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Transtheoretical Model

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Transtheoretical Model founder
Prochaska and DiClemente (1982)
Transtheoretical Model essence
Behavior change is a process that occurs in stages
Constructs of the theory include not only the stages of change, but also the
processes of change and self-efficacy
Transtheoretical Model provides practitioners
a way in which to understand how clients change, as well as what motivates them to change.

It can be used to teach case conceptualization, and build appropriate stage related interventions into treatment plans.
Central organizing construct of the model
Stages of Change
The Transtheoretical Model views change as
a process involving progress through a series of five stages
5 stages of change
1) Precontemplation

2) Contemplation

3) Preparation

4) Action

5) Maintenance
The goal of the model is to
determine which stage of change the client is in and assist the client in progressing through subsequent stages
The change process is
cyclical, and individuals typically move back and forth between the stages, and cycle through the stages at different rates.
Individuals can move through stages
quickly. Sometimes they move so rapidly that it is difficult to pinpoint where they are because change is a dynamic process
Not uncommon for individuals to
linger in the early stages
For most substance-abusing individuals, progress through the stages of change is
circular or spiral in nature, not linear. Relapse is normal in this model because many clients cycle through diff. stages several times before achieving stable change
Key Points
1) Change should be thought of as a process that may take months or even years.

2) Many 'behavioral change' programs are characterized as lasting for a predetermined number of weeks and consisting of structured content. Such programs do not take into account the uniqueness of each client, and the subtle changes that often go unnoticed. Some clients will respond very positively and make significant changes. However, for those who do not, they are said to lack motivation and/or willpower.

3) We tend to acknowledge change has occurred when we see a change in behavior, e.g. a period of abstinence, leaving an unhealthy relationship. These are then categorized as successes.

4) The stages of change model suggests that change occurs along a
continuum and therefore cannot be measured by one criteria alone, i.e. a change in a specific problem behavior. If we view change as a process then we can report positive changes each time an individual progresses from one stage to the next. Small steps constitute changes and should therefore be recognized and supported.

5) Since clients differ in their readiness to make changes Prochaska
and DiClemente suggest matching interventions to the appropriate stage (or readiness). "Success, moreover, is defined not just by changing the behavior but by any movement toward change, such as a shift from one stage of readiness to another."

6) There is an emphasis on the maintenance of change. Relapse is
common and should not be seen as a sign of failure. Clients are encouraged to learn from their relapse.

7) A great deal of importance is placed on the decision making capability of the individual
Motivational interviewing is guided by several principles: (7)
• Avoiding argumentation
• Rolling with resistance
• Expressing empathy
• Developing discrepancies
• Supporting self-efficacy
• Counselors avoid harsh confrontations
• MI counselors emphasize the need for change and
increase confidence and hope that change can occur
Precontemplation Description
Individuals in the pre-contemplation stage are often viewed as unmotivated clients who are not ready for change.

They may not believe they have a problem, and state they do not intend on making any changes in the near future (not within the next 6 months).

It is also possible these individuals may not fully realize the negative consequences of their behavior.

The goal of the pre-contemplation stage is to raise the client's awareness and have them consider change as a possibility.

Ultimately, we are assessing the possibility of moving client to the contemplation stage.
Precontemplation example for older adults and exercise behavior
Some older adults view exercise as a behavior for the young and believe it is not good for people with certain health conditions. This exhibits a case where being uninformed explains why change to a healthy behavior, exercise, is avoided. Being informed could create change though
Another reason, besides being misinformed, why people are in the precontemplation stage is
past experience
Knowing why people are in the pre-contemplation stage is useful when
trying to understand why unhealthy behaviors are not changed
Precontemplation Techniques (6)
• Validate client's feelings and thoughts regarding lack of readiness

• Agree with the client that it is her/his decision whether or not to change.

• Encourage re-evaluation of current behavior

• Self-exploration, not action, should be the goal

• Raise awareness

• Ask about awareness of risks
Precontemplation Questions to Ask
• "What would have to happen for you to know that this is a problem?"

• "What would you consider as warning signs that would let you know that this is a problem?"

• "What things have you tried in the past to change?"
Precontemplation Strategies
• Use self motivational statements with questions such as:
- "How does this concern you?"
- "What do you think will happen to you if you do not make any changes?"
- "What has your alcohol/drug use prevented you from doing?" • If client is reluctant, try asking:
- "What would have to happen for you to know that this is a problem?"
- "What would you consider as warning signs that would let you know that this is a problem?"

• Try not to assume client believes he/she has a substance abuse problem. Instead, start from the viewpoint "do you think there is a possibility that substance abuse is a problem for you?"

• Try not to come from the 'counselor as expert' point of view.
• If client is willing, explain the stages of change model. Involve them in the process.

