Whether you are thinking about changing your diet, changing a relationship, changing your career or changing an addiction, how to change is predictable, according to Prochaska, Clemente and Norcross. In their article “In search of How People Change: Applications to Addictive Behaviours,” they describe five basic stages of the prediction to change as:
Pre-contemplation (happy to not change behaviour)
Contemplation (considering changing behaviour)
Preparation (deciding how to change behaviour)
Action (learning to change behaviour)
Maintenance (changing behaviour with pre-contemplation)
Prochaska and DiClemente’s trans-theoretical model of behavioural change (TTM) has provided a basis for developing effective interventions into health behaviour change since 1983. The model attempts to describe how people modify a classified unhealthy behaviour through its exchange with a classified healthy behaviour. TTM heavily relies on the change capabilities of the individuals involved in its processing. It provides a peer supported framework for therapists working with people who are generally against changing who they are because of control issues. TTM is a way of describing the process by which people can overcome an addiction should they have the desire to do so.
TTM stages of change can be applied to a range of other behaviours that people want to change, but have difficulty doing so; But this model is most widely recognized for its notations in treating people with addictions. It was developed as a result of extensive 1970’s research into how change occurs in therapeutic settings and the outcome said through therapeutic ‘chaos’. Proschaska’s finding was that therapeutic behaviour change was a ‘battlefield’ of therapeutic differentials and he decided to bring them all together under an umbrella labelled CHANGE.
Today, TTM is embraced by motivated, goal oriented and cognitive strengths based, person centred approaches to change psychology as opposed to the confrontational and almost pathological therapeutic differential approaches of the early 20th century. Yet, despite innovative changes in the differentials of strategic change approaches, one fact remains and that is without human intent TTM just looks good on paper.
In TTM, the five main stages of intent are pre-contemplation, contemplation, preparation, action and maintenance and they all contain relapse because of the conflicting intentions of those involved.
These stages of intent can be represented as a stairway to heaven, labelled in boxes or drawn in a circle, and therapists can suggest that people go through these stages in sequence. Yet, in reality, the model lives like Mr Squiggle scribbling between stages, striking backwards and forwards, and colouring in more than one stage at a time. TTM is an excellent guide that works particularly well as an open for business goal changing tool. It also provides a way to promote an understanding about what kind of housing change can be processed in. However, what goes on within that housing is relatively up to all participants involved in the behaviour changing process. At the very least TTM provides hope that addictive behaviours can be changed. Hope seems to be the intent of Prochaska Ph.D, TTM’s co-author, who researched change psychology in the name of his father who died in denial from an untreated addiction. TTM is, without a doubt, altruistic if not openly optimistic. For those seeking a model of intention to change, it would be fair to say that TTM supports the most positive.
Clinicians Slater, Daniel and Banks (2003) in the Complete Guide to Mental Health for Women, rely on the trans-theoretical model in their explanation that, during the pre-contemplative stage, individuals are not thinking about change. Instead, they might be feeling out of control from a large dose of denial where they probably are disregarding any consequential impacts, of their addictive behaviour, on those closest to them.
Therapists, considering the pre-contemplation stage, can help to identify hopeful, if not passive, expressions of the desire to change in addicted individuals. Whether or not those individuals hear the cry of help is another matter. In this stage it is important to remember that the individual with the addiction generally has very different priorities about what constitutes health, than their therapist, lover, friend or relative. Should the goal be about increasing awareness about the need for behavioural change, an individual struggling with lack of personal awareness, about the impacts of their behaviour on others, might need to be encouraged to answer the following self-directed questions.
- What has to happen to me for me to recognise that I have a problem?
- What warning signs are telling me that there is a problem?
- What is the problem?
