Grill and Drill: Transtheoretical Model of Therapy

Breaking down behavior change into manageable stages helps us understand why people struggle to make lasting changes and how we can better support them through the process. The Trans-Theoretical Model provides a practical framework for conceptualizing behavior change as a non-linear journey through six distinct stages, each requiring different therapeutic approaches.

• Pre-contemplation - clients don't recognize they have a problem or need to change
• Contemplation - weighing pros and cons while feeling ambivalent about making changes
• Preparation - planning specific steps and intending to take action within the next month
• Action - actively modifying behavior and implementing new strategies
• Maintenance - sustaining changes for six months or more and focusing on relapse prevention
• Termination - complete confidence in maintaining changes without risk of relapse

Remember the stages with our simple memory trick: PCP AMT (Pre-contemplation, Contemplation, Preparation, Action, Maintenance, Termination)

If you're preparing for your licensing exam, understanding the Trans-Theoretical Model and its stages of change is essential knowledge that will likely appear in your test questions.

If you need to study for your national licensing exam, try the free samplers at:  LicensureExams


This podcast is not associated with the NBCC, AMFTRB, ASW, ANCC, NASP, NAADAC, CCMC, NCPG,  CRCC, or any state or governmental agency responsible for licensure.

Transcript

Eric 0:10

Well, hello there. Welcome to our first Grill and Drill podcast, where we're going to review today the trans-theoretical model Now, if you've been following the podcast, you may have listened to the one from November way back in 2023, on the theory to therapy, which we dealt with, the trans-theoretical model, or also called the stages of change model. So we've been doing it that long, possibly even longer. It's hard to tell, but the TTM, or the trans-theoretical model, is a framework that was developed by James Prochaska and Carlo De Clementi that conceptualizes behavior change as a process that occurs through a series of distinct stages, rather than just one event where you have a bad habit and you stop. They recognized that there was a process to it. Hey, do you have any idea how they figured that out, eric? I bet one of them had an addiction they were trying to get rid of.

Linton 1:11

Yeah, well, that's close. But they received a grant to study how clients become non-smokers and in the process they came out and developed this idea and they called it trans-theoretical model.

Four Key Constructs of TTM

Eric 1:24

Huh, so we can be assured that it wasn't funded by Philip Morris, really. Well, yes, but it does distinguish itself from other approaches because it recognizes that behavior change involves progressing through a bunch of stages, each one characterized by different attitudes, intentions and behaviors, and it acknowledges that relapse is a common occurrence that clients are often cycling through multiple times before they get to the lasting change which anybody that's worked in addictions can tell you. That's how that works, really. So there are four key constructs of it the stages of change, the process of change, the decisional balance of how you decide and the concept of self-efficacy.

Linton 2:12

So basically what I hear you saying, Eric, is that it's just a bunch of different theories that have been thrown together.

Eric 2:18

Well, yes, it is, but it was written in an academic way and, remember, if it's academic and it's research, then that's legitimate, and it draws from a bunch of different theories. That's why it's trans-theoretical. So there are cognitive parts to it, there are behavioral parts to it, so there are all of these, and it ends up being a non-linear kind of thing because, like I said, it goes in a circle. People will, you know, start doing it, relapse, go back, and so it's something that takes that into account and isn't surprised by the fact that people fail to make lasting decisions the first time.

The Six Stages of Change

Linton 2:56

Okay. So of those four key constructs, let's start with the stages of change. In fact, probably if you run into anything on the trans-theoretical model on your licensing exam, it'll be around the stages of change. So the stages of change are the core, basic construct of TTM and what it does. It describes the temporal progression clients go through during their modification of their behavior, right? So the first part of the stages of change is called pre-contemplation. So during pre-contemplations, clients are not considering change, they're unaware that they have any kind of problematic behavior. They don't want to make any kind of changes, at least for at least six months. They don't think there's a problem to address. Like I said, they have really limited insight on how their behavior is linked to the negative consequences that are happening in their lives. They may have tried to modify their behaviors, but they've been unsuccessful in the past and basically they become discouraged. So the concept of the pre-contemplation stage is that they're just not ready and that leads to when they finally are ready.

Eric 4:16

That's the contemplation stage. So pre-contemplation before they start contemplation is where they actually start looking at the pros and cons. They still feel ambivalent, but they're getting their mind around the fact that whatever the people around them think is problematic, they're finally beginning to see it as problematic as well, but they're still flip-flopping. So that's why it might last a while in the contemplation stage and the overall concept then is getting ready.

