(p. 161) The Transtheoretical Approach
Impetus for the transtheoretical approach came from several sources. First and foremost was a discontent with the state of affairs in psychotherapy theory, research, and practice. The narrowness and frequent dogmatism of the proponents of many therapies and the consistent research findings of few differences in outcome between therapy systems encouraged a search for alternatives. Therapy systems focused more on theories of psychopathology and single mechanisms of change than on an exploration of the more extensive process of intentional behavior change. Positive regard, authenticity, living in the here and now, confrontation of beliefs, social interest, conditioning, and contingencies are valuable rules for human functioning but are not sufficient to explain psychotherapy change.
In 1977, Prochaska, with the help of his graduate students, embarked on a journey through the major systems of therapy to seek the commonalities across the boundaries of the most popular theories of psychotherapy. Systems of Psychotherapy: A Transtheoretical Analysis (Prochaska, 1979; Prochaska & Norcross, 2018) represents the culmination of this journey. The map used for the journey indicated that active ingredients identified by theories of psychotherapy can be summarized by 10 processes of change. Although the framework used in this analysis appeared to have face validity, it remained a conceptual integration with no empirical basis.
Since that initial work, we and many collaborators applied and studied the transtheoretical model, created assessment instruments, expanded its scope, and explored its limitations. This research supported our model of change and encouraged us to continue the development of The Transtheoretical (p. 162) Approach: Crossing the Traditional Boundaries of Therapy (Prochaska & DiClemente, 1984). As our applications expanded beyond office-based psychotherapy of psychopathology in individuals to a proactive treatment of health problems in entire populations, we have expanded the model. Changing for Good (Prochaska, Norcross, & DiClemente, 1994) and Changing to Thrive (Prochaska & Prochaska, 2016) are apt titles for helping individuals and populations progress across the stages of change. Hundreds of outcome studies using the transtheoretical model have now been conducted around the world on dozens of health and behavioral problems.
A final impetus for our work was the zeitgeist among psychotherapy practitioners and theorists. We heard the pleas for a more integrated and comprehensive approach to psychotherapy that would take into account the differences in the experiences of therapists and clients. Moreover, in our thinking, an integrative approach should account for how individuals change on their own (unaided by psychotherapy) as well as how individuals change with the assistance of psychotherapy.
The Integrative Approach
The proliferation of psychotherapy systems reflects the complex, interactive nature of psychotherapy. The daily dilemma facing the clinician is what to do, when to do it, with whom, in what way, with which problem. Both in the research literature and in clinical experience, it has become clear that no one system of therapy addresses adequately all these questions.
From our perspective, an integrative perspective will accomplish the following goals:
1. Preserve the valuable insights of major systems of psychotherapy. Trying to reduce all therapy systems to their least common denominator removes their richness.
2. Provide practical answers to pressing questions faced by clinicians. However elegant a theory might be, an impractical, simplistic, or clinically irrelevant integration will never be adopted.
3. Bring some order to the chaotic diversity and divisiveness in psychotherapy but not by merely throwing a collection of techniques into a toolbox to hide the chaos.
4. Offer a researchable alternative to single-system and comparative research designs. Explanation without experimentation will not silence critics of integration or psychotherapy.
5. Generate a systematic approach: a structure or set of principles that are comprehensive enough to include crucial dimensions of the work of psychotherapy and behavior change and, at the same time, provide a perspective that promotes collaboration, creativity, and choice.
The transtheoretical approach attempts to meet these goals by means of four critical dimensions: the processes of change, the stages of change, the pros and cons of change, and the levels of change. In the following sections, we review these four dimensions and their important interconnections.
Processes of Change
An analysis of the 24 most popular theories of psychotherapy (Prochaska, 1979) yielded the first of the four dimensions of the transtheoretical approach: the processes of change. Transtheoretical therapy began with the assumption that integration across a diversity of therapy systems most likely would occur at an intermediate level of analysis, somewhere between overarching theory and specific techniques. Coincidentally, Goldfried (1980, 1982), in his well-known call for a rapprochement, independently suggested that principles of change were the appropriate starting point for integration.
The processes of change, then, may best be understood as a middle level of abstraction between the global theoretical assumptions of a system of psychotherapy and its specific techniques. A process of change represents the activities initiated or experienced by an (p. 163) individual in modifying thinking, behavior, or emotion related to a particular problem. Although there are many coping activities, there appear to be a finite set of processes that represent change principles. In a similar manner, techniques of therapy can be analyzed to see which change process they would draw on or promote. Thus, therapist feedback would provide new information and challenge current thinking about the problem. These therapist activities would enable the individual to engage in more accurate information processing. From a transtheoretical perspective, these activities activate the process of change known as “consciousness raising” in the client.
Subsequent research has driven modifications of our original formulations. That research has consistently yielded 10 distinct processes of change: consciousness raising, self-liberation, social liberation, counterconditioning, stimulus control, self-reevaluation, environmental reevaluation, contingency management, helping relationships, and dramatic relief/emotional arousal.
Our studies indicate that people in the natural environment generally use these 10 processes of change to modify problem behaviors (DiClemente & Prochaska, 1982). Most major systems of therapy, however, theoretically employ only two or three processes (Prochaska & Norcross, 2018). One of the assumptions of the transtheoretical approach is that therapists should be at least as cognitively complex as their clients. They should think in terms of a more comprehensive set of processes and apply techniques to engage each process when appropriate.
