{"id":267,"date":"2019-12-04T17:31:11","date_gmt":"2019-12-04T17:31:11","guid":{"rendered":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/chapter\/ch-3-name-5\/"},"modified":"2020-12-07T16:15:02","modified_gmt":"2020-12-07T16:15:02","slug":"ch-3-name-5","status":"publish","type":"chapter","link":"https:\/\/pressbooks.ulib.csuohio.edu\/substancemisusepart1\/chapter\/ch-3-name-5\/","title":{"rendered":"Ch. 7.3: Theory Integration in the Transtheoretical Model of Behavioral Change"},"content":{"raw":"

A great deal of effort both in our course and in research has been directed toward understanding the processes involved in substance use initiation and the progression from use to misuse and substance use disorder. At this point, we examine a model concerned with processes of change and recovery\u2014moving back from problematic and disordered substance use into recovery. The model we focus on in this chapter is known as the transtheoretical model of behavior chang<\/em>e<\/strong><\/a> (the TTM for transtheoretical model, or sometimes the TMBC for the transtheoretical model of behavior change). The model originally emerged in transtheoretical analysis of psychotherapies (Prochaska, 1979; Prochaska & DiClemente, 1982) and continued to evolve during the 1980s and 1990s based on research concerning the process of change in smoking behavior (Prochaska & DiClemente, 1983) and expanded to include other addictive behaviors (Prochaska, DiClemente, & Norcross, 1992). It has been applied across disciplines (social work, psychology, medicine, nursing, physical therapy, occupational therapy, and others) and across a wide array of behaviors, including but not limited to individuals making changes in their smoking (tobacco), alcohol use, adhering to a medication or medical treatment regimen, dieting, exercising, safe-sex, and intimate partner violence behaviors.<\/p>\r\n

Use of the word \u201ctranstheoretical\u201d in the model name reflects its theoretical inclusiveness and that it integrates and applies across theories. The transtheoretical approach represented an important shift in emphasis among intervention options towards identifying mechanisms of change and the elements or factors common across a variety of intervention approaches. The TTM\u2019s developers distilled from research and clinical observation a set of principles describing behavior change processes and factors that facilitate or pose barriers to achieving change goals. The TTM identified a series of five stages in the typical cycle of change, common processes involved in intentional behavior change, and implications for intervening to support individuals\u2019 intentional behavior change efforts.<\/p>\r\n\r\n

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Stop and Think<\/strong><\/p>\r\n

While you review the remainder of this chapter, consider a specific behavior that you have wished or tried to change in the past. See how the model seems to fit your own experience with intentional behavior change (something like getting more sleep, drinking more water, using less electricity, praising your partner or kids more often, spending less money on coffee, stop biting your fingernails, expressing gratitude for small favors others do for us\u2014it does not have to be about an addictive behavior).<\/p>\r\n\r\n<\/div>\r\n

Stages of Change<\/strong><\/h2>\r\n

Like most stage theories, the TTM identified a series of progressive stages that are qualitatively distinct from each other. Originally, the TTM specified four stages: Precontemplation, Contemplation, Action, and Maintenance; data reanalysis led to specification of a fifth stage, Preparation, between Contemplation and Action. An important difference from many other stage theories is acknowledgement that individuals do not move through the stages in a linear \u201cupward\u201d fashion but that they often cycle upwards and downwards through stages as they work to achieve their change goals (Prochaska, DiClemente, & Norcross, 1992). For example, a person perhaps beginning in Precontemplation may progress through some of the other stages, return to prior stages (including back to Precontemplation), and progress again over time, and that this cycle may repeat multiple times before the desired change goal is ultimately achieved. In research concerning smoking cessation, three to four Action attempts occurred before individuals were able to quit smoking for the long-term (Prochaska, DiClemente, & Norcross, 1992)\u2014in other words, relapsing and falling back to earlier stages is normative, not atypical. A determining factor in how quickly someone is able to again move forward in the process concerns how relapse is handled: if seen as a failed attempt, the person may return to precontemplation and remain there for a lengthy period; if seen as an opportunity to learn from one\u2019s mistakes, identify potential pitfalls and solutions, the person may move more quickly back into action instead. In fact, one criticism of the TTM is that individuals may move between stages so quickly that assessment tools are rendered inaccurate, and that a person may be situated between stages rather than in a single stage.<\/p>\r\n