Linton 4:42

Right. Then they go into the preparation or planning stage. This is when the client is intended to take action soon and they're thinking of maybe having small steps that will help them do that. So they will get a piece of paper. They've written down the pros, they've written down the cons and they've decided that the scales have tipped in the side of pro, that they do need to make changes. So they have intention to make some kind of changes within the first month or so. Basically, the preparation stage is that they are ready. They're ready to make those changes.

Eric 5:18

And then, after you've, you know, done that, now you're in the action phase. You're starting to actually do what it takes to modify your behavior, and some changes are occurring Now. Whether they're lasting or not, that's something else, but you're making the actual steps to change, you know. Whatever the techniques are, however, you modify habits. All of that changes depending on what you're trying to change, but the overall concept is you're doing it.

Linton 5:46

And then after that they go into the maintenance stage. And in the maintenance stage they've been able to change their behaviors for half a year or so and they are still focusing on relapse prevention. So they're still working on consolidating any gains that they've made and their new behaviors have become habitual. They use fewer change processes. So they're sort of in a place where if they went out clubbing, they're not going to pick up a cigarette or they're not going to start drinking at that particular point. They're sort of good to go, so they're continuing to go. So they keep going on with the changes that they've made during the maintenance.

Eric 6:30

And finally the Arnold Schwarzenegger phase, the terminator phase, the termination phase, and you have complete confidence that you have made the changes. You don't need to bother with behavioral aspects of it anymore. You used to smoke and now you never have. It's been quite a while and you don't even think of it anymore. So you actually are ready to stop going to therapy, stop working a process, whatever it was you were doing you thought you had to. You don't need to anymore. So the overall concept is no problem.

Linton 7:03

Okay. So when that happens and you see that your client is able to do that maybe it took five years, I don't know but when they do come to that stage, then it's time for you to do what.

Eric 7:17

It's time for you to have a party. No, it's time for you to terminate the client. Oh yes yes, it's when you, as a therapist, would terminate the client. That's right.

Linton 7:27

Eric, how are you going to remember all this information? I mean, you know you're already studying for the exam, you've got all kinds of different things, so how am I going to remember the stages of change?

Eric 7:39

Well, that's the tough part, isn't? It Is remembering all of this stuff. Okay.

Linton 7:44

Let me help you out here. Do you remember angel deaths from the 60s?

Eric 7:52

Sherm love.

Linton 7:53

Boat.

Eric 7:53

O's Hogg, it sounds like you're talking about how marijuana used to be called Mary Jane, or Marajacuna, or the Devil's Lettuce.

Linton 8:02

This is how you're going to remember the stages of change. Very easy, just remember PCP, amt. Pcp was a drug also known as angel dust. Yes, okay, pcp. Amount pcp it was okay, so okay. So p would stand for the pre-contemplation right, yeah, c was the contemplation.

Eric 8:26

So pre-contemplation contemplation okay, that that makes sense and p for preparation. So okay, preparation yes amount amt a action, action, right, and then maintaining, keep it going right, maintaining, and then finally, uh t termination, termination. Okay T Termination.

Linton 8:46

Termination Okay, termination. Don't look at it and tell me what the stages are. So PCPAMT.

Eric 8:54

So pre-contemplation, right Contemplation, preparation, right Action, maintenance and termination, termination. Okay, I almost got it, okay that's good.

Remembering Stages with PCP AMT

Linton 9:07

So that's the first part of the trans-theoretical model and that's what you need to remember for the exam. I think I'm going to give you some examples and you're going to tell me what stages they are in. Are you ready, right? So you have a client that comes in and says I don't see why I need to reduce my salt and fat consumption. I've been fine without doing that for years, and if I do when I go out to a restaurant I won't be able to eat anything.

Eric 9:37

Okay, so that sounds like they haven't even fathomed the idea that they need to change, which sounds like pre-contemplation. Okay, all right.

Linton 9:46

You got that All right? How about if they said I've decided to only drink celery juice for?

Eric 9:55

breakfast and just today I told my family to get ready. Oh, okay, I've decided to make, so they've gone. They've already contemplated it, right? So they're in the preparation phase. They've decided to do it, but they haven't preparation phase.

Linton 10:07

They've decided to do it but they haven't done it. Exactly. They're planning the preparation. Okay, right, what if your client said you know I should start eating healthier, but I really still enjoy, like you do, mcdonald's and I'm not really ready to give up my Big Mac and fries. Just yet Big Mac. Stop making yet Big Mac.

Eric 10:29

Stop making me hungry man, so all right. So the pre-contemplation was I don't need to be ready. The planning was get ready, I'm doing it. So this must be the contemplation stage. And why is that? Because they're thinking about it, I know I should do it and I've put it in the should do category as opposed to the why are you bothering me category. But I haven't started planning yet. Okay, All right.

