Transtheoretical model

1. Introduction

Version followed: the Prochaska–DiClemente Transtheoretical Model (TTM) with five stages (precontemplation, contemplation, preparation, action, maintenance; termination noted as an optional end point) and ten processes of change, as set out by the URI Cancer Prevention Research Center (adapted from Velicer, Prochaska, Fava, Norman & Redding, 1998) and applied to psychotherapy in Norcross, Krebs & Prochaska (2011). The five levels of change come from secondary summaries of Prochaska & DiClemente and Prochaska & Norcross (primary chapters not drawn on).

The TTM is a framework, not a single therapy. It does not supply its own techniques. It tells the clinician when to use which kind of change activity, drawn from many therapy systems, according to the client's readiness for one specific problem. It was developed from the late 1970s by James Prochaska and Carlo DiClemente (University of Rhode Island), first from studies of smokers who quit on their own, and later extended with John Norcross to psychotherapy [source: SAGE encyclopedia intro; URI CPRC detailed overview; Norcross et al. 2011].

Core idea of change: intentional change is a process over time, not a single event. People move through ordered stages of readiness, often cycling back several times. Movement between stages is driven by a small common set of covert and overt processes of change. It is tracked by shifts in decisional balance (pros vs cons of changing) and in self-efficacy (confidence to avoid relapse) versus temptation. Outcomes improve when the processes and the therapist's stance fit the client's current stage. Stages answer when change happens, processes how, and levels what must change [source: URI CPRC; Norcross et al. 2011; Mayor 1995].

2. Framework

The framework is organised by stage, assessed separately for each target problem. Stages are defined by intention and time criteria. Each stage is a span of time plus a set of tasks the client must complete to move on [source: Norcross et al. 2011; URI CPRC].

[source: URI CPRC detailed overview; Norcross et al. 2011; termination per Wikipedia summary citing Prochaska & Velicer 1997]

Regression and recycling. Regression (moving back a stage) can occur from any stage. Relapse is regression from action or maintenance. Most people who relapse return to contemplation or preparation, not precontemplation (about 15% go all the way back, for smoking and exercise). Most people cycle through the stages several times before lasting maintenance, which the 1992 paper calls the "spiral" pattern [source: URI CPRC; Mayor 1995; Wikipedia].

Markers for moving between stages. These patterns are used as progress markers alongside self-reported intention [source: URI CPRC]:

• Decisional balance. For an unhealthy behaviour, the pros of the behaviour outweigh the cons in precontemplation, the two are about equal in contemplation, and the cons outweigh the pros in later stages. For a healthy behaviour to adopt (e.g. exercise), the pros of change stay high into action and maintenance.
• Self-efficacy rises and temptation falls steadily across the stages. Both are most sensitive to later-stage change and predict relapse.
• Process use is lowest in precontemplation, peaks in the middle stages and declines in maintenance. Experiential processes peak earlier and behavioural processes later.

Typical session count and format. The TTM prescribes no fixed course. It overlays whatever treatment is being given, and stage is reassessed as the work goes on.

• The SAGE entry by Prochaska says tailored TTM counselling typically takes about three sessions of 20–45 minutes, guided by evidence-based algorithms.
• Population programmes have used computerised expert systems that deliver individually tailored reports at assessment points over months. One weight-management trial used up to three tailored reports, one per behaviour, at baseline, 3, 6 and 9 months [source: SAGE intro; Wikipedia summary of trials] [uncertain: details of the expert-system algorithms].
• In psychotherapy, success within a time-limited course can mean moving one stage, such as from precontemplation to contemplation [source: Norcross et al. 2011].

Levels of change (what is treated). The TTM organises the content of therapy on five interrelated levels [source: Mayor 1995; Piotrowski 2007; Wikipedia, citing Prochaska & DiClemente 2005 and Prochaska & Norcross 2014]:

1. Symptom or situational problems
2. Maladaptive cognitions
3. Current interpersonal conflicts
4. Family or systems conflicts
5. Intrapersonal (long-standing personality) conflicts

Intervention usually starts at the symptom or situational level. Change happens most easily there, it is usually why the client came, it is the most conscious level, and because the levels are linked, change there tends to spread to other levels [source: Mayor 1995]. The developers have said that therapist and client should agree on the level being targeted [source: Wikipedia, citing Prochaska & DiClemente 2005] [uncertain: primary chapter].