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Another observation made by the model\u2019s developers was that what a person learns about changing one type of behavior may help them learn what will or will not help them change a different type of behavior. However, if someone is concerned about changing two or more behaviors at the same time, the change process for each will most likely differ\u2014in other words, a person may be in one stage for one behavior change effort and a different stage for another. Consider, for example, that someone wishes both to quit smoking cigarettes and to quit drinking alcohol to excess. Each of these change attempts, although occurring at the same time, will progress on its own trajectory (Velasquez, Crouch, Stephens, & DiClemente, 2016). The individual may move through the cycle more quickly with one behavior compared to the other and may spiral back and forward more times. It is difficult enough to change an addictive behavior; it is far more difficult to change more than one at a time.<\/p>\r\n

The five stages identified in the TTM distinguish between the different behaviors, attitudes, experiences, and motivations representing each stage.<\/p>\r\n

Precontemplation.<\/strong> The hallmark of Precontemplation<\/em><\/strong><\/a> is the absence of an intent to change the identified behavior, at least not in the foreseeable future. This includes individuals who are un- or under-aware of a need to make changes. It also may include someone who wishes they could change but does not seriously intend to make the changes wished for. This stage also may involve resistance to change in response to pressure from others. For example, if a person is compelled to quit smoking while incarcerated in jail or prison, that individual may only comply as long as extrinsic (external) pressure is applied. There may be no intention to extend the change in behavior to the post-release period. The kinds of statements endorsed by someone in this stage include denial that a problem exists, that the behavior is not problematic, or that it is \u201ctheir\u201d business and no one else\u2019s concern. On the other hand, they may engage in blame about the problem (\u201cIf I drink too much, it is because you are always nagging me\u201d) or focus on an inability to change (\u201cI have tried to quit smoking too many times, face it\u2014I am just a failure\u201d or \u201cIt is in my genes, I am destined to die this way.\u201d)<\/p>\r\n

Contemplation.<\/strong> A person in the Contemplation<\/em><\/strong><\/a> stage demonstrates awareness of a problem and serious consideration of making a change without making a specific change commitment. One characteristic of the Contemplation stage is the person struggling with the \u201cpros and cons\u201d dilemma\u2014the advantages of making the change versus the disadvantages. For example, someone might realize the health benefits of changing their binge drinking and appreciate the amount of money that could be saved by making a change, but at the same time recognize that they like drinking, would be lonely without binge drinking with \u201cbuddies,\u201d and that it will take a great deal of effort to make this change (see discussion of decisional balance below). An intention to make significant change within the next six months is considered a characteristic of Contemplation. However, individuals may remain in Contemplation for lengthy periods (despite the \u201cwithin six months\u201d intent) without moving further in the process\u2014for two years or more among a group of participants in a smoking study (Prochaska, DiClemente, & Norcross, 1992). Examples of statements that a person in Contemplation might endorse generally include awareness of a problem and a desire to make a change: \u201cI think I may have a problem with my drinking,\u201d \u201cI am really starting to feel the effects of my smoking when I try to walk upstairs,\u201d \u201cI am getting to the point where I can\u2019t keep doing this to myself anymore.\u201d A person in Contemplation might engage in information-gathering, exploring options for how to make the desired change (even looking into formal intervention\/treatment options), but not actually engage with or commit to any of them.<\/p>\r\n

Preparation.<\/strong> The Preparation<\/em><\/strong><\/a> stage extends beyond an intent to change to include early change behaviors toward the goal of taking serious action within the next 30 days. They will have set a plan in motion, even if not actively engaged in it yet, and have set a target day\/date for the action to begin. For example, the person may enroll in a change-focused program, identify a specific change strategy or plan, and may begin taking \u201cbaby-steps\u201d toward the change goal. For example, a person preparing to quit smoking may purchase supply of nicotine replacement \u201cpatches\u201d or gum, schedule an appointment for prescription smoking cessation medication, register with a smoking cessation program. In addition, they may break their cigarettes in half to smoke less when they do smoke and gather together all their \u201cstashed\u201d cigarettes into one, visible collection. They may tell friends and family to refuse their requests to \u201cbum\u201d cigarettes and not invite them to share a smoking session.<\/p>\r\n

