the challenge lies in determining which countering method fits.

Environment control includes restructuring the environment so that the probability of a

problem-causing event is reduced (Prochaska et al.). Effective environmental control
techniques that successful self-changers have used include avoidance (staying away from
environments that encourage unbeneficial behavior), cues (desensitizing oneself to triggering
items), and reminders (placing friendly reminders in your environment to control unwanted
behaviors). For example, an individual who is trying to quit smoking may avoid buying
cigarettes, place pictures of a smoker’s lungs around the house as a reminder that smoking
damages lungs, or place positive affirmations of success in high traffic areas. Placing No
Smoking signs has helped some individuals as well.

Rewards modify the consequences that follow desirable behavior and reinforce it
(Prochaska et al.). Rewards include treating oneself in the event of beneficial behaviors.
Effective reward techniques that individuals have used successfully include covert management
(when resistance to temptation occurs and a private kudos is offered to oneself), contracting
(devising a rewards plan for each step taken towards one’s goal), and shaping behavior (this
happens gradually). Self-praise, buying a gift, or investing the money saved as a result of
beneficial actions describe rewarding oneself. For example, in the event of quitting smoking the
individual may find that they have extra money from not buying cigarettes, and decide to treat
themselves and their family to a day at the water park.

Helping relationships can mean recruiting outside help, which may be friend, family,
spouse, partner or other, to provide support, caring, understanding and acceptance (Prochaska
et al.). Engaging with another individual who has the same goals works well, as does receiving
praise from designated family members or friends.

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 Emily: I noticed that you quit smoking.
Isabella: Yes, I finally came up with a plan. When I have the urge to smoke, I chew
sugarless gum instead and I completely avoid the cigarette counter when shopping.
Also, my cousin quit too so we give each other support. I haven’t smoked in 32 days!

In this example Isabella outlines the elements of her plan that help her to resist
temptation and continue taking action in relation to her goal of not smoking.

The motivational strategies that health care professionals may utilize with individuals
who are in the action stage of change include starting the action plan, eliciting change talk,
rewarding progress, using relapses as learning opportunities, involving, nurturing and sustaining
social supports, developing specific action steps to work on target behaviors, encouraging self-
efficacy and identify examples of same, reviewing and reinforcing actions that are producing
behavior change, reviewing and identifying new goals as client continues to change, and
emphasizing healthy alternatives.

Box 4: Motivational Strategies for the Action Stage

• Start action plan

• Elicit change talk
• Reward progress. Use slips as learning opportunities.
• Involve, nurture and sustain social supports
• Develop specific action steps to work on target behaviors
• Encourage self-efficacy and identify examples of same
• Review and reinforce actions that are producing behavior change
• Review and identify new goals as client continues to change
• Emphasize healthy alternatives

Maintenance
The maintenance stage is as essential as the action stage, but it is much more difficult to
attain. It is during the maintenance stage, which may last from six months to as long as a
lifetime, that an individual must work to consolidate the gains achieved during the action and
other stages, and struggle to prevent lapses and relapses which is most likely to occur in the
first month or two (Prochaska et al.).

The factors that are significant to successful maintenance include sustained, long-term
effort and a revised lifestyle (Prochaska et al.). To succeed in maintaining a change that was
made, one must be able to identify the danger signs that could lead to a relapse. The most
common threats to maintenance are social pressures, internal challenges, and special situations
(Prochaska et al.). Social pressures are evident when self-changers spend time with those who
engage in the undesirable behavior, and those don’t understand its impact, internal challenges
usually result from overconfidence, temptation, and self blame, and special situations arise
when confronted by an unusual, intense temptation (Prochaska et al.).

During the maintenance stage of change, the individual must keep up their commitment
to the change and avoid people, places, and things that could compromise the change, work to
create alternative behaviors, and be aware of their attitudes toward the change. Secretly
coveting a relapse is an example of a practice that will inevitably lead to engaging in unhealthy
behaviors once again. Patience and persistence is key. Helping relationships, environmental

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control, rewarding, and countering are the processes that remain important to the maintenance
stage of change.

Emily: How long has it been since you quit smoking.

Isabella: It has been seven months now and I couldn’t have done it without the support
of my family and friends. I am so happy.
Emily: That’s wonderful. Good job!

In this example, Isabella indicates that she has maintained her goal of not smoking for
three months. She also mentions that although she has been successful to date, without the
extrinsic support of her friends and family she would not have been able to accomplish what she
has. This statement reveals that she knows her own limits in regards to smoking and uses
family and friends to guard against those limits.

The motivational strategies that health care professionals may utilize with individuals
 
who are in the maintenance stage of change include keeping focus on the client’s goals,
reinforcing links between change behavior and accomplishment of client’s goals, identifying
continuing high risk situations, developing relapse prevention plans, reinforcing self-efficacy,
focusing attention on client’s gains, reviewing for new areas of risk, supporting continued social
engagement for mutual aid, leisure, spirituality, learning & volunteering.

Box 5: Motivational Strategies for the Maintenance Stage

• Keep focus on client’s goals

• Reinforce link between change behavior and accomplishment of client’s goals
• Identify continuing high risk situations
• Develop relapse prevention plans
• Reinforce self-efficacy
• Focus attention on client’s gains
• Review for new areas of risk
• Support continued social engagement for mutual aid, leisure, spirituality, learning &
volunteering

Recycle
Although relapse is undesirable, it does show that movement toward change can be non-
linear, even circular and is usually the rule rather than the exception. Once an individual
relapses, they might slide back to the contemplation stage of change most commonly and begin
making plans to institute the change again, working their way forward. Prochaska et al. (1994)
outline ten lessons of relapse as follows:

• Few changers remain in the maintenance stage of change – only about 20 percent of the
population permanently conquers long-standing problems on the first try.
• Trial and error is inefficient – using relapse as a guide to effective learning can help
benefit from experiences.
• Change costs more than budgeted – what is needed is a commitment over time to an
action plan that exploits all that the processes have to offer.
• Using the wrong processes at the wrong time – by becoming misinformed, misusing
willpower, and substituting one bad behavior for another.