Stages of Change
A second dimension of the transtheoretical approach is the stages of change, which reflect the temporal and intentional aspects of change. Intentional change is not an all-or-none phenomenon but a gradual movement through specific stages. Lack of awareness of the stages led some theories of therapy to assume that clients arriving at therapy present in the same stage of change and are ready for the same change processes.
Studies of various outpatient populations (e.g., Carbonari & DiClemente, 2000; DiClemente & Hughes, 1990; McConnaughy, DiClemente, et al., 1989; McConnaughy et al., 1983) have found a variety of profiles on a Stages of Change measure. Clearly, all individuals who come to therapy are not at the same place in terms of their stage of change.
We have identified five stages of change: precontemplation, contemplation, preparation, action, and maintenance. A stage of change represents both a period of time and a set of tasks needed for movement to the next stage. Although the time spent in each stage may vary, the tasks to be accomplished to achieve successful movement to the next stage are assumed to be invariant. In the move from precontemplation to contemplation, an individual must become concerned and aware of the problem, make some acknowledgment of or take ownership of the problem, confront defenses and habitual aspects that make it difficult to control, and see some of the negative aspects of the problem or positive aspects of change in order to move to the next stage of seriously contemplating change.
One of the most helpful findings to emerge from our research is that specific processes of change are emphasized during particular stages of change. The integration of stages and processes of change has been well supported across problem areas. In fact, a meta-analysis of 47 cross-sectional studies (Rosen, 2000) examining the relation between the stages and processes found moderate to large effect sizes: .70 for variation in cognitive-affective processes by stage and .80 for variation in behavioral processes by stage.
This integration serves as an important guide for therapists. Once a client’s stage of change is clear, the therapist likely knows which processes to activate to optimally help the client complete critical tasks and progress to the next stage of change. Rather than try to engage change processes in a haphazard or trial-and-error approach, integrative therapists can use change processes more systematically.
Table 8.1 summarizes the integration that emerged in our research explorations of the (p. 164) stages and processes of change (DiClemente, 2018; Prochaska & DiClemente, 1983). During precontemplation, individuals use change processes significantly less than people in any other stage. Individuals in precontemplation process less information about their problems, spend less time and energy reevaluating themselves, experience fewer emotional reactions to the negative aspects of their problems, are less open with significant others about their problems, and do little to shift their attention or their environment in the direction of overcoming their problems. In therapy, these are clients who are labeled “resistant.”
Table 8.1 Processes of change emphasized at particular stages of change
What can help people move from precontemplation to contemplation? Table 8.1 suggests several change processes that prove most helpful. First, consciousness raising interventions, such as observations, feedback, and interpretations, can help clients become more aware of the causes, consequences, and cures of their problems. To move to the contemplation stage, clients have to become more aware of the negative consequences of their behavior. Often, we must help clients become more aware of their defenses before they can become more conscious of what they are defending against. Second, the process of dramatic relief or emotional arousal provides clients with helpful affective experiences (e.g., psychodrama, gestalt empty chair), which offer emotional experiences related to problem behaviors. Life events, such as illness or death of a friend or lover, can also move individuals in precontemplation emotionally.
As clients become increasingly more aware of themselves and the nature of their problems, they are freer to reevaluate themselves both affectively and cognitively. The self-reevaluation process includes an assessment of which values clients will try to actualize. The more central problems are to their core values, the more their reevaluation will involve their sense of self. Contemplators also use environmental reevaluation to reevaluate the effects that their behaviors have on their environments, especially the people they care about most. Addicted individuals, for example, may ask, “How do I think and feel about living in an environment that places me and my family in increasing risk of disease, death, poverty, and/or imprisonment?”
Movement through the contemplation stage involves increased use of cognitive, affective, and evaluative processes of change leading to a decision to change. To better prepare individuals for action, changes are required in how people think and feel about their problem behaviors and how they value their problematic lifestyles.
Preparation indicates a readiness to change in the near future and realization of valuable lessons from past change attempts and failures. They are on the verge of taking action and need to set goals and priorities accordingly. Patients in preparation often develop an implementation intention and action plan for how they will proceed. In addition, they build firm commitments to follow through on the action option they choose. In fact, they are often already engaged in processes that would increase self-regulation and initiate behavior change (DiClemente et al., 1991). People typically begin by taking some small steps toward action.
(p. 165) During the action stage, clients act from a sense of self-liberation. They need to believe that they have the autonomy and to take responsibility to change their lives in key ways. Yet they also accept that coercive forces are as much a part of life as is autonomy. Self-liberation is based in part on a sense of self-efficacy (Bandura, 1977, 1982), the belief that one’s own efforts play a crucial role in succeeding in the face of difficult situations.
Self-liberation, however, requires more than an affective and cognitive foundation. Clients must also be effective using behavioral processes, such as counterconditioning and stimulus control, to cope with those external circumstances that can coerce them into relapsing. If necessary, therapists can provide training in behavioral processes to increase the probability that clients will be successful when they do implement plans and take action.