• Ask subject what he/she would like the next step to be
Individuals in the pre-contemplation stage rarely show for treatment by choice. Most are required to attend treatment. One goal is therefore to create thoughtfulness within the client, such that they may question their risky behaviors. When you first meet: (3)
- Establish rapport and trust

- Explore events that precipitated treatment entry

- Commend clients for coming
Strategies to get a patient to move from pre to contemplation
- Readiness ruler

- Get an idea of a typical day

- Explain risks and effects of unhealthy behavior
Readiness Ruler
The simplest way to assess the client's willingness to change is to use a Readiness Ruler or a 1 to 10 scale, on which the lower numbers represent no thoughts about change and the higher numbers represent specific plans or attempts to change. Ask the client to indicate a best answer on the ruler to the question, "How important is it for you to change?" or, "How confident are you that you could change if you decided to?" Pre-contemplators will be at the lower end of the scale, generally between 0 and 3. You can then ask, "What would it take for you to move from an x (lower number) to a y (higher number)?"
When people move from precontemplation to contemplation it means they recognize
there is a problem and they are starting to think about changing
Things that get people thinking about change
cues to action, such as newspapers, magazines, TV, news reports, family, friends, health care professionals
Contemplation Description
During the contemplation stage, individuals are ambivalent about changing. They are aware their behavior is resulting in negative consequences and may be considering making a change. However, no commitment has been made to take action. One could say these individuals are 'sitting on the fence'. Contemplation is characterized by ambivalence and feelings of being 'stuck'.
Contemplation Techniques (4)
• Agree that it is her/his decision whether or not to change

• Encourage evaluation of pros and cons of behavior change with the goal of helping tip the balance toward change

• Identify and promote new, positive outcome expectations

• Have client state their next step
Contemplation Questions to Ask
• What are the pros and cons for not changing?
• What are the pros and cons (costs/benefits) for changing?
• Why do you want to change at this time?
• What would keep you from changing at this time?
• What are the barriers today that prevent you from changing?
• What things (people, programs and behaviors) have helped in the past?
• What would help you at this time?
Contemplation Strategies
Cost/Benefit Analysis
decisional balance
the process of weighing the perceived pros and cons or costs and benefits of the new behavior against the old
when it takes more than 6 months to make a decision, this is
behavioral procrastination or chronic contemplation
Preparation Description
Individuals in the preparation stage intend to take action (within the next month) and may already have had previous failed attempts at trying to change. Some may have already 'tested the waters' by engaging in small changes, e.g. going without a drink for a night. Client may have an initial plan.
The preparation stage begins once
the decision to change the behavior is made
Preparation lasts only about
1 month
Preparation stage used to
make a plan, obtain any tools needed, learn new skills, acquire resources of money or support, housing, etc.
In the case of a smoker, the preparation stage may mean
setting a quit date, obtaining a prescription for a nicotine patch, or signing up for a smoking cessation program
For a woman at risk of osteoporosis, preparation may mean
learning exercises to prevent bone loss, attending a lecture on new treatments, buying weights or new sneakers, or developing an exercise plan
Preparation Techniques (3)
• Identify and assist in problem solving, e.g. identify barriers and brainstorm solutions

• Help identify client resources such as social supports

• Encourage and support small initial steps
Preparation Questions to Ask
• What barriers do see ahead, and how can you minimize or
eliminate them?

• Who can you turn to for support?

• What kind of support do you feel you need the most, and where can you get this support?
Preparation Activities
• Identify client's needs/wants/desires

• Emphasis is on outlining and developing plans in order to break the pattern of substance abuse, and find other ways of meeting clients needs

• Goal Setting
- Use the miracle question. - Where do you want to be 6 months, 1 year, 5 years from now? What will life look like for you?

• Encourage client to come up with their own plans, and have them state specifically how they will achieve them

• Identify alternative ways in which to meet needs. Identify areas of support that can be utilized

• Commend client for deciding to change because they always have the option not to

• Create an action plan

• Have client state their next step
Once preparation is complete,
the action stage begins
Action is when
people are in the active process of modifying their behavior to address the problem they identified in earlier stages. These modifications tend to be observable changes and to be recognized and rewarded by others
Action Description
Individuals are actively changing their behavior and/or environment in a positive manner in order to address their problem (s). Client has changed behavior for less than 6 months.
Action Techniques (3)
• Focus on restructuring cues and social support

• Bolster self-efficacy for dealing with obstacles

• Combat feelings of loss and reiterate long-term benefits
Action Questions to Ask
•Use strategies listed for Preparation Stage if necessary

•Continue consolidating client's motivation for change

•What actions have you taken?

•What has helped/not helped?

•What might you do to replace things that have not helped?
Action Strategies
• Elicit client's sources of support

• Understand client is trying to fill a void having given up their substance of choice

• How can this void be filled with healthier behaviors so that they client can meet their needs
In order for action to be successful, it needs to be measured against
criteria previously determined to reduce the risk of disease
For a smoker, the change that needs to be accomplished is
quitting; switching to a low-tar cigarette or cutting down by half is not enough
For the woman at risk of osteoporosis, the change that needs to be accomplished is
improvements in bone density measurements
__________ is the final stage of change
Maintenance
Maintenance Description
Maintenance involves the individual proactively working to prevent relapse. Begins after 6 months of being in the active stage and continues for at least 6 months. Change is continuous; it does not end at Maintenance.
Maintenance Techniques (3)
• Conducting a Functional Analysis

• Developing a Coping Plan

• Plan for follow-up support
Functional Analysis
an assessment of the common antecedents and consequences of substance use.

