The Transtheoretical Model – processes of change

The stages of change tell you ‘when’ people change; the processes of change describe ‘how’ people change. These are the processes that people need to apply, or be engaged in, to move along the stages. People need and use various types of motivational support depending on which stage of change they are in and into what stage they are moving. If the fitness professional attempts to use strategies not suitable for the stage the person is in, the outcome could be resistance or non-compliance. For example, if the client is at the contemplation stage weighing the pros and cons of starting an exercise programme as opposed to continuing the sedentary lifestyle, and the fitness professional pursues strategies appropriate to the action stage, the client will inevitably resist. The reason for this response is that the fitness professional has taken the ‘pro’ side (change), leaving the client to argue the ‘con’ side (no change), which results in a standoff (Miller and Rollnick, 2002).

To think about change, people in the precontemplation stage must have awareness raised. To settle their ambivalence, people in the contemplation stage need help choosing positive change over their present situation. People in the preparation stage need help recognising possible change strategies and choosing the most suitable one for their situation. Those in the action stage need help carrying out and complying with the change strategies. During the maintenance stage, people may have to cultivate new skills for sustaining change. Furthermore, if people return to a sedentary lifestyle, they can be helped to carry on the change process as quickly as possible.

Ten processes have been identified and can be divided into two groups – cognitive and behavioural processes. Each process is a broad group that includes multiple techniques, methods and interventions.

Cognitive processes

Cognitive processes can be defined as the set of processes through which a person gathers relevant information on the basis of their actions or experiences. Cognitive processes involve thinking, attitudes and awareness:

  1. Consciousness raising (increasing awareness) involves providing information to increase awareness about causes, consequences and cures for a particular problem health behaviour (e.g. sedentary lifestyle), and the value and drawbacks of the safer behavioural alternatives (such as physical activity/exercise). Interventions that can increase awareness include feedback, observation, education, confrontation and interpretation. Encourage reading and thinking about the unhealthy lifestyle behaviour.
  2. Dramatic relief (emotional arousal) involves nurturing identification, experiencing, and expression of emotions related to the risky behaviour (e.g. sedentary lifestyle). This initially produces increased emotional experiences followed by reduced emotional impact if appropriate action can be taken.
  3. Environmental re-evaluation (social reappraisal) combines both emotional and cognitive assessments of how the presence or absence of a personal habit affects a person’s social environment (for example, the effects of smoking on others). It allows a person to reflect on the consequences of their health behaviour on others and can also include the awareness you can serve as a positive or negative role model for others. Encourage recognition of how a health behaviour affects family, friends and colleagues.
  4. Social liberation (environmental opportunities) involves noticing and using social conditions that support change. This requires an increase in social opportunities or alternatives, especially for relatively deprived or beleaguered people. Help to increase awareness of opportunities for increasing physical activity/exercise.
  5. Self re-evaluation (self reappraisal) combines both emotional and cognitive assessments of a person’s own self-image with and without a particular unhealthy habit (for example, a person’s image of themselves as a couch potato or an active person).

Behavioural processes

Behavioural processes are the set of processes in which the information is generated by environmental events and behaviours. Behavioural processes involve actions.

  1. Stimulus control (re-engineering) involves removing cues for unhealthy habits and adding prompts for healthier alternatives. Avoidance of high-risk cues, environmental re-engineering (restructuring the environment), tapering techniques, and self-help groups can provide stimuli that support change and reduce risks for relapse. Planning parking or journeys with a few minutes walk to the office and putting displays in staircases are examples of re-engineering that can encourage more physical activity.
  2. Helping relationships (supporting) combine caring, trust, openness and acceptance as well as support for the healthy behaviour change. Rapport building, a collaborative partnership and buddy systems can be sources of social support. Encourage the person to find a family member, friend or colleague who is willing and able to provide support.
  3. Counter conditioning (substituting) requires the learning of healthier behaviours that can substitute for problem behaviours.
  4. Reinforcement management (rewarding) provides consequences for taking steps in a particular direction. Encourage the individual to praise themselves and give themselves rewards for sticking to the behaviour change or meeting goals.
  5. Self-liberation (committing) is both the belief that you can change and the commitment to act on that belief. New Years resolutions, public testimonies and multiple, rather than single options can increase self-liberation (or willpower). People with two options have greater commitment than people with one option; those with three options have even greater commitment; but four or more choices does not appear to increase commitment any further.

The table below suggests how the above cognitive and behavioural processes relate to the five stages of change.
Processes of change
Click image to enlarge.

Interventions therefore need to be matched to people’s stage of change. This increases the chances of sticking to the health behaviour change, increases the chances of meeting their short- and long-term goals, and decreases the chances they will relapse.