Successful maintenance builds on each of the change processes that has come before and involves a candid assessment of the conditions under which a person is likely to be encouraged or coerced into relapsing. Clients assess the alternatives they have for coping with such coercive forces without resorting to self-defeating defenses and pathological responses. Perhaps most important is the sense that one is becoming more of the kind of person one wants to be. Continuing to apply counterconditioning, stimulus control, and reinforcement management is most effective when it is based on the conviction that maintaining change maintains a self that is highly valued by oneself and at least one significant other.
The amount of progress patients typically make in treatment is a function of their pretreatment stage of change. A meta-analysis of 76 psychotherapy studies (encompassing 21,424 patient) found that stages robustly predict (d = .41) distal outcomes (Krebs, Norcross, & Prochaska, 2018). Several longitudinal studies illustrate this meta-analytic finding. In an intervention study with smokers with heart disease, Ockene and her colleagues (1992) found that 22% of smokers in precontemplation prior to treatment were not smoking at a 6-month follow-up. However, of those in contemplation, 44% were abstinent and approximately 80% of those in preparation or in action were not smoking at 6 months. With a household sample of Mexican American smokers in Texas (Gottlieb et al., 1990), at a 12- to 18-month follow-up, smokers originally in contemplation progressed to the action and/or maintenance stages four times as frequently as smokers originally in the precontemplation stage. The amount of progress head-injury adults made in rehabilitation also was directly related to their stage of change prior to treatment (Lam et al., 1988).
Pros and Cons of Changing
A third dimension of the transtheoretical model is the pros and cons of changing, which represent the decisional and motivational aspects of change. Janis and Mann’s (1977) model of decision-making inspired our original work on the pros and cons of change. They identified four types of “pros” or benefits of decisions and a similar set of “cons” or costs: instrumental benefits/costs to self, instrumental benefits/costs to others, approval/disapproval from self, and approval/disapproval from others.
Questionnaires assessing the pros and cons included items to represent each of these eight categories. Principle components analyses consistently demonstrated that decision-making could be reduced to two core constructs: pros and cons of changing (Velicer et al., 1985). When weighing important life changes, people do not differentiate benefits to self from those for others or instrumental benefits from affective or evaluative. They do clearly differentiate the pros from the cons.
Most importantly, there are clear and consistent associations between the stages of change and the pros and cons of changing across all types of problems. A meta-analysis was performed on the relation of the pros and cons and stages of change across 43 behaviors in more than 60,000 people from nine nations (Hall & Rossi, 2003). The problem behaviors included depression, stress, anorexia, alcohol abuse, heroin addiction, cocaine abuse, obesity, smoking, partner abuse, and more. Figure 8.1 demonstrates how clear integration can be even in the face of so many differences. (p. 166)
Across 43 behaviors, the cons of changing outweigh the pros by .7 standard deviations (SD) for people in precontemplation. The opposite is true for people in maintenance where the pros of changing are .7 SD higher than the cons. The pros of changing are clearly higher in contemplation than in precontemplation. In contemplation, the pros and cons are about equal, reflecting the profound ambivalence that characterizes the contemplation stage. The pros and cons cross over for people in the preparation stage who are more convinced that the huge efforts needed during the action stage are likely to be worth it. The further along people are in the stages, the more convinced they are that the struggles to change are worthwhile.
It might be helpful here to briefly apply these change dynamics to people’s decisions to participate in treatment. We need to keep in mind that the weighing of the pros and cons of changing is not fully conscious or rational. The clear patterns in Figure 8.1 only emerge if standardized scores rather than raw scores are used. If raw scores were used, then the pros of changing would outweigh the cons at each stage.
Imagine clients in the precontemplation stage who are prescribed psychotherapy or medication for depression. Their cons of treatment would clearly outweigh the pros. So, if they started treatment, they would likely be among the 40% who would discontinue treatment quickly and prematurely. That is exactly what we found in predicting more than 90% of premature termination from psychotherapy: those in precontemplation were highly likely to discontinue. Those in the action stage were likely to finish therapy quickly but appropriately, as judged by their therapists (Brogan et al., 1999). A growing number of studies indicate that by matching processes of change to stage of change, patients in precontemplation can complete a treatment program at the same high rates as those in preparation (e.g., Prochaska et al., 1993; Prochaska, Velicer, Fava, Rossi, & Tsoh, 2001; Prochaska, Velicer, Fava, Ruggiero, et al., 2001).
Levels of Change
At this point in our analysis, we appear to be discussing how to approach a single, well-defined problem. However, as clinicians know, reality is not so accommodating. Although we can isolate certain symptoms and syndromes, these occur in the context of complex, interrelated levels of human functioning. In changing any one behavior there is the life context surrounding that change. The fourth dimension of the transtheoretical approach addresses this issue.
The levels of change represent an organization of five distinct and interrelated levels of psychological problems that can be addressed in psychotherapy:
◆ Symptom/situational problems
◆ Maladaptive cognitions
◆ Current interpersonal conflicts
(p. 167) ◆ Family/Systems conflicts
◆ Intrapersonal conflicts
Historically, systems of psychotherapy have attributed psychological problems primarily to one or two levels and focused their interventions on these levels. Behavior therapists have focused on the symptom and situational determinants, cognitive therapists on maladaptive cognitions, family therapists on the family/systems level, and psychoanalytic therapists on intrapersonal conflicts. It is crucial that both therapists and clients agree as to which level they attribute the problem and at which level or levels they are willing to target as they work to change the problem (Begin, 1988).
