The Transtheoretical Model

This model was developed by Prochaska and DiClemente in the early 1980s when studying how people gave up smoking on their own without any professional intervention. They found people passed through a series of stages as they “move from being unaware or unwilling to do anything about the problem to considering the possibility of change, then to becoming determined and prepared to make the change, and finally to taking action and sustaining or maintaining that change over time” (Prochaska and DiClemente, 1984). This model focuses on two factors:

• Motivation for change
• Actual behaviour change.

The process of change is cyclical, and people typically move back and forth between the stages at their own individual rate. People can move through the stages very quickly, although it is quite common for people to remain in the early stages. Relapse or recurrence of an unhealthy behaviour is considered a normal experience since most people cycle through the different stages many times before reaching stable change.

Precontemplation

People in this stage live a sedentary/unhealthy lifestyle. They are not thinking about, and have no intention of, increasing their physical activity/exercise levels in the foreseeable future – they are ‘couch potatoes’. They may be partly or totally unaware that a problem exists, that they have to make changes, and that they may need help to do this; “It isn’t that they can’t see the solution, it’s that they can’t see the problem” (Chesterton). On the other hand, they may be in this stage because they are disheartened about their ability to change, or may believe they are too set in their ways to change.

In this stage, there is often resistance to recognising or modifying a problem – they are not seriously thinking about changing their activity levels within the next six months or deny they need to change. People may be in this stage because they are uninformed or misinformed about the consequences of their behaviour. They tend to avoid reading, talking or thinking about their high risk behaviour. People may be forced into changing their behaviour and may demonstrate change as long as the pressure is on. Once the pressure is off, however, they often quickly revert to their old habits and lifestyle. People in this stage have not usually faced unpleasant outcomes or illness because of their unhealthy lifestyle. They are often not convinced that their unhealthy lifestyle is a problem or even potentially risky.

Contemplation

As people become aware a problem exists, they begin to recognise there may be a cause for concern and reasons to change. They seriously think about overcoming it, but have not yet made a commitment to take action. Despite their intentions, people can remain stuck in this stage for long periods, fluctuating between wanting and not wanting to change – this is often characterised as chronic contemplation or as behavioural procrastination.

Another aspect of this stage is the weighing up of the pros and cons of the problem. People in this stage seem to struggle with the amount of effort, energy and loss it will cost to overcome the problem. They are ambivalent in that there is a conflict about choosing between two courses of action – lifestyle change or maintaining the sedentary behaviour. They may search for relevant information, re-examine their lifestyle, or seek out help to support the possibility of increasing activity levels. When working with someone who is feeling ambivalent about change, an overtly persuasive style may lead to resistance and affect the subsequent outcome. Rather, a negotiation method in which they, not the fitness professional, articulate the benefits and costs involved may enhance motivation.

Preparation

When a person perceives the advantages of change and the negative consequences of the present sedentary lifestyle overshadow any positive aspects it offers, the decisional balance inclines towards change. The client also scrutinises their perceived abilities (or self-efficacy) for change. Once change has started, a person enters the preparation stage.

People in this stage may be undertaking some physical activity, but not at the levels necessary to gain major benefits. Their activity levels may be infrequent with little commitment. Although they have made some changes in their behaviour, they have not yet reached a criterion for effective action (for example, ACSM’s recommendations). They are intending, however, to take such action within the next 30 days. They start setting goals for themselves and make commitments to change, even informing significant others about their plans (for example, joining a gym, taking up jogging, getting a personal trainer, etc).

Action

People are classified as being in the action stage if they have successfully altered their behaviour for a period of one day up to six months. People in this stage decide on a strategy for change and begin to work at it; they are actively amending their lifestyle habits and environment. This behaviour alteration means reaching a particular criterion, such as abstinence (for example, from smoking) and/or adherence (sticking to an exercise programme). They have undertaken physical activity/exercise at the recommended frequency, intensity and duration to obtain health and fitness benefits.

This stage involves the most overt behavioural changes and requires considerable commitment of time and energy. Motivation and investment in behaviour change are at sufficient levels at this stage to maintain the change, and the perceived benefits are greater than the perceived costs. This is the least stable stage, however, and people in this stage are at the greatest risk of relapse. This stage is characterised by the existence of a clear goal and a realistic plan.

Maintenance

During this stage, efforts are made to sustain the improvements attained during the action stage. This is where people work to sustain healthy lifestyle changes and prevent relapse or recurrence of the old behaviour/lifestyle – clients may have made physical activity/exercise a habit and undertaken the recommended amounts for six months or more. People work to prevent relapse and consolidate the gains attained during the action stage. Additional precautions may be necessary to keep them from slipping back to a sedentary lifestyle. People learn how to identify and defend themselves against uncertain and risky situations, as well as other triggers that may cause them to revert to unhealthy behaviours; the risk of relapse is low and people are increasingly more confident that they can continue their change. This stage extends from six months to an indeterminate period.

Termination

If the new behaviour is successfully consolidated into a person’s lifestyle, they exit the cycle and a sixth stage, termination, is reached. Termination represents a point at which a person has 100% confidence in their ability to maintain the behaviour change and there is no risk of relapse to previous stages.

Relapse and recurrence

Along the way to a permanent change of behaviour, most people experience relapse. Relapse is often accompanied by feelings of discouragement and feelings of failure. While relapse can be discouraging, most people who successfully change their behaviour experience it, and do not follow a straight path to maintenance. Rather, a person attempts behaviour change and fails several times before achieving success. This model considers relapse a normal part of the process. People move back and forth through these different stages. Relapses can be important opportunities for learning and becoming stronger, or they can be excuses to give up. There is a risk a person will experience an immediate sense of failure that can seriously undermine their self-confidence. People may discover particular goals are unrealistic, certain strategies are unsuccessful, or specific settings are not supportive of successful change.

Click images to enlarge.