Through functional analysis, you help clients understand what has "triggered" them to drink or use drugs in the past and the effects they experienced from using alcohol or drugs. With this information, you and your clients can then work on developing coping strategies to maintain abstinence.

"Tell me about situations in which you have been most likely to drink or use drugs in the past, or times when you have tended to drink or use more. These might be when you were with specific people, in specific places, or at certain times of day, or perhaps when you were feeling a particular way." Make sure to use the past tense because the present or future tense may unsettle currently abstinent clients.

Once the client has finished giving antecedents and consequences, you can point out how a certain trigger can lead to a certain effect. First, pick out one item from the Triggers column and one from the Effects column that clearly seem to go together. Then ask the client to identify pairs, letting the client draw connecting lines on the paper or blackboard.

For trigger items that have not been paired, ask the client to tell you what alcohol or drug use might have done for her in that situation, and draw a line to the appropriate item in the Effects column. Sometimes there is no corresponding item in the Effects column, which suggests that something has to be added. Then do
the same thing for the Effects column. It is not necessary, however, to pair all entries.

With this information, you can develop maintenance strategies. Point out that some of the pairs your client identified are common among most users. Next, you can say that if the only way a client can go from the Triggers column to the Effects column is through substance use, then the client is psychologically dependent on it. Then make clear that freedom of choice is about having options--different ways--of moving from the Triggers to the Effects column. You
can then review the pairs, beginning with those the client finds most important, and develop a coping plan that will enable the client to achieve the desired effects without using substances

(Miller and Pechacek, 1987)
The most difficult phase is
permanently incorporating the new behavior, or the change, into one's lifestyle
The second construct of the TTM is
self-efficacy
SE plays a major role in
how successful people are in changing their behavior and maintaining the change
While the stages of change help us understand when people change their behavior, the processes of change helps us understand
how change occurs
10 processes of change
Cognitive Processes

1) consciousness raising

2) dramatic relief or emotional arousal

3) environmental reevaluation

4) social liberation

5) self-reevaluation

Behavioral Processes

6) stimulus control

7) helping relationships

8) counter conditioning

9) reinforcement management

10) self-liberation
Consciousness Raising
process whereby people obtain information about themselves and the problem behavior

becoming aware of the problem and the causes and consequences of continuing a particular behavior
Consciousness Raising example
"I didn't realize fast food was bad for me until I saw Super Size Me"
Dramatic Relief (emotional arousal)
being able to express feelings about or react emotionally to the behavior in question
Dramatic Relief example
For the fast food junkie, this might mean getting upset with fast food commercials on TV
Environmental Reevaluation
looking at the behavior in light of its impact or effect on the physical environment
Environmental Reevaluation example
understanding the environmental effects of secondhand smoke or the environmental damage caused by pesticide use
Social Liberation
the process whereby options or alternatives are sought that support the new behavior
Social Liberation example
For the fast food junkie, this would mean ordering a salad at a fast food restaurant
Self-Reevaluation
the process in which people look at themselves with and without the problem behavior and assess the differences in their self-esteem
Self-Reevaluation example
for fast food junkies, it means asking "If I stopped eating fast foods, would I be healthier and happier, and would I like myself better?"
Stimulus Control
when people remove the cues or triggers for the problem behavior from their environment
Stimulus Control example
the fast food junkie might drive to work on back roads rather than the highway in order to avoid passing fast food restaurants
Helping Relationships
relationships with people who act as a support system for changing the unwanted, unhealthy behavior
Helping Relationships example
might be a roommate who agrees to keep only fruit to snack on in the room
Counter Conditioning
a healthier behavior is substituted for the unhealthy one
Counter Conditioning example
fast food junkie might bring fruit to eat in the care on the way home from work instead of stopping for fast food
Reinforcement Management
has to do with rewards and punishments
Reinforcement Management example
a reward for not eating fast food during the week might be a dinner at a nice restaurant with friends
Self-Liberation
people choose to change their behavior, believe they can, and commit to making the change
Self-Liberation example
choosing to stop eating fast food
Processes of change help people move through the stages of change. Thus, different processes for different stages:
Pre-contemplation to Contemplation: (increase awareness of behavior as being a problem)
- consciousness raising
- dramatic relief
- environmental reevaluation
- social liberation
- counter conditioning

Contemplation to Preparation: (all are used, but these mostly- helps people talk with others and express feelings about change, to look at themselves with respect to the problem behavior, and to evaluate types of support)
- helping relationships
- self-reevaluation
- social liberation
- dramatic relief

Preparation to Action:
- self-liberation

Action to Maintenance: (help sustain new behaviors, have support available, avoid triggers, reward change)
- counter conditioning
- helping relationships
- reinforcement management
- stimulus control
Article at end of chapter
Brought together the pressing problem of alcohol abuse on college campuses and promising solution-- stage-based interventions applied at multiple levels
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