If individuals are unable to ask themselves these questions, it is highly likely that they are pre-contemplative. The term pre-contemplation can be construed, when used to consider how to change addictive behaviour, because the characteristics of this stage are generally denial, if not ignorance, that the problem lies with the pre-contemplator. While pre-contemplation may provide a reason for why a change should be considered, it is not part of the change process of any individual who does not consider they have any reason to change. Pre-contemplation may well be a desire of the clinician, lover, friend or relative of the addicted individual that s/he should be labelled as pre-contemplative, but the reality is that, only the mind considering the individual as having an addiction in need of being changed can be pre-contemplative if using TTM. Therefore, TTM pre-contemplation for an individual does not exist unless they demonstrate awareness of its existence by agreeing to enter into therapy. How to introduce awareness of the need for controlled change is worth considering, if you find yourself trying to help another individual to recognise that they have an addiction, that is influencing your ability to live a healthy life or your ability to help them live a healthier life. Just because an individual is attending a therapy session or appearing to listen to you, does not mean that they understand what you are suggesting. They may have also been coerced into attending and /or appearing to listen to you by another. The addictive behaviour may be supporting any number of historical personal “stories” that are unable to be identified in the pre-contemplative stage. It is reasonable for anyone in the pre-contemplative stage to not consider their behaviour to be a problem. It may well be that they have not experienced any negative consequences of their behaviour, or the positive benefits of their behaviour far outweigh the negative consequences under consideration. If the addictive behaviour is not illegal or causing any physical or mental harm to anyone other than the addict, the addict may not be interested in hearing about how their health and/or relationships with others could or would be improved by living a life free from their present addiction. Here, a different trans-theoretical model may be required to stimulate the pre-contemplative stage of TTM into contemplation and the ethical and moral dilemmas, not to mention the mental health consequences of inducing pre-contemplation, would be worth considering here. As far as this model of intention to change is concerned, if an individual does not enter pre-contemplation willingly, this model is unable to be performed sequentially. However, this does not mean that any of its stages is unable to be experienced by the addict. It just means experienced by whom, the carer or the cared for. Change will continue to occur in the lives of all trying to control it, irrespective of whether or not pre-contemplation happens or not. Life changes have a way of happening with trans-theoretical models as well as without them. In this way open-mindedness and flexibility is crucial when considering matters of addiction. It can also be useful to consider who desires the change and why when planning to use any trans-theoretical model on others as well as on yourself. As Prochaska understood resistance to change to be about the need for freedom of control, it might be an idea to ask the question ‘who has the freedom to change?’, when considering issues arising in the pre-contemplation stage of Prochaska and DiClemente’s TTM. The individual who has the freedom to change their perspective when utilising TTM, also has the freedom to change their mind, but do they have the freedom to change the minds of others despite having the authority to try to do so.
Individuals, who are fighting control issues, generally do not have enough freedoms in their mind to change their mind as much as someone who is not fighting control issues. In pre-contemplation, how to free the mind is worth contemplation.
Contemplation is the second part of the trans-theoretical model being explored in this article. Contemplation occurs when you, as the pre-contemplative therapist, lover, relative, friend or addict begin to weigh the benefits and costs of the addictive behaviour. Ambivalence towards the addictive behaviour is a normal part of this processing of behavioural change because in this hopeful stage, it is important to remember, that the person contemplating change may be the therapist, lover, friend or family member and not the individual with the addiction, unless the person with the addiction willingly freed the pre-contemplative stage with the sense that something about them needed to change. If the consciousness of the person facing change isn't raised in the pre-contemplative stage, relapse and TTM stagnation can be the result. Self-directed questions arising from pre-contemplative stagnation could be:
- What are my reasons for not wanting to think about changing my behaviour?
- What are the barriers against my thinking about the need for change?
- What or who could help me to open up those barriers?
The goal of these questions is to examine the benefits and costs of changing the identified behaviour and to begin building the peer supports needed to maintain the identified change through its changing process.
Clinician/Author’s Slater, Daniel and Banks (2003) advise their readers that any stages can occur at any time, in any order and in any way. They also consider that addict’s can to be more open to receiving information about the possible consequences of their addictive behaviour when in the Contemplative stage than any other. Here, the therapist may also consider their client as being more open to learning about different strategies for controlling or quitting the addictive behaviour. However, these considerations are open for interpretation. This is because people with addictions have the ability to remain in the contemplation stage for many years. They may move forward to the next phase, the preparation stage, or they may move backward to the pre-contemplation stage. It all depends on what the addict is personally gaining from their behaviour, known or unknown, despite any empowerment encouragements by a TTM practitioner. Empowerment, at its worst, can reduce contemplation about addictive behaviour by promoting frustrated and/or confused thinking in an addict fearfully determined to remain in denial. That contemplator's typically benefit from non-judgemental information-giving and motivational approaches to encouraging change (as opposed to confrontational methods) is also open for therapeutic interpretation. However, despite the intention of the TTM contemplation stage to conclude with a marked preparation of the potential benefits of goal setting behavioural change, it can also end with a relapse that reinforces the record to be stuck in an almost permanent contemplation. This may be because contemplation can represent itself as a behavioural change away from emotional benefits the contemplator would prefer to hang onto, for whatever reasons, as opposed to gaining emotional release through a change in explanatory style. In this way, issues of grief and loss, trauma or personality disorders may surface along with personality strengths in anxiety or resilience. Should optimism prevail, self-assessment questions in the Contemplation stage might be:
- What do I want to change?