3. Guiding principles

• Change is a process over time, not an event. Plan for multiple sessions and multiple attempts; judge progress by stage movement, not only by behaviour [source: URI CPRC].
• People at every stage can be helped; never assume readiness. Offer something useful to the client who does not want to change yet, instead of refusing or discharging them [source: URI CPRC].
• "Assess the client's stage of change" for each problem separately, and reassess, because stage is problem-specific [source: Norcross et al. 2011].
• "Beware treating all patients as though they are in action." Most clients are not ready for action, so action-only plans cause dropout. Match the plan to the stage [source: Norcross et al. 2011; URI CPRC].
• "Set realistic goals by moving one stage at a time." Count movement from precontemplation to contemplation as a real gain [source: Norcross et al. 2011].
• "Treat precontemplators gingerly." Pushing for action drives them away. Do not blame "resistance" on the client before examining your own fit [source: Norcross et al. 2011].
• "Tailor the processes to the stages." Use experiential and awareness processes early and behavioural processes late [source: Norcross et al. 2011; URI CPRC].
• "Avoid mismatching stages and processes." Insight without action stalls a client who is ready to act. Action without the earlier awareness and decision work gives only temporary change [source: Norcross et al. 2011; Mayor 1995].
• Match the relationship as well as the technique. Shift your stance (nurturing parent, Socratic teacher, coach, consultant) as the client moves [source: Norcross et al. 2011].
• Practise integratively. Borrow techniques from any therapy system as long as they deliver the process the stage needs [source: Norcross et al. 2011].
• "Anticipate recycling." Build relapse planning in from the start, and frame relapse as returning to an earlier stage, not failure. This reduces client shame and therapist guilt [source: Norcross et al. 2011].
• Work with natural change processes. Strengthen what successful self-changers already do rather than imposing foreign methods [source: URI CPRC].
• Do the right things at the right time. The same technique can help in one stage and hinder in another [source: Mayor 1995].
• Prefer reward to punishment, and offer a few choices. Reinforce steps toward change. Two or three options strengthen commitment, while four or more add nothing [source: URI CPRC].
• Measure more than the end behaviour. Track decisional balance, self-efficacy and temptation, and stage, so you can see small gains before behaviour changes [source: URI CPRC].
• Agree on the level of change and start at the most accessible one. Move to deeper levels only when needed [source: Mayor 1995; Piotrowski 2007; Wikipedia].

4. Intervention inventory

The TTM's own procedures are (A) assessment and matching tools, (B) the ten processes of change, which the clinician delivers using techniques from any therapy system, and (C) stage-matched relationship and planning procedures. The URI CPRC gives example techniques for each process; the step-by-step clinical wording below is mine unless quoted [source: URI CPRC; Norcross et al. 2011].

A. Assessment and matching

A1. Stage assessment (staging questions)

• Purpose: Place the client in a stage for one specific target, to choose processes and stance. Use it at intake, whenever a new target arises, and periodically [source: Norcross et al. 2011].
• Steps:
  1. Define the target behaviour precisely, e.g. "drinking more than two drinks on weeknights", not "my drinking" [source: Piotrowski 2007].
  2. Ask the time-anchored questions in this order: Have you already changed it? If so, for more or less than 6 months? If not, do you intend to change it in the next 30 days? In the next 6 months?
  3. Score the stage: more than 6 months changed = maintenance; under 6 months = action, but only if the change meets an accepted criterion such as total abstinence; intends within 30 days, with some recent step = preparation; intends within 6 months = contemplation; no intention = precontemplation [source: URI CPRC; Norcross et al. 2011].
  4. Repeat for every problem on the list. A client with several disorders can be in different stages for each [source: Norcross et al. 2011].
  5. Re-stage at intervals and after any lapse.
• Example language (illustrative): "Thinking just about the bingeing, not everything else: are you planning to do anything about it in the next month? What about in the next six months?"
• Watch for: A "yes" given to please you, so check it against what the client actually did in the past year. Cutting down without reaching the criterion is preparation, not action [source: URI CPRC]. The assessment itself can nudge a precontemplator [source: Piotrowski 2007].

