The transtheoretical model of change

Change seems to be something people experience differently, which is to say it seems apparent, at least to me, that some people struggle with change (read: to change) more than others do. Some people are more entrenched and invested in their way of being, others less so. Change does not come equally to everyone. Change, too, seems to take on different meanings in different contexts. Consider a social situation: you've been home all day, lounging about and taking it easy, and you've decided to go out to a nice dinner with a friend as a capstone to the day. What might you do? You might change, which is to say you might modify the way you are dressed to be in accordance with the social expectations of the restaurant you are going to. This example does, I think, two things for us: first, it helps us to find a sort of foundational definition of change. Change is alteration. Change is becoming. Second, it is seen as a singular event. Change came and it went. It happened and it's over. The first is helpful, albeit perhaps self-evident. The second, I think, while it can be found in the wild (read: in culture), is not aligned with my views as a professional. Change is not a singular solitary happening, although I will admit that it can, and often does, have the appearance of that. For example, a little over a year ago I decided to become a vegetarian. I changed my diet. I no longer eat meat. When I began to tell people this, a common response was surprise. It was a sudden change, especially to those on the periphery of my life, those people that I don't talk to all that much. To those people, one day I wasn't a vegetarian and the next day I was. My change was seen in isolation. It was seen as a singular solitary event. However, this is not how I experienced my change. To me, my change was a long time coming. I had been considering going vegetarian for some time by then and for various reasons. I had thought about what life might look like should I go vegetarian: what it would be like to live with people who were not vegetarian, how my diet might need to become more intentional to ensure proper nutrition, and what it would be like to no longer be able to eat some of the food I've enjoyed up to that point in my life. If nothing else, it is this reality that I am trying to shed light on with this writing: change is a process that is continuously unfolding over time. It is not a single solitary happening. It is not an event. We are always and at all time somewhere in relation to change. Our field (read: psychology) has come up with multiple ideas about and ways to conceptualize of change and how it works. When I was initially learning about these models of change, the first one I learned about in any depth was the transtheoretical model of change. It seems fitting to start today where I started so long ago.

The transtheoretical model sees "change as a process involving progress through a series of six stages". The six stages are as follows: precontemplation, contemplation, preparation, action, maintenance, and termination. Let's begin at the beginning.

Precontemplation is a stage that encompasses people who have no particular inclination or intention to change in the foreseeable future (approximately 6 months). People in this stage don't necessarily see a problem with the behavior that they are engaging with. They may be uninformed or underinformed about potential consequences of said behavior. People in this stage are often seen by others, be it those in their life personally or other professionals, as unmotivated. These people are seen as resistant and/or uninterested in change. Historically, and at times currently, treatment programs have not been a boon to people in this stage. These programs have not been structured and designed in a way to be a support to those people at this stage of readiness to change. These people are often seen as "not ready for therapy" by others. To refer back to my earlier example of my becoming vegetarian, to be in this stage would have been me before I began to consider things like the environmental impact of eating meat or the ethical concerns regarding how we treat livestock.

Contemplation is the stage where awareness of the 'problem' is being developed and/or has developed. The inclination to change is closing in. It is becoming more immediate and pressing. People here recognize the consequences of the behavior(s) they are engaging in, however they have yet to make a commitment one way or the other. It is in this stage where the pros and cons of said behavior are beginning to be weighed and this back and forth may engender ambivalence. People may find themselves stuck here in chronic contemplation. Like the previous stage, people in this stage are also not served adequately by more traditionally structured action-oriented treatment programs that expect people to act immediately. This is the stage where, in my vegetarian example, I have begun to consider the things I was not considering during precontemplation: environmental impact and ethics. This, too, may entail me weighing these and seeing how they stack up to my lifelong enjoyment of consuming meat and deliberating as to whether or not what I would be giving up is worth what I would be gaining.