Linton 10:56

Is that it? Yeah, that's it, okay. Okay, how about this? Your client tells you that they've been buying their food from Whole Foods and they'd rather do that than go the smoky bones, and they've been doing it for the past two months.

Client Examples for Each Stage

Eric 11:10

They know it's challenging, but they're starting to see some results so a big plate of kale instead of some nice juicy ribs? Hey, so okay, doesn't sound like they've gone into the maintenance stage yet? No, so it sounds like they're gone into the maintenance stage yet. No, so it sounds like they're actually doing it, they're doing something. They're going to Whole Foods, not going to Smokey Bones. So it's action, right, yeah, it is action. Yeah, yeah, okay.

Linton 11:39

All right. How about if they say I've been a vegetarian for eight months now and I've developed new coping strategies, like eating celery sticks when I crave a blooming onion or a juicy steak from Outback?

Eric 11:53

Hmm, so I've been doing it for eight months, so not long enough to really make it a total lifestyle change, but they've set themselves up for success, right yeah. So it doesn't sound like they're ready to terminate yet, but they've been in the action stage for long enough that it's become a new habit. So I'd say maintenance.

Linton 12:15

So if you found yourself in Outback, where would you go?

Eric 12:20

Big juicy steak in front of you and you'd say give me that plate of kale over there. I want some big juicy celery stick, while my friend eats the bloomin' onion and the sirloin steak. Okay, all right, good on you.

Linton 12:36

All right. So lastly, to your chagrin, your client tells you I've been a vegetarian for the last five years. Even when I'm stressed, the thought of eating meat doesn't ever cross my mind.

Eric 12:48

Right, well, that sounds like five years. Yeah, they've been your client for five years. All right, it sounds like it was time for termination about four years ago. Really, okay, okay, yes, I've got to say that sounds like termination time, because if they just don't even think about meat anymore and they, you know, just love being a vegetarian then it sounds like they're ready to terminate the process. Uh-huh, you know that could happen to you, as that's not out of the realm of possibility. Certainly, absolutely okay, I had some celery just last month I just had some celery this morning you.

Eric 13:26

You're on your way, man, there you go Okay.

Linton 13:29

so those are the kind of scenarios that you might find and they may ask you where you are in the stages of change. So again, remember, that is PCP amount.

Eric 13:41

So pre contemplation preparation, wait, wait, pcp. Yeah, p is pre, okay, contemplation. Uh-huh, I didn't say contemplation, okay, all right, you didn't have to say it twice. So pre-contemplation contemplation, right. Preparation, uh-huh. Action m maintenance and termination. Okay, you got, you got it.

Practice Questions for Exam Preparation

Linton 14:06

Now we're going to go and give you some questions. I think I'm ready Shoot. What is the primary reasons clients remain in the pre-contemplation stage? All right, pre-contemplation stage. Lack of motivation, high levels of stress, okay. Lack of awareness about their problems. All right, or success, past experience.

Eric 14:31

So why would I stay in the pre? Why would I stay ignorant of the fact that I have a problem? Right, I'm going to say that I'm so stressed I can't deal with it. B.

Linton 14:42

Close, but no cigar. Oh man, Okay, it's their lack of awareness about their problem. Oh, all right, yes, right, so clients in the pre-contemplation stage are unaware of their problems, which keeps them from even considering change. Their lack of awareness is significant and it's a barrier to moving forward to the change process. All right.

Eric 15:04

One down, all right, try a second one. All right. One down, all right, try a second one.

Linton 15:07

How do clients in the contemplation stage typically feel about changing their behavior?

Eric 15:14

Okay, so we're in the contemplation stage now, and how do they feel about whether they need to change? Okay.

Linton 15:19

Okay. Are they confident and motivated? Ambivalent and conflicted? Okay, unaware and unmotivated. Or successful and satisfied All right.

Eric 15:33

So how do they feel about changing their behavior? Well, if they were successful, they wouldn't be in the contemplation stage. So D is out. And if they were confident and motivated they wouldn't be in the contemplation stage. They'd already be acting on it. So A is out, unaware and unmotivated. See now, that sounds like pre-contemplation to me. It is Unaware and unmotivated, so I'm going to go with B ambivalent and conflicted, right.

Linton 16:01

So when clients are in this stage of the contemplation, they often experience ambivalence. Stage of the contemplation, they often experience ambivalence. They're weighing the pros and cons of changing their behavior, but you know they're still in that whole process. Okay, all right. How does the preparation stage differ from contemplation stage? It involves taking immediate action. It involves weighing pros and cons. It involves planning and intention to act soon or it involves ignoring the problem.

