The Transtheoretical Model of Behavior Change

The Transtheoretical Model (TTM) is the most popular stage theory of behavioral change. It is a composite of numerous different behavior change approaches from the field of psychology. Prochaska and his colleagues (1992) developed the TTM in order to integrate the many fragmented theories of intervention. Noting the merits of each theory in explaining some of the puzzle that is behavioral change, the TTM points out that at each stage of change, different behavioral theories are applicable. The TTM notes that people do not necessarily go through a single process in making a health-related decision, but go through many processes as part of a continuum of change.

The TTM argues that behavioral change rarely occurs in a linear pattern. Instead, change often occurs in something of a spiral pattern - people make it so far, then relapse to an earlier stage, then catch-up to their previous stage and advance, only to relapse again. Prochaska et al. illustrated the model in such a manner:

Prochaska, J.O., C.C. DiClemente, & J.C. Norcross (1992) In Search of How People Change: Applications to Addictive Behaviors. American Psychologist. 47: 1102-1114.

The TTM identifies 6 stages of change, from precontemplation to termination. The TTM may, on the surface, seem similar to the PAPM, but upon a careful read you will see the differences in the two models.

Stages of the TTM

The first stage of the TTM is precontemplation. During the precontemplation phase, people have no intent to take action/change behavior. Individuals in this phase may be unaware of the risk associated with the issue, or may simply not be motivated to change their behavior.

Following the precontemplation stage is contemplation. During this stage, people are aware of the problem and are considering doing something about it, though they have not definitely decided to do so. Most intend to take action within a period of 6 months. Prochaska et al. refer to this stage as a period of behavioral procrastination. This is a period in which individuals intend to change soon, but have not taken steps to actually do so.

Preparation follows contemplation. In this stage, people intend to take action soon, within a month s time. Many individuals begin taking small steps toward this intended action - cutting back on the number of cigarettes one smokes, talking to their physician about the issue, looking up the issue online or reading up on it in a book.

Thereafter comes the action stage. Action is the stage in which people have made specific and pronounced changes in their behavior or environment with the intention of overcoming the health problem or challenge. Individuals are considered to be in the action stage if they have successfully altered their behavior for between 1 day and 6 months.

If an individual succeeds in maintaining this behavior for more than 6 months, they enter into the maintenance stage. Here, individuals still battle the possibility of relapse. A smoker may sneak a cigarette, thus exiting him from the maintenance stage.

Temptation to relapse lessens as time progresses, until the individual enters into the final stage, termination. In the termination stage, individuals no longer succumb to the temptation to return to their poor behavioral patterns, and have self-efficacy about their maintenance. They are sure that, regardless of their circumstances, they will not return to their negative behaviors.

Individuals move from stage to stage based upon numerous change processes. The Prochaska et al. reading outlines 10 of these change processes in greater detail, but among them:

1. Consciousness-raising: increased awareness of the issue, including its causes and consequences. This process can easily be tapped as part of a public health behavioral intervention campaign, through media campaigns.
2. Environmental re-evaluation: a process in which individuals think about the impact of their behavior on others in their social environment. Public health campaigns may attempt to remind others about the impact of their action on family members and friends, such as including information on the risk of second-hand smoke, or by including the testimony of a child who lost their parent to smoking-induced lung cancer.
3. Counter-conditioning: healthier behaviors are learned in place of less-healthy ones. A campaign aimed at reducing smoking may include something like exercise classes or yoga in an attempt to work with this process.

Evaluation and critique of the TTM

At the core of the TTM is the assumption that no single theory can account fully for behavioral change. Change is a process that unfolds over time, but this process may better be described as circular (or spiral) in nature rather than linear. People take one step forward and two steps back. A considerable strength of the model is that it notes the significance of determining which stage an individual is in in order to invoke change. People in different stages require different strategies, and respond to different change processes.

Several evaluations have been conducted to determine the usefulness of the TTM for understanding behavioral change. First, we see that there is evidence that people do move through each of the various stages on the path to behavioral change. Further, there is evidence that these stages are distinct, and that individuals in different stages make use of different change processes. Individuals in the contemplation stage, for instance, seem to be most effected by consciousness-raising techniques, and also by environmental re-evaluation. Individuals in the action and maintenance stages, on the other hand, responded to processes like counter-conditioning and stimulus control. Further, the majority of studies that attempted to tailor communications to the stage of the individual have found these approaches to improve rates of behavioral change. That said, several other studies have challenged the usefulness of the TTM for understanding behavioral change. Some argue that the stages are inadequate; others that there is not sufficient evidence of the link between change processes and the purported stages. Others question whether the TTM works equally well for all people, or whether its usefulness may be limited for minorities or low income people.