Preparation is the stage where intention and action are beginning to become unified. In this stage, the person is both aware of the problems and consequences of the behavior they are engaging in, as well as the fact that change would be beneficial. People here are often beginning to take small steps to prepare for the impending 'change' (remember: change is a process, not an event) and intend to take action soon (in this case, typically approximately 30 days). It is common that people in this stage have already made small efforts in engaging with the desired change (e.g., going 48 hours without eating meat or 24 hours without a cigarette). People in this stage have begun or already developed a plan of action, and unlike the previous stages, people here are suitable for the more traditionally structured action-oriented treatment programs.

Action is the stage where people have begun modifying their behavior or environment to overcome problems and intend to continued moving forward with their desired change. Given that our behavior, our action, is observable, I suspect it has played a role in our tendency to conflate change with behavior. Consider the first two stages we talked about: precontemplation and contemplation. Both of these stages are stages that don't necessary entail observable behavior. These are often stages we are going through quietly, internally, albeit they can be shared with others via disclosure. Action (and preparation) are the stages that are beginning to be seen and confirmed by our external world, by those around us. However, not all changes in behavior 'count' as action. It is often the case that some criteria must be met. For example, with smoking, it may be the case that action doesn't take place until total cessation happens, until one is no longer smoking at all rather than reducing the overall amount of cigarettes. In other words, "people must attain a criterion that scientists and professionals agree is sufficient to reduce risks for disease".

Maintenance is the stage we arrive at once we have maintained our desired changes for approximately 6 months. People here are beginning to develop confidence in themselves, their self-efficacy, to maintain and continue with these changes. People in this stage are working towards preventing relapse. This stage has no limit, which is to say you may be here indefinitely. Many people are. This is the stage I find myself at with my nicotine consumption. Like my vegetarianism, I am a little over a year into my smoking cessation journey, which had previously lasted about 15 years of active use. I feel confident in myself and my ability to maintain the changes I have made, however when I see someone smoking, be it in person or on tv, I find myself often thinking "one of those would be nice". I have, at least so far, not partook, but the temptation is present at times.

Termination is the stage in which people have no desire to return to their previous behavior. There is zero temptations for relapse. As you can imagine, most people don't end up here. Change, as noted above, is a process and one we affirm and say 'yes' to every day. I have not reached this stage with respect to smoking. That much is evident. However, I do find that this place feels like home for my vegetarian efforts. Although I remember enjoying non-vegetarian meals historically, I feel no pull to go back to that in the way I have noted I do with smoking. I have, somehow, managed to achieve "100% self-efficacy". To include some more perspective beyond my anecdotal experience, "in a study of former smokers and alcoholics, we found that less than 20% of each group had reached the criteria of zero temptation and total self-efficacy. The criteria may be too strict, or it may be that this stage is an ideal goal for the majority of people. In other areas, like exercise, consistent condom use, and weigh control, the realistic goal may be a lifetime of maintenance."

For context, the use of self-efficacy in the above is a reference to "the situation-specific confidence people have that they can cope with high risk situations without relapsing to their unhealthy or high risk habit". Likewise, temptation "reflects the intensity of urges to engage in a specific habit when in the midst of difficult situations". Temptation often shows up and manifests as "negative affect or emotional distress, positive social situation, and craving".

As I mentioned above, the transtheoretical model of change is but one model of change in psychology as to how change works. It was the first one I learned, and it seemed appropriate for it to be the first one I share. This model of change is often commonly used in the more behaviorally oriented theoretical frameworks, orientations, and modalities. Other frameworks, other modalities, have different ideas and ways of conceptualizing and thinking of change. The more humanistic and existential therapeutic orientations tend to lean away from the transtheoretical model of change, instead seeing things through the lens of paradoxical change. Paradoxical change is where we will start next time.

However, before we get ahead of ourselves, I wonder while reading this where it has taken you (read: the reader). Do you see yourself in any of these stages, whether historically or currently? Do these ideas resonate with you? Are they discordant? I invite you to take a moment and consider change that you have experienced in your life, does any of this fit what you went through?

Thank you for reading. Cheers and take care.

All quotes were taken from https://pubmed.ncbi.nlm.nih.gov/10170434/

Image provided by Evergreen Therapeutics