In the transtheoretical approach, we consider intervening initially at the symptom/situational level because change tends to occur more quickly at this level and symptom/situational problems are often primary reasons for entering therapy. The further down the levels we focus, the further removed from awareness are the determinants of the problem and the more historically remote and more interrelated the problem is with the sense of self. Thus, we often predict that the “deeper” the level that needs to be changed, the longer and more complex therapy is likely to be and the greater the resistance of the client (Prochaska & DiClemente, 1984).
These levels, it should be emphasized, are not independent: change at any one level is likely to produce change at other levels. Symptoms often involve intrapersonal conflicts, and maladaptive cognitions often reflect family/system beliefs or rules. In the transtheoretical approach, the complete therapist is prepared to intervene at any of the five levels of change, although the preference is to begin at the highest, most contemporary level that clinical assessment and judgment can justify.
Integrating Levels, Stages, and Processes
In summary, the transtheoretical approach sees therapeutic integration as the differential application of the processes of change at specific stages of change according to identified problem level. Integrating the levels with the stages and processes of change provides a model for intervening hierarchically and systematically across a broad range of therapeutic content. Table 8.2 presents an overview of the integration of levels, stages, and processes of change.
Table 8.2 Interaction of levels, stages, and processes of change
Three basic strategies can be employed for intervening across multiple levels of change. The first is a shifting levels strategy. Therapy would typically focus first on the client’s symptoms and the situations supporting those symptoms. If processes could be applied effectively at this level and the client could progress through each stage of change, treatment could be completed without shifting to a more complex level of analysis. If this focus proved ineffective or incomplete, therapy should shift to other levels in sequence to achieve desired change. Table 8.2 illustrates the strategy of shifting from a higher to a deeper level by the arrows moving first across one level and then down to the next level.
The second strategy is the key level strategy. If clinical assessment points to one key level of causality and the client can effectively be engaged at that level, the therapist could work almost exclusively at that level. The key level may also represent the problem area where the client has the most motivation or is in the most active stage of change.
The third alternative is the maximum impact strategy. With many complex cases, it is evident that multiple levels are involved as a cause, an effect, or a maintainer of the client’s problems. Interventions in these cases need to address multiple levels of change in order to establish a maximum impact for change in a synergistic rather than a sequential manner.
Each system of psychotherapy has distinctive strengths within the transtheoretical model. Table 8.3 illustrates where leading systems of therapy fit best within the integrative framework of the transtheoretical approach. Depending on the patient’s level and stage of change, different therapy systems will play a more or less prominent role. Behavior therapy, for example, has developed specific interventions at the symptom/situational level for clients who are ready for (p. 168) action. At the maladaptive cognition level, however, Ellis’s rational-emotive therapy and Beck’s cognitive therapy are most prominent for clients in the contemplation and action stages.
Table 8.3 Integration of psychotherapy systems within the transtheoretical framework
Maladaptive cognitions therapy
Interpersonal therapy conflicts
Family/ systems conflicts
Dialectic behavior therapy
We have not excluded any therapy systems from the transtheoretical approach. Our approach is an open framework that allows for integration of new and innovative interventions, as well as the inclusion of existing therapy systems that either research findings or clinical experience suggest are most helpful for clients in particular stages at particular levels of change (DiClemente, 2018).
Assessment and Formulation
Accurate assessments of the clients’ stage, level, and processes of change are crucial to the transtheoretical approach. Therapy should prove most effective if patient and therapist are matched and working at the same stage and level of change. The joining of the patient and therapist is centered around the structure and process of intentional change. The therapist’s role is one of maximizing self-change efforts by facilitating neglected processes, de-emphasizing overused processes, correcting (p. 169) inappropriately applied processes, teaching new processes, and redirecting change efforts to the appropriate stages and levels of change.
Clinical assessment of the stages, levels, and processes requires a specific focus within the clinical interview. Knowledge of both the attitudes and intentions toward a change, as well as the actions taken about it, are needed for accurately assessing the stages of change. It is important to know that an individual stopped drinking 1 week ago when his partner left him. However, equally important is knowing whether this is the first step in taking significant action toward intentional change of his drinking or an attempt to change his partner’s behavior. Another method of assessing the current stage of change is to evaluate how adequately an individual accomplished the tasks of any prior stage of change. If someone has contemplated changing only casually or briefly, for example, then that person often would not have made a decision strong enough to support the commitment and plan needed to take action.
Assessment of the levels of change requires a clinical interview that addresses each of the levels. In a case of vaginismus, we must know the symptomatic expression and situational determinants of the sexual dysfunction but should also explore explicit and implicit thoughts, the couple’s interpersonal functioning, family system involvement, and any possible intrapersonal conflicts regarding identity, self-esteem, and so on. In this assessment, it is important to establish at which level or levels the patient perceives the problem, as well as the levels that the clinician assesses are integrally involved in the problem. For one couple it could be related to a religious or moral belief, for another an issue of interpersonal control or anger, and for another a physiological anxiety symptom.
Evaluating the processes of change being employed by the patient can be a rather extensive task. Therapists should explore what the patient is currently doing about the problem, how often these activities are occurring, and what has been done in the past in attempts to overcome the problem. An obsessive patient may be relying heavily on consciousness-raising as the most important process while neglecting more action-oriented processes.
