1. The Transtheoretical Model
CHAPTER 4
The Transtheoretical Model

2. Historical Perspectives
Late 1970s: James Prochaska from the University of Rhode Island undertook a task to review various theories behind psychotherapy
1980s: The University of Rhode Island Change Assessment (URICA) scale was developed
1990s: Two scales were developed on TTM
Readiness to Change Questionnaire (RCQ)
Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)
2000s: Variety of health applications
2010s: Health coaching & online applications
At present enjoys the status of being the most popular model

3. Stages of Behavior Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
Termination
General thumb rule: 40% precontemplation, 40% contemplation, 20% preparation
© JPS/Shutterstock

4. Stages of Behavior Change
Figure 4-1: Stages of change in the transtheoretical model. The progression through the stages is not linear but cyclical or spiral; one might progress from precontemplation to action and then regress to contemplation and then again progress to action and so on.

5. Decisional Balance Relative weighing of the pros and cons of changing
Pros: The benefits of changing
Janis and Mann (1977) identified the following components (recent work has found not much gain in predictive value):
Instrumental gains for self
Instrumental gains for others
Approval for self
Approval for others

6. Decisional Balance (cont’d)
Cons: The costs of changing
Janis and Mann (1977) identified the following components:
Instrumental costs to self
Instrumental costs to others
Disapproval from self
Disapproval from others

7. Self-Efficacy Confidence Behavior specific Situation specific
“Here and now”
Build small steps
© Olivier Le Moal/Shutterstock

8. Self-Efficacy (cont’d)
Temptation
Counteract stress
Avoid negative social occasions
Control cravings
Important in preparation and action stages
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9. Consciousness Raising
Increased awareness of behavior
Experiential process
Methods
Feedback
Confrontations
Interpretations
Important in contemplation, preparation, and action stages

10. Dramatic Relief Transition to emotional awareness Experiential process
Psychodrama
Role playing
Personal testimony
Grieving
Important in contemplation and preparation stages
© Andy Dean Photography/Shutterstock

11. Self-Reevaluation
Cognitive and affective assessment of one’s self-image
Experiential process
Value clarification
Healthy role modeling
Mental imagery
Important in preparation and action stages

12. Environmental Reevaluation
Affective and cognitive assessment of how one’s behavior affects the social environment
Experiential process
Empathy training
Documentary reflection
Important in contemplation, preparation, and action stages

13. Self-Liberation Belief that one can change Behavioral process
Commitment and recommitment
“Skill power”
Resolutions
Public testimony
Important in contemplation and preparation stages
© Tashatuvango/Shutterstock

14. Helping Relationships
Caring, trust, openness, acceptance for behavior change
Behavioral process
Rapport building
Therapeutic alliance
Professional calls
Buddy systems
Important in action and maintenance stages

15. Counterconditioning Learning of healthy coping Behavioral process
Relaxation
Assertion
Desensitization
Nicotine replacement
Positive self statements
Important in preparation, action, and maintenance stages

16. Contingency Management
Consequences for taking steps in a particular direction
Behavioral process
Contingency contracts
Overt and covert reinforcements
Group recognition
Important in action and maintenance stages

17. Stimulus Control Removes cues for unhealthy habits Behavioral process
Avoidance
Environmental reengineering
Self-help groups
Important in action and maintenance stages
© Kheng Guan Toh/Shutterstock

18. Social Liberation Increase in social opportunities or alternatives
Experiential process
Smoke-free environment
Access to healthy alternatives
Important in action and maintenance stages

19. Stages & Processes of TTM
Figure 4-2: Relationship of the constructs and processes of the transtheoretical model to stages of change.

20. Five Phases for Planning Interventions
Recruitment phase
Retention phase
Progress phase
Process phase
Outcomes phase

21. Application of TTM to Smoking Cessation
Figure 4-3: Application of the transtheoretical model for a smoking cessation program.