- Is there anything preventing me from changing?
- Who or what can help me to change the behaviour I have identified as in need of changing?
During the TTM preparation stage, those involved might be making small life changes in preparation for perceived larger than life changes. For example, if the behavioural change decision is about quitting smoking, the addict might smoke a lighter brand of tobacco which would automatically put further questions of non-smoking on the behavioural change agenda. Gathering and sorting information about how to change, a no longer desired behaviour, can help to move an individual from Contemplation into the Preparation stage of this trans-theoretical model. However it is important to note that the individual, undergoing the behavioural change, must be the one who considers the ‘old’ behaviour as one no longer desired because s/he is going to be the one who has to throw it away.
In the preparation stage, a person facing behavioural change might experiment with small changes in accordance to what they think needs to be changed. For example., Michael might limit his alcohol intake to 200mls of wine with dinner (instead of the usual 750mls), he might smoke a marijuana joint once a week instead of once a night and he might switch from Valium to a less addictive prescription to help him sleep at night and he might stop watching horror on the television all together. Michael may fail or succeed in achieving these goals, again depending on his emotional attachments to his ‘old’ behaviours and his awareness and personal sense of control freedoms supporting his ability to change.
As contemplation means to consider or think about something deeply, Michael might use contemplation to reflect on his preparation stage attempts of withdrawal. Again, despite the contemplation stage being given as separate from the preparation stage or the action stage of the trans-theoretical model, mental health clinicians Slater, Daniels and Banks (2003) defend that they are interlinked and can occur at any time and in any sequence.
The preparation stage of TTM generally means that the individual has moved into forward planning. In this way the individuals involved may find themselves also moving from a pessimistic explanatory style into a slightly more optimistic one. Also, depending on the mental health ‘mood’ issues of the addict, the therapist may also need to add other mental health therapeutic models into their processing of preparation stage outcomes.
In an ideal world, where TTM pre-contemplation represents positive cognitive strengths, self-development questions, of preparatory decision-making, might be:
- What are the behaviour triggers I intend to change?
- What behaviours do I intend to reduce for the identified change?
- What behaviours do I intend to increase for the identified change?
- Who will and what can, help, resource and support me?
During the action stage, attempts at change are evident enough to be noticed by others because of the direct actions taken to change behaviour. Resolutions may fail because the previous steps have not been given enough thought or time. However, goals identified and refined in the preparation stage, if they are clearly agreed as ready for actioning, have a reasonable chance of succeeding.
In Michael's case, he identified that he wanted to stop drinking alcohol, smoking marijuana, taking Valium and sitting in front of the TV night after night. The fact that he both identified and was willing to action behavioural changes meant that Michael was ready to trial a reduction, along with an increase, in drug related and other habitual behaviours. One of his answers to his ‘what can help me?’ questions was ‘relaxation and meditation skills’. Therefore, one of Michael's preparatory intention’s was to reduce his drugs consumption by replacing drug absorption behaviours with the mindful absorption behaviours of relaxation and meditation. Therefore, the strategy of Michael changing his management of his anxiety from medicating it with drugs to medicating it with meditative and relaxing mindfulness was to agree to learn new habits while dis-regarding old ones. Michael embarked on learning something new in the hope that his learning efforts would help him overcome the need for drugs. Given clinical research evidence into how drugs change the synapses of the brain, it would be fair to say that Michael's Action Plan is an ambitious, if not hopeful one that requires a fair amount of professional as well as peer support.
Clinicians Slater, Daniel and Banks (2003) suggest that maintenance of this new behaviour would be most successful if the person is able to integrate the new coping skills into a new pattern of relating. Keeping in mind that relapse is part of any changing process, it is important to quickly forgive, action review preparation strategies, and get straight back into the changing process with minimal grief. Should the new coping skills not produce the desired result, constantly remembering that relapse is very much a normal part of TTM helps. In this way, people should never be encouraged to feel demoralised when TTM relapse surfaces, which it will because it is there in every stage of TTM just waiting in the wings like a pessimism.