In our research, we developed assessment instruments to evaluate the stages, levels, and processes of change. The University of Rhode Island Change Assessment Scale (URICA), or Stages of Change Questionnaire, is a 32-item questionnaire with four scores: precontemplation, contemplation, action, and maintenance (DiClemente & Hughes, 1990).
Several forms of a questionnaire to assess the processes of change have also been developed (www.uri.edu/cprc; www.umbc.edu/psyc/habits). The questionnaires typically contain two to four questions about activities that would represent each of the processes, and clients are asked to indicate how frequently each activity occurs. Because change processes differ somewhat for diverse problems, we have adapted this format to a variety of problems, such as alcoholism, overeating, depression, and exercise. These questionnaires have shown robust consistency across problem areas (Prochaska & DiClemente, 1986), and principal component analyses have yielded 10 or more consistent components in their use with both clients and therapists. Processes of Change Scales can be used to assess change processes before, during, and after therapy to examine how therapy interventions affect utilization of processes (Prochaska & DiClemente, 1985). Change process activity has been found to relate to therapist theoretical orientation (Prochaska & Norcross, 1983) and client activity in the various stages of change (DiClemente & Hughes, 1990; Snow et al., 1992; Tejero et al., 1997) and to be predictive of successful movement through the stages of change (Carbonari & DiClemente, 2000).
The Level of Attribution and Change (LAC) Scale contains four or more questions representing each of the five levels of change used in the transtheoretical model. In addition, five other levels are assessed because people do not attribute their problems only to psychosocial sources. Individuals often blame bad genes, bad luck, or bad karma for their inability to change. Other levels of attribution include spiritual determinism, biological (p. 170) determinants, insufficient effort, and preferred lifestyle (Norcross et al., 1984,1985; Norcross & Magaletta, 1990; Penny, 1987).
Applicability and Structure
The transtheoretical model applies to all clinical problems of psychological origin as well as to many health problems that require behavior change (Marcus et al., 1992; Prochaska, Norcross et al., 1992). Thus, the approach is applicable to psychopathology and health-related problems. In addition, the framework can categorize treatment delivery systems according to the types of clients and problems they primarily address.
Because we often intervene first at the symptom/situational level, the transtheoretical approach can be used in both a short-term and a long-term format. Ideally, length of therapy, setting, and modality will be determined more by the stage of change, level of problem involvement, and type of change processes employed rather than a predetermined set on the part of the therapist. A family intervention that brings family members together to make an effective intervention with the patient can be used for an alcohol-dependent individual in precontemplation. Individual and couples therapy can work through contemplation and achieve effective action when working with sexual dysfunctions. Group therapy can be tailored to patients in all stages of change (Velasquez et al., 2015).
Because the transtheoretical approach concentrates on intentional change, contraindications are settings or problems where intentional change is not the primary goal. In a correctional setting or in managing the self-destructive behavior of a child, control, not intentional change, may be the primary goal. However, external behavioral control appears to be the treatment of choice using the processes of contingency control and stimulus control. Once the immediate threat to self or others has been managed, therapists can bring the problem behaviors under intentional self-control rather than external control. In fact, this should be an important secondary goal if treatment or incarceration goals are to be maintained after the individual is released into the community.
In working with intentional change, the transtheoretical approach is quite compatible with the traditional structure of psychotherapy (Connors et al., 2013). Weekly, hour-long sessions can implement the treatment process. Because we envision psychotherapy as an adjunct to self-change, what occurs between therapy sessions is as important as what happens within therapy sessions. A longer, more intense therapy session with the inclusion of significant others may be needed for an individual in precontemplation to overcome defenses. Less frequent sessions can be used for individuals in contemplation and maintenance. For the former, more time between sessions can allow clients time to use the processes of consciousness-raising and self-reevaluation in the service of decision-making. For the latter, time between sessions can be used to monitor temptation levels and encounter any obstacles to continued action or maintenance that occur less frequently. Thus, in effect, therapy sessions become booster sessions.
The goal of our clinical and research work is to identify the variables most effective in helping clients move through the stages of change regarding a particular problem. In this context, treatment selection is too generic a term. In the best spirit of using case formulation, we identify which tasks of a particular stage need to be addressed and which processes will prove most effective in helping an individual move from one stage to the next. The decision to engage a particular process is multiply determined. Rather than stating a priori that counterconditioning (e.g., exposure, cognitive therapy, behavioral activation) is the treatment of choice for phobic or depressive problems, we prefer to analyze first the stages and levels of change before making prescriptive matches.
We realize that this approach places a sizable burden on the therapist. However, simplicity can be a source of mediocrity and confusion. We have found, for example, that insufficient use of consciousness raising in the (p. 171) contemplation stage forces individuals to rely excessively on self-liberation or will power in their efforts to change and leads to what Janis and Mann (1977) have called post-decisional regret. The overuse of self-reevaluation during maintenance and while abstinent, on the other hand, is predictive of relapse (DiClemente & Prochaska, 1985). Thus, matching patients with change processes requires both a general knowledge of the stages, processes, and levels of change as well as specific information about individual clients and what they have been using, underusing, or overusing to effect changes in their lives.
