Transtheoretical model

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The transtheoretical model in health psychology is intended to explain or predict a person's success or failure in achieving a proposed behavior change, such as developing different habits. It attempts to answer why the change "stuck" or alternatively why the change was not made.

The transtheoretical model is also known by the acronym "TTM"[1] and by the term "stages of change model"[2][3]. A popular book[4] and articles in the newsmedia[5][6][7][8][9] have discussed the model. It is "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted exceptional criticism"[10].

Contents

[edit] History and core constructs of the model

James O. Prochaska of the University of Rhode Island and colleagues developed the transtheoretical model beginning in 1977[11]. It is based on an analysis of different theories of psychotherapy[12], hence the name "transtheoretical." The original model consisted of four variables: "preconditions for therapy," "processes of change," "content to be changed," and "therapeutic relationship"[13].

Prochaska and colleagues later refined the model on the basis of research that they published in peer-reviewed journals and books[14][15][16][17][18][19][20][21][22][23][24][25][26][27]. By 1997, the model consisted of five "core constructs": "stages of change," "processes of change," "decisional balance," "self-efficacy," and "temptation"[26].

[edit] Stages of change

In the transtheoretical model as of 1997, change is a "process involving progress through a series of six stages"[26]:

  • Precontemplation - "people are not intending to take action in the foreseeable future, usually measured as the next 6 months"
  • Contemplation - "people are intending to change in the next 6 months"
  • Preparation - "people are intending to take action in the immediate future, usually measured as the next month"[nb 1]
  • Action - "people have made specific overt modifications in their life styles within the past 6 months"
  • Maintenance - "people are working to prevent relapse," a stage which is estimated to last "from 6 months to about 5 years"
  • Termination - "individuals have zero temptation and 100% self-efficacy... they are sure they will not return to their old unhealthy habit as a way of coping"[nb 2]

In addition, the researchers conceptualized "relapse" which is not a stage in itself but rather the "return from action or maintenance to an earlier stage"[26][nb 3].

[edit] Processes of change

The 10 processes of change are "covert and overt activities that people use to progress through the stages"[26]. These processes are most emphasized at different transitions between stages of change[26][nb 4]:

  • For movement from precontemplation to contemplation, the processes of "consciousness raising," "dramatic relief," and "environmental reevaluation" are emphasized.
  • Between contemplation and preparation, "self-reevaluation" is emphasized.
  • Between preparation and action, "self-liberation" is emphasized.
  • Between action and maintenance, "contingency management"[nb 5], "helping relationship," "counterconditioning," and "stimulus control" are emphasized.

Prochaska and colleagues state that their research related to the transtheoretical model suggests that interventions to change behavior must be "stage-matched," that is, "matched to each individual’s stage of change"[26].

[edit] Decisional balance

This core construct "reflects the individual’s relative weighing of the pros and cons of changing"[26][nb 6].

[edit] Self-efficacy

This core construct is "the situation-specific confidence people have that they can cope with high risk situations without relapsing to their unhealthy or high risk habit"[26][nb 7].

[edit] Temptation

This core construct "reflects the intensity of urges to engage in a specific habit when in the midst of difficult situations"[26][nb 8].

[edit] Controversy

Among the criticisms of the model are the following:

  • Little experimental evidence exists to suggest that application of the model is actually associated with changes in health-related behaviors.
    • In a systematic review published in 2003 of 23 randomized controlled trials, the authors determined that "stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour"[28].
    • A second systematic review from 2003 asserted that "no strong conclusions" can be drawn about the effectiveness of interventions based on the transtheoretical model for the prevention of pregnancy and sexually transmitted disease[29].
    • A 2005 systematic review of 37 randomized controlled trials claimed that "there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change"[30].
    • According to a randomized controlled trial published in 2006, a stage-matched intervention for smoking cessation in pregnancy was more effective than a non-stage-matched intervention, but this finding could have resulted from the "greater intensity" of the stage-matched intervention[31].
    • A randomized controlled trial published in 2009 found "no evidence" that a smoking cessation intervention based on the transtheoretical model was more effective than a control intervention that was not tailored for stage of change[32].
    • A 2009 review stated that "existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model" as related to dietary interventions for people with diabetes[33].
  • "Arbitrary dividing lines" are drawn between the stages[34].
  • The model makes predictions that are "incorrect or worse than competing theories"[34].
  • The model "assumes that individuals typically make coherent and stable plans," when in fact they do not[34].
  • The algorithms and questionnaires that researchers have used to assign people to stages of change have not been standardized, compared empirically, or validated[35][36].
  • The designs of many studies supporting the model have been cross-sectional, but longitudinal study data would provide stronger causal inferences[35].
  • In a 2002 review, the model's stages were characterized as "not mutually exclusive"; furthermore, there was "scant evidence of sequential movement through discrete stages"[37].