A2. Standardised stage measures (URICA, SOCRATES)

• Purpose: Continuous stage profiles for complex or research-minded practice [source: Norcross et al. 2011].
• Steps:
  1. Choose the instrument. The URICA (University of Rhode Island Change Assessment) has 32 items scored on four continuous scales: precontemplation, contemplation, action and maintenance. It is the measure used most often in psychotherapy research. SOCRATES has 19 items for problem drinking, scored on three scales: ambivalence, recognition and taking steps.
  2. Administer the instrument with the problem named at the top.
  3. Read the profile rather than forcing one category, e.g. high contemplation together with high precontemplation.
  4. Feed the results back to the client (B1) [source: Norcross et al. 2011]. Items are not reproduced here; use the published versions.
• Example language (illustrative): "Your answers show you've been thinking about this a lot, and also that part of you isn't sure it's a problem. Both make sense. Shall we look at that?"
• Watch for: Profiles that conflict with your clinical staging. Ask the client about the discrepancy. Re-administer to track movement [synthesis].

A3. Decisional balance assessment and exercise

• Purpose: Map the pros and cons of changing. Use it in precontemplation and contemplation, and to track movement, since the cons of the problem behaviour should overtake its pros as the client progresses [source: URI CPRC, drawing on Janis & Mann].
• Steps:
  1. Draw a grid: pros of the current behaviour, cons of the current behaviour, pros of changing, cons of changing.
  2. Elicit each box in the client's own words. Start with the pros of the current behaviour so the client feels understood [synthesis].
  3. Rate the importance of each item.
  4. With a precontemplator, explore how they may underrate the pros of change and overrate the costs [source: Norcross et al. 2011; Wikipedia].
  5. Revisit the grid later to see whether the balance has shifted.
• Example language (illustrative): "What does smoking do for you? ... And what's the downside? ... If you did stop, what would you gain, and what would you miss?"
• Watch for: A balance that stays even for months, which suggests chronic contemplation (see 5). In contemplation the pros and cons are typically about equal [source: URI CPRC].

A4. Self-efficacy and temptation assessment

• Purpose: Find high-risk situations and confidence gaps. Use it in preparation, action and maintenance, where these measures predict relapse [source: URI CPRC; DiClemente 1981 and 1986, cited there].
• Steps:
  1. List situations in three typical clusters: negative emotions or distress, positive social situations, and craving or habit.
  2. For each situation, rate temptation (0–10) and confidence to resist (0–10).
  3. Target the situations with high temptation and low confidence using counterconditioning and stimulus control (B6, B8).
  4. Re-rate them over time [source: URI CPRC; rating format synthesis].
• Example language (illustrative): "On a Friday with friends who are drinking, how tempted would you be, 0 to 10? How sure are you that you'd stick to your plan?"
• Watch for: Confidence that is far above recent behaviour (overconfidence early in action). Confidence and temptation should move in opposite directions as the client improves [source: URI CPRC].

A5. Level-of-change selection

• Purpose: Decide what to work on: symptom or situation, cognitions, current interpersonal conflict, family or system, or intrapersonal conflict [source: Mayor 1995; Piotrowski 2007].
• Steps:
  1. Start with the symptom or situational level unless the client's formulation points elsewhere [source: Mayor 1995].
  2. Agree the level explicitly with the client [source: Wikipedia, citing Prochaska & DiClemente 2005].
  3. Stage the client separately for each level. They may be in action on the symptom but in precontemplation about a marital conflict that maintains it [source: Piotrowski 2007].
  4. If progress stalls, check whether a problem at another level needs its own staging and intervention [source: Piotrowski 2007].
  5. Pick techniques suited to the level. Secondary summaries map behavioural and exposure methods to the symptom level, cognitive therapies to cognitions, interpersonal therapy to interpersonal conflict, family therapies to systems, and psychodynamic, existential or Gestalt work to intrapersonal conflict [source: Wikipedia, citing Prochaska & Norcross 2014]. The original texts also describe named strategies for moving between levels. Their wording is [uncertain].
• Example language (illustrative): "We could start with the panic attacks themselves, or with the worry about your marriage that seems to feed them. Where would you like to begin?"
• Watch for: Working on a deeper level the client has not agreed to, which is a mismatch [synthesis].