Although stage matching is a complex process, mismatches are readily apparent. A therapist committed to consciousness raising and exploration of all the levels of change prior to taking action may frustrate a client ready to take action at the symptomatic level. An action-oriented therapist may be constantly disappointed by clients in precontemplation who drop out quickly or fail to implement suggested behavioral techniques. A family therapist insisting that change take place at the family systems level with the whole family present may be unable to engage a system with a key member in precontemplation.
Treatment matching should be to the process of change and not simply to the problem being addressed. From our perspective, the problem with using a more medical model in psychotherapy is that it focuses on diagnosis and cure rather than process and intentional change. Even with most physical health problems and chronic conditions that require health behavior modification, the medical model has proved problematic. Medication compliance, diet control, and exercise all require intentional change and are not simply solved with a prescription or advice. Disorder is an important concept for developing a taxonomy that enables us to bring together certain symptoms and syndromes for classification. Although this information is valuable in understanding a problem, knowledge of a disorder by itself has limited value in prescribing therapy interventions when intentional behavior change is an important part of the remedy (Consoli & Beutler, Chapter 7, this volume).
Although psychotherapists have not struggled with all the problems faced by their clients, all therapists have experience with the processes of change. This is the common experiential ground that forms the basis of the relationship between therapist and client. In general, the therapist is the expert on change—not in having all the answers, but in being aware of the crucial dimensions of change and offering assistance. Clients have potential resources as self-changers that must be actualized to effect a change. In fact, clients shoulder much of the burden of change and look to the therapist for consultation on how to conceptualize the problem and on methods to free themselves to move from one stage to another.
As with any interactive endeavor, rapport must be built to accomplish the work. However, the type of relationship will vary with the stage and level of change being addressed. Initiation of therapy with a precontemplation client, for example, takes on a different flavor. A client’s unwillingness to see or own a problem is not viewed as resisting the therapist or being uncooperative but as resisting change and preserving autonomy. Therapists must become aware of how frightening and anxiety-provoking the prospect of change can be. With this shift in perspective, the therapist can take on the role of a concerned advisor or nurturing parent who can help the individual explore the problem (DiClemente, 1991). The therapist becomes an ally rather than another person attempting to coerce change.
For a person contemplating change, the therapist takes care not to be too impatient. Contemplation can be a lengthy, frustrating stage—not only for the patient, but also for the therapist. Although therapists should not support chronic contemplation, they must tolerate ambivalence and avoid blame, guilt, and premature action. To decide to change, patients must see that change is possible and in their own best interests. The therapist, like a Socratic teacher, can challenge clients by making explicit the pros and cons of both the problem behavior and the change. Support, understanding, compassion, and a relationship that enables (p. 172) the therapist to make explicit the hopes, fears, and concerns of the client are needed during this time.
During the action stage, the therapist assumes a more formal teaching and coaching relationship. During these stages, the client is likely to idealize the therapist. When initiating action, the client needs the support of a helping relationship and may need to lean on the confidence of the therapist rather than a self-generated sense of efficacy. Initial efforts are likely to be tentative, and seeing the therapist as a change expert can prove comforting. However, as soon as is feasible, it is important for the client to develop more self-confidence and independence. For therapists who need to be needed, this can pose a difficult problem.
In the maintenance stage, the therapist becomes an occasional consultant—preventing relapse, consolidating gains, and identifying potential trouble spots. Letting go, saying goodbye, and helping the client assume ownership of the change are the final tasks of the therapy relationship.
Processes of Change
As already noted, the transtheoretical approach identified the processes that are most effective in producing change at different stages. The mechanisms that move someone from precontemplation to contemplation are different from the processes that move someone from preparation to action (Velasquez et al., 2015).
The important issue here is that intentional change, such as occurs in psychotherapy, is only one type of change that can move people. Developmental and environmental changes can also cause people to alter their lives. However, imposed change often is not sustained (Stotts et al., 1996). The transtheoretical approach focuses primarily on facilitating intentional change, but it recognizes and, at times, relies on other types of change when working with clients. We assume, however, that unless developmental or environmental changes produce intentional change as well, clients can feel coerced by forces not of their choosing and will likely revert to previous patterns once the coercion is removed.
Intentional change is a universal human phenomenon, and the concepts and approaches described in this chapter have been translated and are being used in a wide range of countries and cultures. Researchers and practitioners from around the world—including Britain, Brazil, France, Poland, South Korea, Australia, India, New Zealand, the Philippines, China, Mexico, and Japan—have found these concepts useful, which supports focusing on process and not simply problems.
At the same time, it is important to consider cultural diversity for clients of historically marginalized backgrounds related to sex, gender, ethnicity, race, poverty, education, and heritage when using this approach. Here are some examples and suggestions for incorporating diversity into the application of the transtheoretical model.
1. Empowerment, resilience, and taking responsibility are important elements of the process of change and represent values of a more individualistic culture. In more collectivist cultures, processes and tasks may have to be broadened to include involvement of family and community. Conversations about change will include cultural considerations and understanding how the cultural context will impact the process as well as the problem.
2. The process of change requires cultural humility. Pros and cons, emotional experiences, and values that move individuals through precontemplation and contemplation are culturally influenced and must be respected. Action plans and coping activities also need to be acceptable and accessible to clients and may need to be adapted (reinforcement, counterconditioning). Some emotional and re-evaluation processes may need to be adapted to include different experiences and values.