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 • Be prepared for complications – problems often coexist; changing one can exacerbate
another.
• The path to change is rarely a straight one – self motivated behavior change follows a
cyclical pattern.
• A lapse is not a relapse – in changing problem behavior there is a possibility of slipping
back into old habits, which does not necessarily mean failure or that a complete relapse
is inevitable.
• Mini decisions lead to maxi-decisions – making poor mini-decisions related to the
problem behavior can easily lead to a complete relapse. eg. keeping beer in the house
for company.
• Distress precipitates relapse – researchers consistently find that distress (including
anger, anxiety, depression, loneliness, and other emotional problems) is involved in 60
to 70 percent of relapses in alcohol, drug, smoking and eating problems.
• Learning translates into action – learning from relapse and using the experience to
prepare for success by basing another attempt on informed change principles.
Most successful changers go through the stages of change at least three to four times.

Substance Abuse Treatment Scale – Revised

Prochaska et al.’s stages of change are very important to know when working with
clients who have an addiction, whether it is a substance addition or a process addiction. The
stages of change are very similar to the Substance Abuse Treatment Scale as is used with
individuals with an addiction (Conners, Donovan, & DiClemente, 2001). The Substance Abuse
Treatment Scale - Revised (SATS-R) was developed to standardize the assessment of clients’
motivation to change their substance use behavior (McHugo et al., 1995; Mueser et al., 1995)
The SATS-R is an 8-point scale based on the four stages of treatment: engagement,
persuasion, active treatment and relapse prevention. Each stage of treatment is broken down
into two substages. Behavioural anchors are used to describe the client’s substance use
behaviour and involvement in treatment, so that reliable and objective ratings can be made
(Mueser et al., 2003)
The following table compares the stages of change with the SATS-R, the definition and
goal of each stage of treatment.

Table 3: Overlap between the Stages of Change and the Stages of Treatment
Stages of Change Stages of Substance Definition
Abuse Treatment
Scale -Revised
Precontemplation Engagement Client does not have
contact with clinician
Contemplation Persuasion Client has regular
Preparation contact with clinician,
and may want to work
on reducing
substance use
Action Active Treatment Client is motivated to
reduce substance
use, as indicated by
reduction for at least 1
month but less than 6
months
Goal
To establish a working
alliance with the client
To develop the client’s
awareness that
substance use is a
problem, and increase
motivation to change
To help the client
further reduce
substance use and, if
possible, attain
abstinence

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Maintenance Relapse Prevention Client has not
experienced problems
related to substance
use for al least 6
months (or is
abstinent)
(Adapted from Mueser et al. 2003, p. 26-27)
To maintain
awareness that
relapse can happen,
and to extend
recovery to other
areas (eg. social
relationships, work)

Conclusion

The Transtheoretical model of Intentional Behavior Change is a model that allows us to

view human intentional behavior change (DiClemente, 2007). The Transtheoretical model
incorporates elements of various theories of therapy, learning, and behavior change, hence the
term ‘Transtheoretical’, and looks at what an individual experiences and participates in as they
create new behaviors, modify existing behaviors, or stop problematic patterns of behavior
(DiClemente). The stages described in the Transtheoretical model include precontemplation,
contemplation, preparation, action and maintenance. Within each stage there is a constellation
of tasks that create the foundation for movement forward in the process of change as they build
upon each other (DiClemente). The path to successful behavior change is to accomplish the
tasks well enough to be successful in creating a new pattern of behavior (DiClemente).

The journey through the Transtheoretical model is not usually linear but instead can be
spiral. Individuals can move forward, backward, and recycle through the stages of change
(DiClemente). The stages of change inherent in the Transtheoretical model coincide with the
Stages of Substance Abuse Treatment model showing the same goals for the client and
motivational strategies for the health care professional. The dynamic framework of the
Transtheoretical model makes it imperative that behavior change specialists be aware of the
critical tasks and stages, know where clients are in this process of change, and focus efforts on
helping them accomplish the parts of the process where they are having difficulty (DiClemente).

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 References
Conners, G. J., Donovan, D. M., DiClemente, C. C. (2001). Substance abuse treatment and the
stages of change. New York NY: Guilford Press.

DiClemente, C. C. (2007). The transtheoretical model of intentional behavior change. Drugs and
Alcohol Today, 7(1), 29-33.

McHugo, G. J., Drake, R. E., Burton, H. L., & Ackerson, T. H. (1995). A scale for assessing the
stage of substance abuse treatment in persons with severe mental illness. Journal of
Nervous and Mental Disease, 183, 762-767.

Mueser, K. T., Bennett, M., & Kushner, M. G. (1995). Epidemiology of substance abuse among
persons with chronic mental disorders. In A. F. Lehman & L. Dixon (Eds.), Double
Jeopardy: Chronic Mental Illness and Substance Abuse. (pp. 9-25). New York, NY:
Harwood Academic.

Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated treatment for dual
disorders: A guide to effective practice. New York, NY: The Guildford Press.

Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994). Changing for good: A
revolutionary six-stage program for overcoming bad habits and moving your life
positively forward. New York, NY: Avon Books.

Information and Evaluation Services mireille.lecharrois@albertahealthservices.ca January, 2012 11

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