Action.<\/strong> The Action <\/em><\/strong><\/a>stage is characterized by a person actively taking very specific, concrete steps to change the target behavior and keep the change momentum going. For a behavior as complex as quitting drinking, for example, the person may engage in a host of strategic alternative behaviors: avoiding the people, places, and situations that tempt them to drink; applying strategies for controlling their mood (e.g., mindfulness practices) and stress management (e.g., exercise); grocery shopping online to avoid impulse alcohol purchases in the store. Additionally, they may have new ways of rewarding themselves for each positive step taken (e.g., putting money that would have been spent on alcohol into an account toward a positive goal; celebrating their \u201csobriety birthday\u201d each week, then month, then year), and reminding themselves of their accomplishments (e.g., journaling their efforts, experiences, and progress). Action is very often the emphasis in treatment programs\u2014teaching, training, and practicing the new skills. A person in Action has specific skills and behaviors to substitute for and manage the old, problematic behaviors and they consciously act to implement these new behaviors. Action, by definition, lasts for at least 6 months and may last much longer for some individuals and some behaviors. Big changes in complex behaviors do not happen overnight. This is a person engaged in multiple, sometimes heroic, action efforts as they are fighting to achieve their change goals.<\/p>\r\n

Maintenance.<\/strong> Once a person has engaged in action behaviors for at least 6 months, they may move into a M<\/em><\/strong>aintenance<\/em><\/strong><\/a> phase\u2014a period of continued vigilance against relapsing to the past behavior. Individuals continue to engage in relapse prevention activities, but it differs from the Action period in that the new changed\/alternative behaviors, attitudes, and experiences are becoming routine and feel relatively natural. They require less effort to maintain. During maintenance, a person continues to be aware that it would take only one \u201cslip up\u201d action to undo their hard work but takes many daily \u201cnon-actions\u201d to avoid relapse\u2014consistently avoiding temptations and relapse triggers, engaging in competing alternative behaviors, and managing temptations and relapse triggers when they do appear. A person in maintenance is not \u201ccured\u201d as long as there are temptations or craving experiences\u2014the maintenance period may persist for a very long period, possibly indefinitely for some individuals. However, a person who managed to quit smoking cigarettes (for example) may reach a point when there is no longer any desire to pick it up again, none of their old cues trigger a temptation or desire to smoke, and they self-identify as a non-smoke (rather than an ex-smoker), even in periods of stress\/distress. At the point where the changed behavior is relatively effortless, the person may be considered to have moved beyond maintenance.<\/p>\r\n

Relapse.<\/strong> Understanding the change process is incomplete without recognizing what relapse<\/em><\/strong><\/a> is and how it might be addressed. Ideally, we want to prevent relapse to the \u201cold\u201d behavior whenever possible; but as the evidence indicates, relapse happens (may even be a \u201cnorm\u201d rather than an exception) and what happens in response to relapse matters very much in the future of a change effort. First, a distinction is made between a recurrence (\u201cslip\u201d) and a full-blown relapse event. A lapse<\/em><\/strong><\/a> or \u201cslip\u201d is time\/event limited\u2014doing it once or more times for a short period, quickly regretting the lapse, and getting back to renewed action. The circumstances surrounding a lapse can be effectively used as a learning experience to strengthen the ongoing change effort for the future. Relapse refers to a return to the old pattern of behavior with no intention of changing again\u2014spiraling back to Precontemplation, especially if the person despairs of ever being able to successfully change. A lapse, relapse, or impending relapse can happen at any point in the change process.<\/p>\r\n

Relapse is a process (rather than an event) that starts before substance use occurs again\u2014it is \u201ca gradual process with distinct stages\u201d (Melemis, 2015). The relapse process may begin days or even months before the actual substance use relapse behavior occurs and can be conceptualized in three parts.<\/p>\r\n\r\n