The interesting thing about hopefulness is that its balancing agent is hopelessness and its balance sheet is reality. Should feelings of hopelessness occur, they must be re-balanced with hopefulness and this can be achieved using a model like TTM which, as mentioned before, is optimistic. Slater, Daniel and Banks (2003) also advise that “remaining flexible, creative and open during the TTM Action process is "critical” because learning by changing requires fluidity in line with the intelligences and capabilities of those involved in its Action stage.
Understanding TTM process of change can also help everyone involved in its stages to develop support mechanisms for the individual undergoing the ‘controlled’ change. TTM processes of change offers a framework in which questions can be raised about how to:
- raise behavioural awareness
- release behavioural emotive’s
- appraise behavioural impacts
- liberate behavioural opportunities
- appraise behaviours
- re-engineer behaviours
- support new behavioural relationships
- substitute and condition old for new behaviours
- reward new behavioural patterns
- commit to healthy behavioural habits
It is important to remember that any change processor who uses a theory of change as a basis for change, is attempting to control the change process in favour of a desired outcome. When considering control issues, it is far easier for an individual to change their mind themselves than it is for them to change the mind of another. People who are employed to help the individual to change can only do so with the individuals awareness, permission and willingness to learn how to both give up and gain mind change stimulants. Coercion's, such as persuasion, might encourage another to agree, but agreement without a sense of personal freedom from extrinsic control influences is a surface agreement and no guarantee of cognitive intent, understanding about what is going on, change of heart or change of mind. TTM is a model where the freedom to change rests with those who chose to act under its umbrella. In this way, the freedom to change rests purely within the confines of who is controlling TTM and why. Utilising a person centred approach to TTM that controller would be the person with the mental health considerations.
The maintenance phase of TTM involves successfully avoiding former behaviours and reinforcing new behaviours. During this stage, individuals may become more assured that they will be able to continue their behavioural changes as the changed behaviour fades into familiarity, as reinforced through habitual use. Individuals may also become doubtful, should the changing process not meet their expectations and they may fall into remission. Letting go of maintenance with a burst of innovative change actions might help to undo the relapse, depending on the motivations of the individuals involved.
If you are trying to maintain a different behaviour, assure yourself that it is normal to relapse, struggle up, brush yourself down and start again. Tomorrow you will see the relapse as the molehill it was, instead of the mountain it felt like. Relapses are common and are a part of the process of learning new habits. It can take anywhere from two to ten years to rehabilitate an unhealthy addiction into a pattern of healthier behaviour and even then, reasons to keep old habits alive die hard. A sense of loss is a normal part of any rehabilitation process and this will challenge all attempts at behavioural change. Identifying and developing effective ways of coping with stressors is crucial during any TTM process. The maintenance stage can be the most challenging, should the stresses of life re-surface unhealthy addictive ways of coping.
James Prochaska Ph.D
The most important part of any change process is being aware that there is no clear way of giving up an addiction and re-placing it with a different habit. Healthy habits become clearer the more the getting well journey is experienced and shared and this is essentially what TTM is all about, a sharing experience of mutual committed people.
James Prochaska wanted to help his addicted father so much, he devoted much of his life, before and after his father died, to finding out how he could help others who were living with addictions; particularly those who were not able to recognise it, just like his Dad. His conclusions that there is no one prescription for change, or easy remedy when considering the mental health issues surrounding changing addictive behaviour, led him and Carlo C. DiClemente Ph.D, to develop an overarching framework of change in which all involved, in changing social behaviours, could meet under its umbrella to apply their preferential therapies of change.
So why not pat yourself on the back for taking on the challenge of behavioural change? It may be emotionally difficult to reach an initial decision to change an attachment to an unhealthy behaviour, but it certainly will not be difficult to recognise the benefits of forgetting that behaviour once the healthier one has settled in. This is why the real action in TTM rests solely on your intention to win at your very own changing game.
© Chris Tyne, 2013
- Slater, L., Daniel, J, H., Banks, A, E., (2003) The Complete Guide to Mental Health For Women: Beacon Press.
- Hartney, E., Orford, J., Dalton, S., Ferrins-Brown, M., Kerr, C. & Maslin, J. (2003) Untreated Heavy Drinkers: a Qualitative and Quantitative Study of Dependence and Readiness to Change.
- Segana, C., Borlanda, R. & Greenwood, K. (2006) Can Transtheoretical model measures predict relapse from the action stage of change among ex-smokers who quit after calling a quit line?
- Velicer, W. F., Hughes, S. L., Fava, J. L., Prochaska, J. O. & DiClemente, C. C. (1995) An empirical typology of subjects within stage of change