Responses to such criticisms include:

  • Many studies that show the model to be ineffective have tailored interventions only to stage of change; if the studies had tailored interventions based on all core constructs of the model, they might have shown positive findings[38]. In particular, the "processes of change" have been characterized as "under-researched"[10]. A 2007 meta-analysis of tailored print health behavior change interventions found that the "number and type of theoretical concepts tailored on," including stage of change and processes of change, were associated with behavior change[39]. In 2008 Hutchison and colleagues published a systematic review of 34 articles examining 24 interventions based on the transtheoretical model for behavior change in physical activity; only 7 of the 24 interventions addressed all four dimensions "stages of change," "processes of change," "decisional balance," and "self-efficacy"[40].
  • Studies that find the model ineffective are poorly designed; for example, they have small sample sizes, poor recruitment rates, or high high loss to follow-up[38][41][42].
  • The conversion of continuous data into discrete categories is necessary for the model, similar to how decisions are made about the treatment of high cholesterol levels depending on the discrete category the cholesterol level is placed into[38].

[edit] See also

[edit] Notes

The following notes summarize major differences between the well-known 1983[15], 1992[23], and 1997[26] versions of the model. Other published versions may contain other differences. For example, Prochaska, Prochaska, and Levesque (2001)[27] do not mention the Termination stage, Self-efficacy, or Temptation.
  1. ^ In the 1983 version of the model, the Preparation stage is absent.
  2. ^ In the 1983 version of the model, the Termination stage is absent. In the 1992 version of the model, Prochaska et al. showed Termination as the end of their "Spiral Model of the Stages of Change," not as a separate stage.
  3. ^ In the 1983 version of the model, Relapse is considered one of the five stages of change.
  4. ^ In the 1983 version of the model, the processes of change were said to be emphasized in only the Contemplation, Action, and Maintenance stages.
  5. ^ In the 1983 and 1992 versions of the model, Prochaska et al. called this process "reinforcement management," not "contingency management."
  6. ^ In the 1983 version of the model, "decisional balance" is absent. In the 1992 version of the model, Prochaska et al. mention "decisional balance" but in only one sentence under the "key transtheoretical concept" of "processes of change."
  7. ^ In the 1983 version of the model, "self-efficacy" is absent. In the 1992 version of the model, Prochaska et al. mention "self-efficacy" but in only one sentence under the "key transtheoretical concept" of "stages of change."
  8. ^ In the 1983 and 1992 versions of the model, "temptation" is absent.

