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Sunday, January 20, 2013

Overview of TTM

The Transtheoretical model of behavior change

Overview of the Model

The ModelThe Transtheoretical Model (TTM; Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992) is an integrative, biopsychosocial model to conceptualize the process of intentional behavioral change.  Whereas other models of behavioral change focus exclusively on certain dimensions of change (e.g. theories focusing mainly on social or biological influences), the TTM seeks to include and integrate key constructs from other theories into a comprehensive theory of change that can be applied to a variety of behaviors, populations, and settings (e.g. treatment settings, prevention and policy-making settings, etc.). Dr. DiClemente published Addiction and Change: How Addictions Develop and Addicted People Recover (2003) which goes into more detail about the develpment of the model and how to appropriately use the model in both research and clinical work.

The Stages of Change

One of the key constructs of the TTM is the Stages of Change.  Behavioral change can be thought of as occurring as a progression through a series of stages.  Previous research has measured a number of cognitive and behavioral markers that have been used to identify these stages. Our measures page has additional information about how to measure this construct as well as other TTM related measures. The Stages of Change are as follows:
  • Precontemplation
  • Contemplation
  • Preparation
  • Action
  • Maintenance
Precontemplation: Individuals in the Precontemplation stage are not thinking about or intending to change a problem behavior (or initiate a healthy behavior) in the near future (usually quantified as the next six months). Precontemplators are usually not armed with the facts about the risks associated with their behavior. Additionally, many individuals make unsuccessful change attempts, becoming discouraged and regressing back to the Precontemplation stage. The inclusion of the Precontemplation stage represents a significant contribution of the TTM, as individuals in this stage comprise a large proportion of individuals engaged in risky or unhealthy behaviors. In comparison to many traditional, action-oriented theories of behavior change, which view individuals in this stage as resistant and unmotivated, the TTM can be useful in guiding treatment and prevention programs by meeting the needs of these individuals, rather than ignoring them. 

Contemplation: An individual enters the Contemplation stage when he or she becomes aware of a desire to change a particular behavior (typically defined as within the next six months). In this stage, individuals weigh the pros and cons of changing their behavior. Contemplators also represent a large proportion of individuals engaged in unhealthy behaviors, as ambivalence between the pros and cons of change keeps many people immobilized in this stage. Resolving this ambivalence is one way to help Contemplators progress toward taking action to change their behavior.
Preparation: By the time individuals enter the Preparation stage, the pros in favor of attempting to change a problem behavior outweigh the cons, and action is intended in the near future, typically measured as within the next thirty days. Many individuals in this stage have made an attempt to change their behavior in the past year, but have been unsuccessful in maintaining that change. Preparers often have a plan of action, but may not be entirely committed to their plan. Many traditional action-oriented behavior change programs are appropriate for individuals in this stage.
Action: The Action stage marks the beginning of actual change in the criterion behavior, typically within the past six months. By this point, where many theories of behavior change begin, an individual is half way through the process of behavior change according to the Transtheoretical Model. This is also the point where relapse, and subsequently regressing to an earlier stage, is most likely. If an individual has not sufficiently prepared for change, and committed to their chosen plan of action, relapse back to the problem behavior is likely.
Maintenance: Individuals are thought to be in the Maintenance stage when they have successfully attained and maintained behavior change for at least six months. While the risk for relapse is still present in this stage, it is less so, and as such individuals need to exert less effort in engaging in change processes.
The Stages of Change addresses a facet of behavior change ignored by many other theories, namely that change is a process that occurs over time. It should be noted here that while progression through the Stages of Change can occur in a linear fashion, a nonlinear progression is more common. Often, individuals recycle through the stages, or regress to earlier stages from later ones, rather than progress through the stages in a linear sequence. Change often comes at it’s own pace – often quickly and in bursts, rather than a consistent rate. It is not unusual for someone to spend years in Precontemplation and then progress to Action in a matter of weeks or months.
Decisional Balance: Decision making was conceptualized by Janis and Mann (1977) as a decisional "balance sheet" of comparative potential gains and losses. Two components of decisional balance, the pros and the cons, have become critical constructs in the Transtheoretical model.  As individuals progress through the Stages of Change, decisional balance shifts in critical ways. When an individual is in the Precontemplation stage, the pros in favor of behavioral change are outweighed by the relative cons for change and in favor of maintaining the existing behavior. In the Precontemplation stage, the pros and cons tend to carry equal weight, leaving the individual ambivalent toward change. If the decisional balance is tipped however, such that the pros in favor of changing outweigh the cons for maintaining the unhealthy behavior, many individuals move to the Preparation or even Action stage. As individuals enter the Maintenance stage, the pros in favor of maintaining the behavioral change should outweigh the cons of maintaining the change in order to decrease the risk of relapse. Please see our measures page if you are interested in learning more about how to measure this construct.
Self-efficacy: The Transtheoretical model integrates elements of Bandura's self-efficacy theory (Bandura, 1977, 1982). This construct reflects the degree of confidence the individual has in maintaining their desired behavioral change in situations that often trigger relapse. It is also measured by the degree to which the individual feels tempted to return to their problem behavior in these high-risk situations. In the Precontemplation and Contemplation stages, individuals’ temptation to engage in the problem behavior is far greater than their self-efficacy to abstain. As individuals move from Preparation to Action, the disparity between feelings of self-efficacy and temptation closes, and behavioral change is attained. Relapse often occurs in situations where feelings of temptation trumps and individual’s sense of self-efficacy to maintain the desired behavioral change. Please see our measures page if you are interested in learning more about how to measure this construct.
Processes of Change: While the Stages of Change are useful in explaining when changes in cognition, emotion, and behavior take place, the processes of change help to explain how these changes occur. These ten covert and overt processes need to be implemented to successfully progress through the stages of change and attain the desired behavioral change. These ten processes can be divided into two groups: cognitive and affective experiential processes, and behavioral processes. Please see our measures page if you are interested in learning more about how to measure this construct.

Experiential Processes:

  • Consciousness raising – Knowledge and awareness about the individual and their problem behavior is increased.
  • Dramatic relief – Emotions about the individual’s problem behavior, and available treatments or solutions, are aroused.
  • Environmental reevaluation – The impact that the individual’s problem behavior has on their environment is reassessed.
  • Self-reevaluation – Cognitions and emotions regarding the individual, especially with respect to their problem behavior, are reassessed.
  • Social liberation – Attempts are made to decrease the prevalence of the individual’s former problem behavior in society.

Behavioral Processes:

  • Reinforcement management – Positive behavioral changes are rewarded.
  • Helping relationships – Trusting and open discussion about the problem behavior is received by a supporting individual(s).
  • Counterconditioning – Positive alternative behaviors are substituted for the individual’s problem behavior.
  • Stimulus control – Stimuli that may trigger lapse back to the problem behavior are prepared to be coped with, removed, or avoided.
  • Self-liberation – Choosing a course of action to change the problem behavior, and committing to that choice.

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