(p. 173) 3. Racism, poverty, stigma, and ethnic alienation create unique barriers to engaging in the process of change. Often, these forces keep people in precontemplation and contemplation, making it difficult to see the pros of change. These systemic forces also tend to promote coercive rather than intentional change, thus further undermining choice and the ability to move through the intentional process of change.
4. Poverty, lack of education, and lack of opportunity create a maelstrom of problems that overwhelm the capacity of the client to address change effectively. Lack of resources and multiple problems interfere with contemplation and preparation activities and make it difficult for individuals to use processes of change. Multiple problems overwhelm the self-regulation system needed to accomplish tasks of the stages. These individuals tend to be reactive and not proactive and are often labeled unmotivated rather than overwhelmed. These clients will require structural and well as relational support.
5. Beliefs systems in cultures and subcultures about sex, gender, and race influence the opportunities for change and can limit the capacity of individuals in these cultures to make change decisions that go against the cultural norms. Therapists must proceed cautiously in imposing views about change that are not cognizant of cultural views.
Behavioral change described in this chapter can be used to understand change at an individual as well as a system level. Culture can constrain and can liberate the potential for intentional change. As with all issues of diversity, understanding the individual, the context, and the culture as experienced by that individual is the only certain way to address differences and diversity competently and to support empowerment and resilience. (p. 174) (p. 175) (p. 176)
(p. 177) Outcome Research
One influential line of research has examined the stages and processes of change in substance abuse treatment. Patients entering alcohol and substance abuse treatment have different profiles on the stages of change (Carney & Kivlahan, 1995; DiClemente & Hughes, 1990; Heather et al., 1993). Using a motivational readiness score based on the stages of change scales, Project MATCH investigators found that baseline readiness scores were one of the strongest predictors of posttreatment drinking outcomes for the 952 outpatients in this large multisite alcoholism treatment matching trial (DiClemente et al., 2003; Project MATCH, 1997, 1998). Baseline stage predicted outcomes when treatment type did not (DiClemente et al., 2001). Client motivation at baseline also related to how individuals engaged with the therapist (working alliance) and how active they were in using the processes of change and other external resources to modify their drinking (DiClemente et al., 2003). Finally, post-treatment stage and process of change activities during treatment, particularly behavioral process activity, predicted drinking outcomes (Carbonari & DiClemente, 2000; Heather & McCambridge, 2013). Results indicate that outcomes are probably due more to what clients do than what therapists do (DiClemente et al., 2003).
During the past 25 years, we have conducted a series of clinical trials on the effectiveness of the transtheoretical model. In our first clinical trial, we randomly assigned 770 smokers in Rhode Island by stage to one of four treatment conditions: standardized, individualized, interactive, and personalized (Prochaska et al., 1993). The standardized treatment used the best self-help program available, the American Lung Association’s (ALA’s) action and maintenance manuals. The self-help manuals were individualized to the stage of change. The interactive condition (ITT) involved computer-generated progress reports with feedback about stage of change; decisional balance measures regarding quitting smoking (Velicer et al., 1985); up to six processes of change that were being underutilized, overutilized, or utilized appropriately (Prochaska et al., 1988) temptations and self-efficacy across the most important smoking situations (Velicer et al., 1990); and techniques for coping with specific situations. The personalized condition (PITT) included the stage-based manuals, computer reports, and four proactive counselor calls. Except for one call, counselors had the computer reports to counsel clients about changes they were making on key process variables.
The results were revealing. The two manual conditions replicated each other through the 12-month follow-up. At the 18-month follow-up, however, the individualized transtheoretical manuals (18.5% abstained) were performing better than the standardized (ALA) manuals (11%). The interactive computer reports outperformed both manual conditions at each of the four follow-ups, producing more than twice as much quitting at each follow-up than the gold standard ALA manual (e.g., 25.2% vs. 11% at 18 months). The personalized counselor calls doubled the quit rates of the two manual conditions up to the 12-month follow-up. By the 18-month follow-up, effects from the PITT condition appeared to have plateaued (18%) and only outperformed the ALA manuals, whereas the transtheoretical manual condition seemed to have caught up with the counselor call condition.
These results suggest that interactive computer feedback on stage-matched variables can outperform the best self-help program currently available. Providing smokers interactive feedback about their stages of change, decisional balance, processes of change, self-efficacy, and temptation levels in crucial smoking situations can produce greater success than just providing the best self-help manuals currently available.
The next controlled trial demonstrated the efficacy of the expert system applied to an entire population recruited proactively. With more than 80% of 5,170 smokers participating and fewer than 20% in the preparation stage, we demonstrated significant benefit of the expert system at each 6-month follow-up (Prochaska et al., 2001). Furthermore, advantages over (p. 178) proactive assessment alone increased at each follow-up for the full 2 years assessed. The implications here are that expert system interventions in a population can continue to demonstrate benefits long after the intervention has ended.
In more recent research, we have been enhancing our expert system to produce even better outcomes. In one trial, we added a personal handheld computer designed to bring the behavior under stimulus control (Prochaska et al., 2001) in a population of smokers in a health maintenance organization (HMO). This innovation was an action-oriented intervention that did not enhance our expert system program on a population basis. In fact, our expert system alone was twice as effective as the system plus the enhancement. There are two major implications: (1) more is not necessarily better, and (2) providing interventions mismatched to stage can make outcomes markedly worse.