A6. Process-use review

• Purpose: See which change processes the client already uses or neglects, to spot a mismatch such as willpower-only attempts with no stimulus control. Process measures exist, e.g. Prochaska, Velicer, DiClemente & Fava 1988, cited by the URI CPRC; they are not drawn on [uncertain].
• Steps:
  1. Ask how the client tried to change before.
  2. Sort the strategies they describe into the ten processes.
  3. Note which processes were missing for the stage they were in [synthesis].
• Example language (illustrative): "Last time you quit, what did you actually do differently day to day?"
• Watch for: Over-reliance on awareness processes in action, or on behavioural tricks without commitment [source: Norcross et al. 2011].

B. The ten processes of change (deliver stage-matched)

Suggested use by stage transition [source: URI CPRC; Norcross et al. 2011; Mayor 1995; minor differences between sources marked [uncertain]]:

• Precontemplation → contemplation: consciousness raising, dramatic relief, environmental reevaluation.
• Contemplation → preparation: self-reevaluation.
• Preparation → action: self-liberation.
• Action → maintenance: counterconditioning, stimulus control, reinforcement management, helping relationships.
• Social liberation: used across stages and most reported in precontemplation [source: Mayor 1995].

B1. Consciousness raising

• Purpose: Increase awareness of the causes, consequences and cures of the problem. It is the main precontemplation and contemplation process [source: URI CPRC].
• Steps:
  1. Ask permission to share information.
  2. Give personalised feedback from the assessment: the client's own data compared with norms or risks. URI examples include feedback, education, media and bibliotherapy.
  3. Ask what the client makes of the information.
  4. Offer reading or media to explore between sessions [source: URI CPRC; sequence synthesis].
• Example language (illustrative): "Would it be OK if I showed you what your questionnaire suggests? ... What stands out for you?"
• Watch for: Defensiveness, which means the delivery is too forceful, so soften and return to the client's view. Do not continue awareness work once the client is ready to act [source: Norcross et al. 2011].

B2. Dramatic relief (emotional arousal)

• Purpose: Arouse and then relieve feelings about the problem. Feelings often lessen once an appropriate action is available. Use it in early stages [source: URI CPRC].
• Steps:
  1. Invite emotional engagement through role play, psychodrama, personal testimonies, or anticipatory grieving for what the problem has cost [source: URI CPRC; Norcross et al. 2011].
  2. Allow the feeling to be expressed.
  3. Link it to the possibility of action, so relief follows arousal.
• Example language (illustrative): "When you pictured your daughter seeing you that night, what did you feel? ... And what might it be like if that didn't have to happen again?"
• Watch for: Overwhelm or shame without any route to relief. Keep arousal tolerable and always end with a path forward [synthesis].

B3. Environmental reevaluation

• Purpose: Assess how the behaviour affects others and the client's social environment, including their role as a model, positive or negative. Use it in early stages [source: URI CPRC].
• Steps:
  1. Explore who is affected and how, using empathy training, documentaries or family interventions [source: URI CPRC].
  2. Ask the client to take the perspective of someone close to them.
  3. Ask what kind of example they want to set.
• Example language (illustrative): "If your son described your drinking to a friend, what would he say? What would you want him to be able to say a year from now?"
• Watch for: The exercise turning into blame or guilt-tripping. Keep it exploratory [synthesis].

B4. Social liberation

• Purpose: Increase social opportunities and alternatives that support change, especially for disadvantaged or stigmatised clients. Examples include advocacy and policy changes such as smoke-free zones [source: URI CPRC]. It is used across stages and is most reported in precontemplation [source: Mayor 1995].
• Steps:
  1. Identify supports or alternatives in the client's world, such as peer groups, smoke-free housing or medication access.
  2. Help the client reach them, and advocate where appropriate.
  3. Challenge belief-level barriers, such as the belief that only people who cannot function take medication [source: Piotrowski 2007].
• Example language (illustrative): "Lots of people in your building have gone smoke-free since the new rule. What do you make of that?"
• Watch for: Practical barriers (cost, transport, stigma) that you can help remove [synthesis].

B5. Self-reevaluation

• Purpose: A cognitive and emotional appraisal of one's self-image with and without the problem: imagining the improved self. It is the key contemplation-to-preparation process [source: URI CPRC; Norcross et al. 2011; Mayor 1995].
• Steps:
  1. Clarify the client's values: what matters most and the kind of person they want to be.
  2. Use imagery of the future self with and without the problem.
  3. Identify healthy role models the client admires.
  4. Name the discrepancy between the present self and the valued self, and let the client draw the conclusion [source: URI CPRC lists values clarification, healthy role models and imagery; sequence synthesis].
• Example language (illustrative): "Picture yourself a year from now, still doing this. Now picture a year from now having changed it. What's different about you in the second picture?"
• Watch for: A shift from "I should" to "I want", and statements about identity ("I'm not a smoker anymore") [synthesis].

