Stages of Change Theory

Definition/Introduction

The factors that influence “change behavior” have been significantly researched, yet one model is the standard-bearer for change. The transtheoretical model (TTM), and its easy-to-follow steps toward change, make understanding human behavior one of the easiest filters to follow. TTM stages include[1][2][3][4][5]: 

1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance

TTM has become one of the most commonly applied theoretical and clinical frameworks in mental health and is effective across a broad spectrum of problems, including smoking, alcohol abuse, addiction, weight control and exercise acquisition, sunscreen use, condom use, school bullying, to preventative measures such as medical screens like mammography and cancer screening.[1] This article explains the important concepts of TTM and how to use it.[1][2][3][6]

Pre-contemplation, the first stage, reveals unmotivated people who see no need to find a solution to a problem because they usually do not believe that one exists. Individuals in this stage are unaware of or have limited awareness of the problem or lack insight into the consequences of their negative/addictive behavior. This patient response is atypical since the majority of people acknowledge their adverse behaviors. It is important to understand that a person in this stage is in complete denial and even tends to defend their actions. People in this stage often present as resistant, unmotivated, and unready, and unwilling to change. Furthermore, this individual often obsesses about the negative side of change rather than recognizing the benefits that they would gain. In other words, the cons outweigh the pros. Should a pre-contemplator present to therapy, it is likely to be due to the constant pressure of others in their life, who are likely pushing them to seek help. At times, they may even exhibit elements of change as long as the pressure from others remains present and constant. If that pressure to change is no longer present, Precontemplators will quickly return to their old habits. How does one progress to the next stage of change when there is no consideration of recognizing a problem in the first place? Consciousness-raising therapy, in addition to changes in life circumstances, may help. When people enter a new stage of their life, they tend to critically evaluate their behaviors and consider if those behaviors are serving them and those around them in a positive way. Until they gain such insight, an individual remains in this pre-contemplation stage and will continue to engage in adverse behaviors. People in this stage have no intention of making a change in the next six months and often make comments like, “I don’t see a problem with what I’m doing, so there’s no reason to change anything.”

The second stage is contemplation. This stage is marked by awareness and acknowledgment of the problematic behavior with serious consideration to change. However, the person is uncertain if the problem behavior is worthy of correcting. Therefore, this internal approach-avoidance conflict results in no commitment to taking the necessary steps toward change. In contemplation, the problem sits “center stage,” but the actor never moves. The ambivalence and indecisiveness that occur in this stage cause people to remain stuck in “contemplation” for at least six months. In general, people in this stage are more open to receiving information regarding their behaviors and finding solutions to correct them. They may make comments such as, “I know I have a problem, and I think I should do something about it.” This behavior is also known as chronic contemplation or behavioral procrastination.

The next stage along the continuum is the preparation stage. At this point in the change process, the person can easily acknowledge that a behavior is problematic and can make a commitment to correcting it. Now, there is an acknowledgment that the pros of change behavior outweigh the cons. People begin gathering information from various sources; self-help books, counseling, change-oriented programs as they start to develop a plan of action. Gathering information is a vital step in preparation. If bypassed, individuals tend to plan insufficiently, without thoughtfully considering the impact the change will play in their lives. As such, they may stumble when challenges arise, and relapse often becomes inevitable. Often appropriate planning is completed; people intend to act in the next thirty days and have usually taken behavioral steps towards that direction over the past year. It is common for people in this stage to make comments such as, “Smoking is such a bad habit. I’ve been reading about different ways to quit, and even though I haven’t totally quit yet, I am smoking less than I did before.”

During the action stage, change happens. Total abstinence of the adverse behavior is the expectation for a period of fewer than six months. While in this stage, people gain confidence as they believe they have the willpower to continue on the journey of change. They continue to review the importance of the behavioral change while evaluating their commitment to themselves. People in this stage are willing to receive assistance and support. Developing short-term positive reinforcement in the form of rewards sustains motivation. Considering potential hurdles to overcome and then developing plans to counteract potential triggers that may lead to relapse is prominent. During this stage, the most overt behavioral changes are acknowledged by the individual and by others. However, the visible changes found in this stage should not be mistakenly equated as the only components of change. Often, people mistakenly associate change solely with action, thereby forgoing all the prerequisite work required to act on changing a behavior. Prematurely jumping to this stage without adequately preparing will lead to difficulty.[2][3] An example of a statement made by an individual in the action stage would be, “It’s easy to say you’ll quit smoking, but I’m doing something about it. I haven’t smoked a cigarette in four months.” 

Continuing the new behavior change is the focus of the maintenance stage. Here, individuals have maintained total abstinence from the adverse behavior for more than six months. As people progress through this stage, the more confident they become in their ability to sustain the positive lifestyle changes and the less tempted/fearful they feel of relapsing. They can maintain a new status quo and can remind themselves of the progress they have made. At times, they may have thoughts of returning to old habits; however, they resist the temptation and remain on track because of the positive strides they have made. People become skilled at anticipating potential triggers that may result in relapse and have constructed coping strategies to combat these situations in advance. Typically, people remain in this stage anywhere between six months to five years.[7] A longitudinal study from the 1990 Surgeon General’s Report showed that after 12 months of abstinence, 43% of people returned to their smoking habit. However, it was not until reaching the 5-year mark of abstinence that the risk for relapse dropped to 7%.[7] Individuals in this stage require support as they re-evaluate their reasons for change, acknowledge the success they’ve made thus far, consider the potential triggers for relapse, and subsequently create contingency plans to try and avoid relapse.

The ultimate goal of TTM is to create an action plan that will assist in preventing relapse and maintaining sobriety. The concept of relapse is a common factor in change behavior and, as such, should be discussed and normalized. Often, change behavior will take a spiral or recycling of stages rather than a linear progression.[1][2][7] For example, smokers can take an average of three to four action attempts before achieving long-term maintenance.[1] At the risk of demeaning one’s achievement up to that point, relapse should not be viewed as a failure. It should be considered an excellent opportunity to revaluate one’s triggers, reassess one’s motivation for change, reassess old/new barriers to achieving the goal, and plan for stronger contingency plans. It is essential to recognize the possibility of relapse and acknowledge it as a potential for growth and improvement. Approximately fifteen percent of people who relapse regress to the pre-contemplation stage and often try to suppress the memory of the unsuccessful trial and thoughts of the negative behavior.[1] Eighty-five percent of individuals return to the contemplation stage or preparation stage rather than pre-contemplation.[1] Individuals require constant active maintenance in the first 3 to 6 months of abstinence since this period is considered the most tempting time for relapse.[1] 

Termination, the final stage, is not often included in the stages of change (TTM) because it is difficult to achieve. It describes a period with zero temptation for relapse and the achievement of 100% self-efficacy. Although this level of success rarely accompanies addictive behaviors, examples of this can be seen in everyday life, when individuals buckle their seat belts as soon as they enter a car or when individuals take their medications at the same time every day. Certain factors are required to assist with stage progression. These factors include the processes of change, decisional balance, and self-efficiency.[1][2][7]

1. The processes of change explain how change occurs. The ten processes illustrate both the external and internal requirements needed to transition through the stages.
2. Decisional balance considers the pros and cons of change. The further one progresses through the stages, the greater the pros of change are valued over the cons.
3. Self-efficiency explains the level of confidence one has in executing and maintaining a positive change despite the temptation for relapse.

Issues of Concern