22. Application of Stages of Change to a Physician Training Program: Four A’s
Ask
Systematically identify all smokers
Advise
Strongly advise smokers to quit
Determine patient’s willingness to make a quit attempt

23. Four A’s (cont’d) Assist Arrange Smoker patient to set a quit date
Prepare the patient for the quit date
Use nicotine replacement therapy or bupropion
Provide self-help materials
Arrange
Schedule follow-up contacts

24. Ask Do you smoke? Current Did you ever smoke? Former/never
How many cigarettes?
How long have you smoked?
Years
Reasons for smoking?
Benefits of quitting?
Swing the decisional balance in favor of “pros”

25. Advise
Clear
“I think it is important for you to quit smoking now and I know it will help you.”
“Cutting down while you are ill is not enough.”
Strong
“As your clinician, I need to let you know that quitting smoking is the most important thing you can do to protect your current and future health.”
Personalized
Emphasize benefits of quitting at a personal level

26. Assist Help the patient with a quit plan
Set a quit date (within 2 weeks). Patient must:
Inform family, friends, coworkers
Remove cigarettes from the environment
Review previous attempts
Anticipate challenges
Use nicotine replacement therapy or bupropion therapy as needed
Emphasize total abstinence

27. Arrange Schedule follow-up contact Timing Congratulate success
In person or via telephone
Timing
First must be soon after the quit date
Second follow-up at one month
Congratulate success
Attribute failures to external reasons and encourage another try; build self-efficacy

28. Population Impact of TTM
Population Impact (PI) = Participation Rate (PR) x Effectiveness Rate (ER)
For example, if 20% of the population of smokers participate in a stop smoking program and 30% of those who participate quit, then 6% of the smokers quit
Matching stage with process has been shown to increase both participation rates and effectiveness rates

29. Strengths of TTM Only theory to talk about behavior change
Tested extensively
Presents five stages of change
Rooted in several theories of psychotherapy
Very elaborate
© Sergey Nivens/Shutterstock

30. Some Limitations of TTM
Stages in the model are arbitrary, and to classify a population in different stages serves little utility
People can move through the stages of the model in minutes
The validity of self-reported behavior with regard to stage is questionable
A significant number of people cannot be assigned to recognized stages
Need to strive for parsimony of stage-matched behavior-specific processes

31. Some Limitations of TTM (cont’d)
Comparative studies of stage-matched versus non-stage-matched interventions are lacking
Applications to vulnerable subgroups of populations are lacking
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32. Application Exercise
One TTM example is the development of a physical activity intervention, “Moms on the Move” (Fahrenwald, Atwood, Walker, Johnson, & Berg, 2004; Fahrenwald & Sharma, 2002), designed for women in the contemplation and preparation stages of physical activity behavior change.
Constructs used in the intervention were decisional balance, self-efficacy for physical activity, three behavioral processes (i.e., self-liberation, helping relationships, and counter-conditioning) and an experiential process (i.e., environmental reevaluation).

33. Application Exercise (cont’d)
The primary delivery mode was provider-delivered counseling supplemented with an interactive brochure and four biweekly provider-delivered telephone contacts.
Using an experimental design, the authors were able to demonstrate statistically significant changes in TTM constructs and physical activity behavior.
Read the two articles and prepare a 250-word critique.

34. Application Exercise (cont’d)
In your critique pay attention to:
Appropriateness of selection of constructs
Adequate operationalization of constructs in the instrument and intervention
Validity and reliability of instruments
Appropriateness of statistical analyses
Appropriateness of conclusions and ability to generalize the results

35. Websites to Explore Applying TTM to Family Practice
Applying TTM to Substance Abuse
Boston University: Webcast by Dr. James Prochaska

36. Websites to Explore (cont’d)
Cancer Prevention Research Center (CPRC): Transtheoretical Model
Transtheoretical Model: Pro Change
University Of Maryland: Habits—Health & Addictive Behaviors: Investigating Transtheoretical Solutions

37. Skill Building Activity
© Alexmillos/Shutterstock
Specific to your behavior, reflect on how you might assess the stage in which individuals in your target group might fall.
Identify learning activities (processes) for those at each stage of change.
How might you improve the population impact for your target group?