The Transtheoretical Model (TTM) of behavior change has become almost universally accepted in addiction treatment. Like all dogmas, it is rarely critically examined, leading to blind belief and unskilled use.
In a nutshell, the TTM assesses an individual’s readiness to both change problem behaviors and act on new, more positive behaviors. The model holds that change occurs across a continuum of six stages beginning with no desire to change and culminating in changes that are hardwired.
These stages include precontemplation, contemplation, preparation, action, maintenance, and termination. Distinct from these stages of change, various “processes of change” are the essential ingredients, or underlying mechanisms, propelling change.
In this article, we’ll rewind to the TTM’s genesis. Next, we’ll fast forward a few decades and look at its use in addiction treatment. Finally, we’ll consider some effectiveness data that severely challenge the model, at least for substance abuse treatment.
In the Beginning
James O. Prochaska, PhD, a major figure in contemporary psychology, developed the TTM in the 1970s. Then, like now, there were hundreds of competing theories of psychotherapy (Glanz K et al, eds. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco, CA: Jossey-Bass; 2008:97–121). Moreover, there wasn’t a clear model for understanding and facilitating behavioral change.
Prochaska and his colleagues analyzed and compared 18 types of psychotherapy to create a comprehensive model for change that cut across various theories. (Transtheoretical means “across theories.”) That work resulted in the familiar “stages of change” concept, plus three other components that make up the TMM: processes of change, decisional balance, and self-efficacy.
Stages of change, widely used in substance abuse treatment, is perhaps the TTM’s most enduring idea (see The Stages of Change on p. 3 for more on those stages).
Maintenance of a new behavior, the usual goal of treatment, can take up to five years to achieve. In fact, a minority of patients ever reach the final stage of termination—where they have zero temptation and are sure they will not return to their old behavior—and act “as if they never acquired the [problem] behavior in the first place” (Glanz K et al, ibid).
Processes of Change
Clinicians are much less familiar with the TTM component known as processes of change. These are defined as the “covert and overt activities that people use to progress through stages [of change]” (Glanz K et al, ibid). On a more basic level, “any activity that you initiate to help modify your thinking, feeling, or behavior is a change process” (Prochaska JO et al, Changing for Good. New York, NY: William Morrow & Co; 1994:25).
So, for instance, a change process might be realizing how problem drinking affects other family members and how the client could have more positive relationships by changing the behavior. From an addiction treatment standpoint, this is where the rubber meets the proverbial road.
The processes of change reside in a middle ground between specific psychological theories and actual therapeutic techniques (Prochaska JO, Norcross JC, Systems of Psychotherapy: A Transtheoretical Analysis. 8th ed. Independence, KY: Cengage Learning; 2014:9).
As examples, in psychoanalysis (theory), clinicians might facilitate this process of change through free association (technique). In person-centered therapy (theory), by comparison, clinicians tend to employ reflection (technique). In cognitive therapy (theory), clinicians challenge clients’ illogical and irrational thinking (technique). And so on.
TTM in Addiction Treatment
The TTM stresses “doing the right thing at the right time,” that is, tailoring interventions to where a client is in the stages of change. This is where addiction treatment often goes off the rails. In many cases, wrong interventions occur: the clinician employs non-specific methods or uses change-promoting techniques at the wrong stage of change.
Psychologist Mary Marden Velasquez, PhD, and colleagues developed perhaps the most robust TTM-based approach to addiction treatment (Velasquez MM et al. Group Treatment for Substance Abuse. New York, NY: The Guilford Press; 2001). Therapy sessions proceed in a linear manner through the stages of change. The change processes for each session are clearly specified and linked to clinician interventions and strategies. When used in a group format, the recommended structure is:
- Group size: 8–12 patients
- Group frequency: 1–3 times per week
- Session length: 60–90 minutes
- Program duration: 29 sessions
The first five sessions, for example, are designed to raise consciousness about the extent of substance use, severity of addiction, and possible reasons for substance use. Clients identify their present stage of change and complete a “Day in the Life” exercise describing current substance use.
The Alcohol Use Disorders Identification Test (http://bit. ly/18Q6dWV) and Drug Screening Inventory are administered to benchmark disease severity. Clients also complete an instrument that explores positive expectancies. Some sample questions, which are true/false in nature, are:
- Using alcohol or other drugs makes me feel less shy
- I’m more romantic when I use alcohol or other drugs
- Alcohol or other drugs help me sleep better
Does it Work for Addiction?
So far, so good. But here’s a question: does TTM actually work for addiction? The answer may surprise you.
Although the TTM literature is vast, essentially all addiction studies have dealt with only smoking cessation. A large narrative review concluded that there are more positive studies than not and that higher quality studies tended to support stage-based interventions (Spencer L et al, Am J Health Promot 2002;17(1):7– 71).
Subsequent meta-analyses, however, cast considerable doubt on stage-based approaches. Two found little evidence that tailoring interventions to stages of change achieved better outcomes than other treatments and non-treatment controls (Riemsma RP et al, BMJ 2003;326(7400):1175–1177; Bridle C et al, Psychol Health 2005;20(3):283–301). Moreover, TTM-based approaches weren’t particularly effective in promoting forward movement through the stages of change.
The most recent meta-analysis looked at 15 studies involving about 12,000 smokers (Noar SM et al, Psychol Bull 2007;133(4):673–693). Tailored interventions showed very slight benefit, at best, with the pooled outcome falling below the usual threshold for a small effect size. Keep in mind that “a medium effect size is conceived as one large enough to be visible to the naked eye” (Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2d ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988:26).
So the benefit of TTM, if real, probably isn’t clinically meaningful. All sorts of reasons exist for these findings. One of the biggest problems is the ability to accurately stage patients. As noted previously, wrong stage equals wrong intervention and (if TTM holds water) lower probability of change.
More fundamentally, there are serious questions about the stages themselves. Critics have noted that the criteria for the various stages are arbitrary and that patients’ intentions are neither coherent nor stable over time (West R, Addiction 2005;100(8):1036–1039). For example, multiple studies have demonstrated that a substantial proportion of smokers try quitting out of the blue (and often succeed) without preceding behaviors consistent with the stages of change (Ferguson SG et al, Nicotine Tob Res 2009;11(7):827–832).
CATR’s TAKE: TTM has been around forever and is so intuitive that it’s unsettling to consider that it might not work for addiction treatment. At minimum, TTM probably oversimplifies the complex, nonlinear nature of change. Although alternative models and methods exist and are being tested, we’re not quite ready for a wholesale paradigm change. TTM will likely continue to benefit some clients but clinical failures or clients who succeed without it shouldn’t surprise us.