B6. Self-liberation (commitment) and offering choices

• Purpose: Build the belief that one can change, and the commitment and recommitment to act on it. It is the key preparation-to-action process [source: URI CPRC; Mayor 1995].
• Steps:
  1. Present two or three concrete options. The URI CPRC reports that two choices increase commitment, three increase it further, and four add nothing. For smokers, for example, the options might be stopping all at once, gradual reduction, or medication support arranged with the prescriber.
  2. Ask the client to choose one.
  3. Make the commitment public, e.g. by telling others or a written commitment. The social-disclosure step comes from a Wikipedia summary; other commitment techniques are [synthesis].
  4. Set a start date within the month.
  5. Plan recommitment after any lapse [source: URI CPRC; Wikipedia].
• Example language (illustrative): "There are a few ways people do this: all at once on a set day, cutting down gradually, or with medical help. Which fits you best? ... Who will you tell?"
• Watch for: Commitment given before the decisional balance has tipped, which is fragile. Overwhelming the client with too many options [source: URI CPRC].

B7. Stimulus control

• Purpose: Remove cues for the problem behaviour and add prompts for healthier alternatives. Use it in action and maintenance [source: URI CPRC; Norcross et al. 2011].
• Steps:
  1. Map the cues: places, people, times, objects and feelings.
  2. Redesign the environment, e.g. remove supplies or change routes.
  3. Plan avoidance or escape for high-risk situations.
  4. Add positive prompts such as reminders and visible cues for the new behaviour.
  5. Link the client to self-help groups [source: URI CPRC lists avoidance, environmental re-engineering and self-help groups; sequence synthesis].
• Example language (illustrative): "Where is the bottle kept now? What would it take to have none in the house for the first month?"
• Watch for: Cues the client hasn't noticed. Check the A4 temptation list for situations stimulus control hasn't covered [synthesis].

B8. Counterconditioning

• Purpose: Substitute healthier responses for the problem behaviour. Use it in action and maintenance [source: URI CPRC; Norcross et al. 2011].
• Steps:
  1. For each high-risk situation from A4, choose a substitute response: relaxation, assertion, cognitive substitution, exposure, or a healthier activity. Medically supervised options such as nicotine replacement are arranged with a prescriber.
  2. Rehearse the substitute response in session, e.g. by role-playing an assertive refusal.
  3. Practise it between sessions and review the results [source: URI CPRC; Norcross et al. 2011; rehearsal steps synthesis]. When exposure is the substitute response, follow standard exposure safeguards: informed consent, a graded hierarchy, and screening for contraindications [synthesis].
• Example language (illustrative): "When the craving hits after work, what could you do in its place for ten minutes? Let's practise what you'll say if they offer you one."
• Watch for: Substitutes that are themselves risky. Track whether temptation ratings fall [source: URI CPRC].

B9. Reinforcement (contingency) management

• Purpose: Reward steps toward change, and reduce the rewards of the problem behaviour. Use it in action; it peaks early in action [source: URI CPRC; Mayor 1995].
• Steps:
  1. Agree small, frequent rewards for specified steps, set by the client or by others.
  2. Write a contingency contract if useful.
  3. Use overt and covert reinforcement, such as positive self-statements.
  4. Arrange group recognition where available.
  5. Emphasise reward over punishment. The URI CPRC notes that successful self-changers rely mainly on rewards [source: URI CPRC].
• Example language (illustrative): "Each smoke-free week, the money goes in the jar for the trip. What will you say to yourself on day seven?"
• Watch for: Rewards that lose their pull, or self-punishment after lapses. Rotate rewards and reframe lapses (C5) [synthesis].

B10. Helping relationships

• Purpose: Provide caring, trust and support for change. These include rapport with the therapist, a therapeutic alliance, counsellor calls and buddy systems. The process is used throughout and most relied on in action and maintenance [source: URI CPRC; Mayor 1995].
• Steps:
  1. Identify a supportive person.
  2. Agree what help the client wants from them, e.g. a phone call at a high-risk time, or no lectures.
  3. Use brief between-session check-ins if your service allows.
  4. Involve family where appropriate [source: URI CPRC; steps synthesis].
• Example language (illustrative): "Who in your life would be glad to help, and what exactly would be helpful for them to do or not do?"
• Watch for: Supporters who undermine the change or keep watch over the client. Coach them, or rely on other supports [synthesis].