[edit] References

  1. ^ Prochaska JO, Butterworth S, Redding CA, Burden V, Perrin N, Leo M, Flaherty-Robb M, Prochaska JM. Initial efficacy of MI, TTM tailoring and HRI's with multiple behaviors for employee health promotion. Prev Med 2008 Mar;46(3):226-31. Accessed 2009 Mar 21.
  2. ^ Greene GW, Rossi SR, Rossi JS, Velicer WF, Fava JL, Prochaska JO. Dietary applications of the stages of change model. J Am Diet Assoc 1999 Jun;99(6):673-8. Accessed 2009 Mar 21.
  3. ^ Pro-Change Behavior Systems. About us. Transtheoretical model. 2008 Mar. Accessed 2009 Mar 21.
  4. ^ Prochaska JO, Norcross JC, DiClemente CC. Changing for good: the revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits. New York: W. Morrow; 1994. ISBN 0688112633.
  5. ^ Goleman, Daniel. New addiction approach gets results. New York Times 1993 Sep 1. Accessed 2009 Mar 19.
  6. ^ Miller, Kay. Revolving resolutions - Year after new year, we vow to lose weight, stop smoking, find love or a better job -- only to fail. A few simple strategies could set us straight. Star Tribune: Newspaper of the Twin Cities 2001 Dec 29.
  7. ^ Stettner, Morey. A methodical way to change bad behavior. Investor's Business Daily 2005 Dec 19.
  8. ^ Understanding change: expect a few bumps. Washington Post 2007 Jan 2. Accessed 2009 Mar 19.
  9. ^ Carbine, Michael E. Health plans use a variety of strategies to identify and ensure compliance among diabetics. AIS's Health Business Daily 2009 Mar 6. Accessed 2009 Mar 19.
  10. ^ a b Armitage CJ. Is there utility in the transtheoretical model? Br J Health Psychol 2008 Oct 14 [Epub ahead of print]. Accessed 2009 Mar 17.
  11. ^ Prochaska JO, DiClemente CC. The transtheoretical approach. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. 2nd ed. New York: Oxford University Press; 2005. p.147-171. ISBN 0195165799.
  12. ^ Prochaska JO. Systems of psychotherapy: a transtheoretical analysis. Homewood, IL: Dorsey Press; 1979.
  13. ^ Prochaska JO, DiClemente CC. Trans-theoretical therapy - toward a more integrative model of change. Psychotherapy: Theory, Research and Practice 1982;19(3):276-288. Accessed 2009 Mar 18.
  14. ^ McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy - measurement and sample profiles. Psychotherapy: Theory, Research and Practice 1983;20(3):368-375.
  15. ^ a b Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol 1983 Jun;51(3):390-5. Accessed 2009 Mar 18.
  16. ^ DiClemente CC, Prochaska JO, Gibertini M. Self-efficacy and the stages of self-change of smoking. Cognit Ther Res 1985;9(2):181-200. Accessed 2009 Mar 22.
  17. ^ Velicer WF, DiClemente CC, Prochaska JO, Brandenburg N. Decisional balance measure for assessing and predicting smoking status. J Pers Soc Psychol 1985 May;48(5):1279-89. Accessed 2009 Mar 18.
  18. ^ Prochaska JO, DiClemente CC. Toward a comprehensive model of change. In: Miller WR, Heather N, editors. Treating addictive behaviors: processes of change. New York: Plenum Press; 1986. p.3-27. ISBN 0306422484. Accessed 2009 Mar 18.
  19. ^ Prochaska JO, Velicer WF, DiClemente CC, Fava J. Measuring processes of change: applications to the cessation of smoking. J Consult Clin Psychol 1988 Aug;56(4):520-8. PMID 3198809.
  20. ^ DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol 1991 Apr;59(2):295-304. Accessed 2009 Mar 18.
  21. ^ Velicer WF, Prochaska JO, Rossi JS, Snow MG. Assessing outcome in smoking cessation studies. Psychol Bull 1992 Jan;111(1):23-41. PMID 1539088.
  22. ^ Prochaska JO, DiClemente CC. Stages of change in the modification of problem behaviors. Prog Behav Modif 1992;28:183-218. PMID 1620663.
  23. ^ a b Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. Am Psychol 1992 Sep;47(9):1102-14. Accessed 2009 Mar 16.
  24. ^ Prochaska JO, DiClemente CC, Velicer WF, Rossi JS. Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychol 1993 Sep;12(5):399-405. Accessed 2009 Mar 18.
  25. ^ Prochaska JO, Velicer WF, Rossi JS, Goldstein MG, Marcus BH, et al. Stages of change and decisional balance for 12 problem behaviors. Health Psychol 1994 Jan;13(1):39-46. Accessed 2009 Mar 18.
  26. ^ a b c d e f g h i j k Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997 Sep-Oct;12(1):38-48. Accessed 2009 Mar 18.