These results also support our assumption that the most powerful behavior change programs for entire populations will be interactive (Velicer et al., 1999). In the reactive clinical literature, interactive interventions like behavioral counseling produce greater long-term abstinence rates (20–30%) than do noninteractive ones such as self-help manuals (10–20%). Providing assessment-driven interactive interventions via computers is likely to produce greater outcomes than relying on noninteractive communications, such as newsletters, media, or self-help manuals.
We next extended the stage-matched expert systems to treatments for populations with alternative problems, like psychological stress. With a national sample suffering from stress symptoms, we recruited more than 70% (N = 1,085) to a single behavior change program (Evers et al., 2006). The transtheoretical program involved assessments on each of the constructs to derive three expert system–tailored communications for 6 months and a stage-based self-help manual. At the 18-month follow-up, the transtheoretical program group had more than 60% of the at-risk sample reaching action or maintenance in terms of stress reduction compared to 42% for the control group. This outcome was maintained during the next 12 months.
Finally, we offer some studies that focus on the effectiveness of transtheoretical therapy for mental health disorders. Primary care patients experiencing major depression or subclinical depression and not receiving treatment (n = 480) and those nonadherent with antidepressant medications were randomized to receive transtheoretical-based treatment (TTM) or usual care. TTM condition participants were more likely to have clinically significant improvement compared to usual care (35% vs. 25%) with an odds ratio of 1.79. Patients with major depression also had greater improvement (22% vs. 6%). This depression program received recognition as an evidence-based practice by Substance Abuse and Mental Health Services Administration (SAMHSA) (Levesque et al., 2011).
In school-based trials examining TTM-based Internet programs compared to controls in reducing bullying and violence, the TTM conditions outperformed the control condition with both middle and high school youth. There were decreases in the three roles of bully, victim, and passive bystander, with a 40% decrease compared to 19% in middle school and 40% compared to 22% in high school youth (Evers et al., 2007).
A meta-analysis of 88 prospective, tailored interventions delivered by mail or computer across smoking cessation, physical activity, healthy diet, and mammography screening demonstrated an effect size of d = 0.18 for TTM-tailored interventions. This represents a 39% increase over assessment or usual care (Krebs, Prochaska, & Rossi, 2010).
With a population of patients in Canada with diabetes, we proactively recruited 1,040 patients to a multiple behavior change program for diabetes self-management (Jones et al., 2001, 2003). With this population, self-monitoring for blood glucose (SMBG), diet, and smoking were targeted. Patients were randomly assigned to standard care or TTM. The TTM program involved monthly contacts that included three assessments, three expert system reports, three counseling calls, and three newsletters targeted (p. 179) to the participant’s stage of change. At 12-month assessments, the TTM group had significantly more patients in action or maintenance for diet (41% vs. 32%) and for SMBG (38% vs. 25%). With smoking, 25% of the TTM group were abstinent compared to 15% of usual care. Similar results were found in a population-based study in Hawaii (Rossi et al., 2002).
We believe that the future of behavior change interventions lies with stage-matched, proactive, and interactive interventions driven by sensitive assessments that focus on client stages, processes, and levels of change (DiClemente, 2018; Heather et al., 2009). Interventions should offer what the client needs to achieve the tasks of the specific stages and to engage in critical processes of change. Our research demonstrates that interventions can promote change in interpersonal settings like therapy as well as in telephone- and Internet-based programs that include feedback and tailored interventions. At a population level, interventions generate greater impacts with proactive programs because of much higher participation rates, even if efficacy rates are lower. But we also believe that proactive programs reaching out to individuals in various stages of change can produce comparable outcomes to traditional reactive programs that wait until clients request help.
The health of our nation and the health of our healthcare systems cannot wait 25 more years for the dissemination of psychotherapy integration. The top priority for the transtheoretical approach is the rapid dissemination of available science and systems. The first problems that are likely to be treated on a population basis are high-cost conditions, such as depression, addiction, and stress. Populations with multiple behavior problems are also high-risk and high-cost and are major candidates for population-based treatments. We are working with healthcare systems, employees, governments, and other organizations to bring the most effective and cost-efficient therapies to these populations.
One clinical strategy that we are studying is a stepped care approach, where we begin with the least intensive and least costly of treatments, such as computer-based TTM programs. Participants who are progressing with these programs would continue with them. Those who are not progressing would be stepped up to a more intensive treatment, such as telephone counseling. Those not progressing with this help would then be stepped up to face-to-face psychotherapy with TTM-trained therapists. Another is to focus on the self evaluations of individuals related to decision making, processes of change and self efficacy (Shaw & DiClemente, 2016; Velasquez et al., 2015).
We also need to test the limits on how many behavior problems can be treated simultaneously without reducing effectiveness. To date, we have effectively treated three behaviors on a population basis with no decreased efficacy but with increased impacts on health and healthcare costs. Even single behavioral targets, such as smoking, could benefit from multiple behavior therapies that can treat major barriers to successful cessation, such as stress, depression, alcohol abuse, and weight gain.
There are hopeful trends that encourage integrated care and precision medicine in the future. Those trends view patients across differing stages of change and in need of comprehensive treatments for multiple health disorders (DiClemente et al., 2016; Prochaska & Prochaska, 2016). Focusing on the individual’s process of change will empower healthcare practitioners of all professions and persuasions to provide targeted yet integrative strategies.
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