C. Stage-matched relationship and planning procedures

C1. Stage-matched relational stance

• Purpose: Prescribe the relationship that fits the stage. Norcross et al. call these therapeutic relationships of choice, alongside treatments of choice [source: Norcross et al. 2011].
• Steps:
  1. Precontemplation: act as a nurturing parent joining a defensive client. Be warm and non-confrontational, and don't push.
  2. Contemplation: act as a Socratic teacher. Ask questions that let the client reach their own insights.
  3. Preparation: act as an experienced coach. Offer a game plan or review the client's own.
  4. Action and maintenance: shift from coach to consultant, offering support and advice when progress stalls and seeing the client less often as they gain autonomy.
  5. Reassess the stage and shift your stance when the stage changes [source: Norcross et al. 2011].
• Example language (illustrative): For contemplation: "What do you make of the fact that you've said 'next month' three times now?" For a coach in preparation: "Here's how people often structure the first week. What would you change?"
• Watch for: Lecturing a precontemplator, or staying Socratic with someone who wants a plan. Both are mismatches.

C2. Stage-sized goal setting

• Purpose: Make the goal the next stage, not the end behaviour [source: Norcross et al. 2011].
• Steps:
  1. Name the current stage with the client.
  2. Agree a goal for the current block of sessions, e.g. "to decide whether this is a problem worth tackling".
  3. Review the stage at the end of the block [steps synthesis]. Moving from precontemplation to contemplation nearly doubles the chance of effective action within 6 months [source: Norcross et al. 2011].
• Example language (illustrative): "You're not sure you want to stop, so let's not aim for stopping yet. Shall we aim to get clearer on what it's costing and giving you?"
• Watch for: Pressure from the service or referrer for an action outcome. Explain stage progress as measurable outcome [source: URI CPRC].

C3. Change plan (preparation)

• Purpose: Turn intention into a concrete plan within 30 days [source: URI CPRC: preparers have a plan of action; Norcross et al. 2011: coach role].
• Steps:
  1. Set a start date.
  2. Choose a method from the options (B6).
  3. List the high-risk situations and a response for each (B7, B8).
  4. Name supporters (B10) and rewards (B9).
  5. Agree what to do if a lapse happens (C5).
  6. Write the plan down [plan components synthesis].
• Example language (illustrative): "Let's put it on one page: the date, how, the three hardest moments and what you'll do, who knows, and what happens if you slip."
• Watch for: Plans with no response to the top-rated temptation. Vague dates mean the client is not yet in preparation [synthesis].

C4. Stage-tailored feedback reports

• Purpose: Individually tailored feedback on stage, pros and cons, self-efficacy and process use, as used in TTM expert-system programmes for smoking, stress, medication adherence, depression and weight [source: Wikipedia summary of trials; SAGE intro].
• Steps (clinical adaptation [synthesis]):
  1. Re-administer the A1–A4 measures at intervals.
  2. Give the client written feedback on where they are, what has improved since last time, and the one or two processes recommended for the next step. The original expert-system algorithms are not drawn on [uncertain].
• Example language (illustrative): "Since last month your 'cons of drinking' have gone up, and you're more confident in social situations. The next step people at your stage find useful is setting a date."
• Watch for: Feedback that reads as generic. Personalise it to the client's own answers [synthesis].

C5. Relapse and recycling management

• Purpose: Expect recycling, prevent relapse, and turn a relapse into a re-entry point [source: Norcross et al. 2011; URI CPRC].
• Steps:
  1. Before action, warn that most people cycle through the stages several times before maintenance.
  2. Build the relapse plan into the change plan (C3).
  3. After a lapse, re-stage the client (A1). Most relapsers return to contemplation or preparation, not precontemplation.
  4. Review what was learned: which situation, and which process was missing.
  5. Re-enter at the client's current stage, with the matching processes and stance [source: URI CPRC; Norcross et al. 2011].
  6. Normalise the relapse to reduce shame and therapist guilt [source: Norcross et al. 2011].
• Example language (illustrative): "Slipping back is how most people eventually succeed. It's information, not failure. