Which of the following is a stage of change in the transtheoretical model?

Transtheoretical Model of Health Behavior Change

It is difficult to counsel families to change a behavior when they may not agree there is a problem or when they are not ready to build an intention to change. Thetranstheoretical model of health behavior change places an individual's motivation and readiness to change on a continuum. The premise of this model is that behavior change is a process, and as someone attempts to change, they move through 5 stages (although not always in a linear fashion):precontemplation (no current intention of making a change),contemplation (considering change),preparation (creating an intention, planning, and committing to change),action (has changed behavior for a short time), andmaintenance (sustaining long-term change). Assessing a patient's stage of change and then targeting counseling toward that stage can help build atherapeutic alliance, in contrast to counseling a patient to do something she is not ready for, which can disrupt therapeutic alliance and lead to resistance.Table 17.2 further describes stages of change and gives examples for counseling that targets the adolescent's stage of change in reducing marijuana smoking.

The transtheoretical model

The transtheoretical model (TTM) (Prochaska et al., 1994, 2002; Prochaska and Velicer, 1997) is a dynamic theory of change based on the assumption that there is a common set of change processes that can be applied across a broad range of health behaviors. TTM conceptualizes behavior change as a process involving a series of six distinct stages: precontemplation, contemplation, preparation, action, maintenance and termination. These stages are transtheoretical, and integrate principles of change from across a variety of theories of intervention. In the early stages of change, individuals apply cognitive, affective and evaluation processes to progress forward; during the later stages, commitments, conditioning, contingencies, environmental controls and support to move toward maintenance and termination (Procheska et al., 2002). Each stage brings an individual closer to making or sustaining behavioral changes. Unique variables, processes and benefits versus costs of behavior change define each stage, and interventions based on this model are meant to increase motivation to change and to resolve ambivalence about change. At times individuals may move back to earlier stages (relapse), but movement through the stages recommences the process of change. TTM is one of the most widely cited and utilized models for interventions regarding health behavior changes. A criticism of TTM is that such distinct stages can not capture the complexity of human behavior; the stages may be more properly understood as mere points on a larger continuum of the process of change. Motivational interviewing (described above) is a technique that is also consistent with the transtheoretical model.

Transtheoretical model

An individual theory, the TTM has four main constructs—stages of change, decisional balance, self-efficacy, and processes of change. James Prochaska, who with colleagues first described the TTM, hypothesized that individuals cycle through the stages as they adopt a specific behavior, from precontemplation (not thinking about changing the behavior), to maintenance (having performed the behavior consistently for at least 6 months).52,53 Together with the other three stages (contemplation—feeling ambivalent about the behavior; preparation—committed to changing the behavior but hasn’t started yet; action—engaged in performing the behavior), the five stages describe varying degrees of readiness to engage in a specific behavior. The processes of change can be used as interventions to move an individual from one stage to another and include cognitive (thinking about the influence of the behavior on self and others) and behavioral (cues and rewards) activities. Decisional balance, weighing the pros and cons of the behavior, influences movement from one stage to another, as does self-efficacy. The higher the list of pros for performing the behavior, the closer to the action stage the individual will move, and the higher an individual’s self-efficacy, the more likely the person is to be performing the behavior. It is important to note that the stages are not meant to be linear, but cyclical, in that individuals don’t progress from one stage to the next necessarily. For example, individuals who stop smoking “cold turkey” can move from contemplation to action without spending time in the preparation stage.

Identifying the stage of change an individual is in allows targeted interventions to be developed that both respect the individual’s readiness to change and resonate with the person’s thoughts and feelings about the change. For example, if a patient is in the contemplation stage for performing his home exercise program daily, it would be appropriate to discuss the pros and cons of the behavior and identify strategies to overcome the cons or barriers and ways to increase the pros or benefits. This approach will ideally move the individual to the preparation or action stage where performing the home program can be achieved. Geertz and colleagues54 used TTM constructs in a study with 40 subjects with multiple sclerosis aged 35 to 65 with moderate disability. Subjects in the experimental group participated in 16 to 24 standardized exercise sessions in 8 to 12 weeks individually tailored to each participant based on baseline stage of change, self-efficacy, barriers to exercising, and social support. Following the intervention, subjects in the experimental group reported a higher stage of change compared to the control group; self-efficacy stayed the same compared to the control group in which it decreased over time, and perception of barriers changed to a less restricting view in experimental group subjects.54

Nicotine Helplines and the Transtheoretical Model of Change

Although individuals committed to smoking cessation appear to benefit most from quitline support, research suggests that quitlines may be efficacious for individuals across a wide range of readiness to change. Previous research suggests that many first-time callers to smoking quitlines have already made plans to quit, and that these individuals tend to benefit most from the quitline intervention.90,213 Helgason and colleagues90 found that 22% of first-time callers were in the action stage (had quit for 6 months or less), 76% were in the preparation (planning to quit within the next 4 weeks) or the contemplation (interested in trying to quit within the next 6 months) stage, whereas only 2% were in the precontemplation stage (not interested in trying to quit within the next 6 months). Although callers who were smoke free (action/maintenance) at the start of the intervention had the highest likelihood of being abstinent at the end of the study, there were also positive outcomes for callers in the other three stages. Half of the first-time callers in the precontemplation stage advanced to either the contemplation or the action/maintenance stage by the end of the quitline intervention. Similarly, for callers in the contemplation stage at baseline, half progressed to either the preparation stage or the action/maintenance stage, whereas only 10% regressed to an earlier stage.90 Of interest, although this research suggests that quitlines can help move callers from one stage of change to the next (e.g., from contemplation to action),90,154 many quitlines in the United States restrict services to callers who are planning to quit.46

2. INTENTION VS. ACTION

The transtheoretical model makes a clear distinction between the stages of contemplation and preparation, and that of overt action [26, 27]. A further application of this distinction comes from one of the most researched models of the relationship between cognitive-attitudinal factors and health behavior change, the health belief model. This model proposes that three constellations of factors or determinants are associated with the likelihood of change at the individual level: socioenvironmental and demographic factors, the individual's perception of the threat of disease, and the individual's perception of the potential value of treatment [39]. If all these factors point in the direction of favorably perceiving change, a person is considered “predisposed to action,” or intending to act. It is only when a “cue to action” sets a further process in motion that he or she actually moves into action.

Motivational interviewing and stages of change

A transtheoretical model of behavioral change was proposed and developed by Prochaska and DiClemente. Based on this model, motivational interviewing has been successful in the treatment of substance addictions. The model has been adopted in the psychotherapy of problematic Internet use. The principle states that behavioral change goes through successive stages of pre-contemplation, contemplation, preparation, action, maintenance, and termination, and individuals at different stages have different needs and levels of readiness. A therapist should be sensitive to the motivational stage of the patient and respond to his or her needs accordingly. If the patient does not recognize any problem with his or her Internet use, it would not be therapeutic for the therapist to propose an action plan. The goal at this precontemplation stage is to help the patient overcome denial by discussing pros and cons of Internet use and overuse. If the patient is already trying to make behavioral changes, it may be unnecessary or inappropriate for the therapist to continue discussing negative ramifications of excessive Internet use. Support and educational materials are provided according to the patient’s readiness to change. A small study of group therapy applying the principles of cognitive behavioral therapy (CBT), motivational interviewing, and stages of change showed improvements in quality of life and depression measures, but no significant changes in the subjects’ computer-use behaviors.

Readiness for Change

According to the Trans-Theoretical Model of Behavioral Change, an individual's readiness to shift from negative to positive behaviors progresses through the five stages outlined in Table 5-1. The adolescent in the pre-contemplation stage denies the need for change and has no desire or intent to change. An adolescent who perceives gun-carrying as survival cannot yet see the gun as risk and therefore has no reason to relinquish it. If other skills are developed that reduce the sense of vulnerability, the adolescent might progress to contemplation, in which the risk-benefit balance begins to shift. Preparation is actively planning to leave the gun at home, and the action is leaving home without it. Maintenance is the set of ongoing efforts to keep the new behavior intact, such as getting rid of the gun completely.

Enabling attitudinal changes

Readiness to change (see the Transtheoretical model) and self-efficacy (see Social Cognition theory) influence willingness to make behavioural changes. Such changes require perceiving importance of change, confidence to do so and these influence readiness to make specific behaviour changes (Rollnick et al 1999). Discussion should promote behaviour change-talk to help identify the pros and cons of change and work through any ambivalence towards changing (Table 6.3).

Motivational interviewing is a technique for helping people explore their motivations for making changes, based on a collaborative process of listening, exploring values and concerns and guiding to make decisions, respecting autonomy to choose whether to change or not (Rollnick et al 2008). There is a growing body of evidence that it promotes self-management in chronic diseases but has been little evaluated in rheumatic diseases as yet (Shannon & Hillsden 2007). Short training courses are available and texts by Rollnick et al (1999 & 2008) provide practical examples of applying techniques in practice.