  27. ^ a b Prochaska JM, Prochaska JO, Levesque DA. A transtheoretical approach to changing organizations. Adm Policy Ment Health 2001 Mar;28(4):247-61. Accessed 2009 Mar 20.
  28. ^ Riemsma RP, Pattenden J, Bridle C, Sowden AJ, Mather L, Watt IS, Walker A. Systematic review of the effectiveness of stage based interventions to promote smoking cessation. BMJ 2003 May 31;326(7400):1175-7. Accessed 2009 Mar 18.
  29. ^ Horowitz SM. Applying the transtheoretical model to pregnancy and STD prevention: a review of the literature. Am J Health Promot 2003 May-Jun;17(5):304-28. Accessed 2009 Mar 18.
  30. ^ Bridle C, Riemsma RP, Pattenden J, Sowden AJ, Mather L, Watt IS, Walker A. Systematic review of the effectiveness of health behavior interventions based on the transtheoretical model. Psychol Health 2005;20:283–301. Accessed 2009 Mar 18.
  31. ^ Aveyard P, Lawrence T, Cheng KK, Griffin C, Croghan E, Johnson C. A randomized controlled trial of smoking cessation for pregnant women to test the effect of a transtheoretical model-based intervention on movement in stage and interaction with baseline stage. Br J Health Psychol 2006 May;11(Pt 2):263-78. Accessed 2009 Mar 18.
  32. ^ Aveyard P, Massey L, Parsons A, Manaseki S, Griffin C. The effect of Transtheoretical Model based interventions on smoking cessation. Soc Sci Med 2009 Feb;68(3):397-403. Accessed 2009 Mar 18.
  33. ^ Salmela S, Poskiparta M, Kasila K, Vähäsarja K, Vanhala M. Transtheoretical model-based dietary interventions in primary care: a review of the evidence in diabetes. Health Educ Res 2009 Apr;24(2):237-52. Accessed 2009 Mar 19.
  34. ^ a b c West R. Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction 2005 Aug;100(8):1036-9. Accessed 2009 Mar 19.
  35. ^ a b Sutton S. Back to the drawing board? A review of applications of the transtheoretical model to substance use. Addiction 2001 Jan;96(1):175-86. Accessed 2009 Mar 19.
  36. ^ Adams J, White M. Why don't stage-based activity promotion interventions work? Health Educ Res 2005 Apr;20(2):237-43. Accessed 2009 Mar 22.
  37. ^ Littell JH, Girvin H. Stages of change. A critique. Behav Modif 2002 Apr;26(2):223-73. Accessed 2009 Mar 19.
  38. ^ a b c Prochaska JO. Moving beyond the transtheoretical model. Addiction 2006 Jun;101(6):768-74. Accessed 2009 Mar 20.
  39. ^ Noar SM, Benac CN, Harris MS. Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychol Bull 2007 Jul;133(4):673-93. Accessed 2009 Mar 21.
  40. ^ Hutchison AJ, Breckon JD, Johnston LH. Physical activity behavior change interventions based on the Transtheoretical Model: a systematic review. Health Educ Behav 2008 Jul 7 [Epub ahead of print]. Accessed 2009 Mar 20.
  41. ^ Spencer L, Pagell F, Hallion ME, Adams TB. Applying the transtheoretical model to tobacco cessation and prevention: a review of literature. Am J Health Promot 2002 Sep-Oct;17(1):7-71. Accessed 2009 Mar 22.
  42. ^ Prochaska JO. Flaws in the theory or flaws in the study: a commentary on "The effect of Transtheoretical Model based interventions on smoking cessation". Soc Sci Med 2009 Feb;68(3):404-6. Accessed 2009 Mar 21.

[edit] Further reading

  • Prochaska JO, DiClemente CC. The transtheoretical approach: crossing traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin; 1984. ISBN 087094438X.
  • Miller WR, Heather N, editors. Treating addictive behaviors. 2nd ed. New York: Plenum Press; 1998. ISBN 0306458527.
  • Connors GJ, Donovan DM, DiClemente CC. Substance abuse treatment and the stages of change: selecting and planning interventions. New York: Guilford Press; 2001. ISBN 1572306572.
  • Velasquez MM. Group treatment for substance abuse: a stages-of-change therapy manual. New York: Guilford Press; 2001. ISBN 1572306254.
  • Burbank PM, Riebe D. Promoting exercise and behavior change in older adults: interventions with the transtheoretical model. New York: Springer; 2002. ISBN 0826115020.
  • DiClemente CC. Addiction and change: how addictions develop and addicted people recover. New York: Guilford Press; 2003. ISBN 1572300574.
  • Prochaska JO, Norcross JC. Systems of psychotherapy: a transtheoretical analysis. 6th ed. Australia: Thomson/Brooks/Cole; 2007. ISBN 9780495007777.

[edit] External links

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