Eric 16:36

So taking immediate action sounds like the action phase, right, so I'm going to rule that one out. Involves weighing the pros and cons. That sounds like the difference between preparation and action to me. That you're weighing the pros and cons, deciding so, instead of contemplation to act, you know, to preparation. That sounds like preparation to action to me. All right, oh, I'm gonna get rid of b. And then involves planning an intention to act soon. Or involves ignoring the problem. Well, ignoring the problem sounds like pre-contemplation. You don't have a problem, what are you bothering me for? So I'm going to go with C on that. Okay, exactly.

Linton 17:20

How can you support clients in the maintenance stage? Could you support them by ignoring their efforts?

Eric 17:28

Yes, providing ongoing support and resources Forcing them to maintain their choices, or by discouraging their action Okay, so ignore their efforts would be to just say you've been doing it okay, and I don't even need to bother because you're on autopilot or providing ongoing support and resources. You're doing it, so keep doing it. Forcing them doesn't sound like therapy. That sounds like what my mother used to do, right. So I'm going to say no to C and then discouraging their actions. That doesn't sound right either. So it's either A or B. A or B, a or B. I'm going to say A You're letting them go. They've done it. They're obviously doing something, right?

Linton 18:17

So no, no, the answer is providing ongoing support and resources. Ok, that's how you as a therapist can assist by offering ongoing support and resources to help them maintain their new behaviors.

Eric 18:32

resources to help them maintain their new behaviors.

Linton 18:33

So really at this stage in maintenance support is critical for preventing relapse.

Eric 18:39

Okay, okay, yes, that does sound more therapist-y.

Linton 18:56

So, okay, how might a therapist approach someone in the pre-contemplation stage? Here are your options Immediately encourage them to take some action, discussing the risk associated with their current behavior, ignoring their current behavior or by forcing them to change. Okay, let's get rid of D, that sounds more like your mom which sometimes it worked.

Eric 19:14

So I gotta give her props on that. But uh, that doesn't sound like a therapisty thing. So d is out, okay, and ignoring doesn't sound like that's going to work either, because if it's really, you know, if we're putting it conceptually in the model, then somebody's not ignoring it. You know you've been smoking for 10 years that that's a problem. You need to deal with it. So I'm going to say discussing the risks B, that's right.

Linton 19:40

What is a common challenge faced by clients in the action stage? Lack of awareness about their problems.

Eric 19:50

No, because they're in the action stage, so they're aware that they have a problem. So A is out. High levels of stress Well, they would have high levels of stress. Yes, although common challenge, I've got to think that not everybody's going to have a high level of stress, okay, so I'm going to put that one off to the side. I've got to hear the rest before I know whether that's okay successful past experiences well, that's not a challenge, so that one's out.

Eric 20:21

Okay, if you've been, if everything's worked, you're not challenged at all. So that wouldn't be a common challenge, okay.

Linton 20:27

So obviously the the last one is maintaining motivation and overcoming obstacles.

Eric 20:34

Yes, that's it.

Linton 20:37

Want another one. Yep, keep going. What is a common challenge faced by clients in the contemplation stage? Common challenge, okay.

Eric 20:47

Lack of resources All right. Lack of resources right.

Linton 20:50

Balancing the pros and cons of changing. High motivation, successful past experiences, yeah, no.

Eric 20:59

So yeah, it's B. It's got to be B because they're weighing the pros and cons right. If they had all the success in the past, they don't need to contemplate, and if they didn't have any resources, then they're probably not contemplating either. So yeah, I go with be there.

Linton 21:16

What is a common misconception about clients in the pre-contemplation stage? They are highly motivated to not change. They're aware of their problems, but choose not to change. They are unaware of their problems all right, or they have successfully changed their behavior they're unaware of their problem.

Eric 21:42

All right, okay, you get it that's. Yeah, I think that's. It is that they. The misconception would be that they're unaware, when they probably are aware, but they just don't want to admit it, right?

Linton 21:57

Well, this has been interesting, as All right, yes.

Eric 22:00

And I got to say, dr Hutchinson, that it's not as complicated. You know, once you have those six down, they sort of sell themselves. Once you, you know, see how that breaks down, right, not that it's easy if you're actually working it, but from once you, you know, see how that breaks down, right, not that it's easy if you're actually working it, but from the outside you could see how they, you know how actions could fall into each of those categories. Exactly, part of the key is to remember the six stages, right PCP, amount, pcp, amt, very good, and remember it's in there, it's in there. Thanks.