(reformatted from PowerPoint presentation)

History
Model emerged from a comparative analysis of the leading theories of psychotherapy and behavioral change.
An analysis of more than 300 fragmented theories of psychotherapy.
Only 10 processes of change were identified among these theories.

Conscious Raising – Freud
Contingency Management – Skinner
Helping Relationships - Rogers

An empirical analysis of self-changers was assessed (1982) and it was determined that behavioral change unfolds through a series of changes.
This model has been used initially in studies of smoking to later including a broad range of health and mental health behaviors
Over time, these studies have expanded, validated, applied, and challenged the core constructs of the Transtheoretical Model.
The core constructs are: the stages of change, the processes of change, and critical assumptions of the model.

Stages of Change
The stage construct represents a temporal dimension.
Behavioral change is a process involving progress through a series of five stages

1. Precontemplation
The stage in which people have no intention to take action in the foreseeable future.
May be due to: uninformed or underinformed about the consequences of their behavior (usually these groups avoid reading, talking or thinking about their behaviors and characterized as not being ready for change, unmotivated clients or resistant).
Are we ready for these clients? Can we identify their needs?

2. Contemplation
The stage in which people intend to change. They are informed, aware of the pros of changing BUT ALSO acutely aware of the cons.
The balance between costs and benefits of change can produce profound ambivalence and keep clients stuck in this stage.
These clients are not ready for change

3. Preparation
Stage in which people intend to take action in the immediate future, usually measured as in the next month.
They typically have taken some significant action within the past year.
These clients have developed their own plan of action.
These clients are those who are usually ready for change and should be actively supported in their ventures.

4. Action
In this stage, clients have made specific overt modifications in their behavior/lifestyle.
Since behavior is observable, behavioral change is often has been equated with action.
Not all behavior is action. Behavior is action when it is sufficient to reduce the undesired effects.

5. Maintenance
The stage in which people work to prevent relapse, but do not apply change processes as frequently as people in the action stage.
They are less likely to relapse and increasingly more confident they can continue their changes.
Temptation and self-efficacy data from the US Dept of Health and Human Services (1990) estimates that maintenance lasts from six months to about five years.

6. Termination (applies to some behaviors)
Usually addictions(substance, obsessive/compulsive disorders)
Individual has no temptations and 100 % self-efficacy (functioning efficiently relying upon one’s abilities). They are sure to not return to their old habits. Approximately 20% reach this stage (Prochaska, Snow, and Rossi 1992).

Processes of Change
These are covert and overt activities clients use to progress through the stages. The processes of change provide guidelines because these are like independent variables that clients apply to move from one stage to another. Ten have been most empirical:

1. Conscious Raising
Involves increased awareness about the particular problem behavior and its consequences.
Interventions  that increase awareness include feedback, confrontations, interpretations, media campaigns.

2. Dramatic Relief
Initially produces an increased emotional experience followed by reduced affect if appropriate action is taken.
This would include role-playing, personal testimonies, media campaigns.

3. Self-reevaluation
Combines both cognitive and affective assessments of one’s self image with and without the unhealthy habit/life style.
Techniques used are: clarifying values, healthy role models, mental imagery.

4. Environmental re-evaluation
Combines both the affective and cognitive assessments of how the absence or presence of the behavior effects one’s social environment. It can also include the awareness that one can serve as a role model for others (such as family).

5. Self-liberation
The belief that one can change and the commitment and recommitment to act on that belief.
Resolutions, public testimonies, multiple rather than single choices can enhance willpower.

6. Helping Relationships
Combine caring, trust, openness, acceptance and support for the change.
Rapport building, therapeutic alliances, and buddy systems can be sources of social support.

7. Counter-conditioning
The learning of positive/healthy behaviors which can substitute for problem behaviors.
This would include relaxation, positive self-statements, and assertion.

8. Contingency Management
Provides consequences for taking steps ina particular direction. Much more effective when rewards are utilized more frequently than punishments.
Contingency contracts, group recognition procedures are used and increase the probability that positive behavior will be repeated.

9. Stimulus Control
Remove cues for unhealthy behaviors and add prompts for healthier alternatives.
Self-help groups can provide the stimulus for change.

10. Social Liberation
Requires an increase in the social opportunities for people who are relatively deprived or oppressed.
Advocacy, empowerment procedures, and appropriate policies/legislation can help people change.

Decisional Balance
Reflects the individual’s relative weighing of the pros and cons of changing.

The Decisional Balance Model (Janis and Mann 1977) includes four categories of pros and four categories of cons:

Pros:
1. Instrumental gains for self
2. Instrumental gains for others
3. Approval for self
4. Approval for others

Cons:
1. Instrumental costs to self
2. Instrumental costs to others
3. Disapproval for self
4. Disapproval from others

Self Efficacy
Confidence - the situation specific confidence people have that they can cope with high-risk situations without relapsing to their prior behavior.
Temptation -  describes the intensity of urges to engage in a specific habit when in the midst of difficult situations. The three most common are: emotional distress, positive social occasions, and cravings

Critical Assumptions of the Transtheoretical Model and Stages of Change
This model concentrates on the five stages of change, ten processes of change, the pros and cons of change, and self-efficacy and temptation. The assumptions are derived from research and practice:

1. No single theory can account for all the complexities of behavior change.

2. Behavior change is a process that unfolds over time through a sequence of changes.

3. Stages are both stable and open to change just as behavioral risk factors are both stable and open to change.

4.Without planned interventions, clients will remain stuck in the early stages, without inherent motivation to progress.

5. The majority of at-risk/oppressed populations are not prepared for action. One will do better by introducing clients to change through action steps

6. Specific processes and principles of change need to be applied at specific stages if progress is to occur.

Chronic behavioral patterns are under some combination of biological, social, and self-control.

Empirical Support
Conducted by researchers at the University of Rhode Island over the past 23 years.
In a sample of 20,000 members of a health maintenance organization  being evaluated for health behavior change, 40% were in precontemplation, 40% in contemplation, and 20% in preparation(Rossi 1992).

Analysis of pros and cons – the findings suggest:

1. To progress from precontemplation to contemplation, the pros of change must increase.

2.  To progress from contemplation to action, the cons must decrease

3. When clients are in precontemplation, target the pros for intervention and save the cons for clients who have progressed to contemplation.

4. Before a client progresses to action, the pros and cons should cross over, with the pros becoming higher than the cons. This suggests that the client is ready to progress to the action stage.

5. Strong and weak principles of progress:

(A.)    The Strong Principle

PC>>>A = 1 SD increase in Pros
Progress from contemplation to action involves an increase in the pros of changing.

PC>>>A = .5 SD decrease in Cons
Progress from precontemplation to action involves approximately an 0.5 SD decrease in the cons of changing.

Relationship between Stages and Processes of Change

The processes of change cannot be entirely integrated. Some are incompatible. (see table).
To help clients progress from precontemplation to contemplation, such processes as conscious raising and dramatic relief.
To help clients move into action from precontemplation, processes such as contingency management, counterconditioning, and stimulus control are appropriate.
In utilizing these for moving from precontemplation to contemplation would be a grave mistake.

Remember, The Transtheorectical Model is a dynamic theory of change and it MUST remain open to modification as more students, researchers, professionals and practitioners apply the stages to a growing number of theoretical and behavioral problems.

"The people with the problems will have the solutions." - Eleanor Roosevelt (1884-1962)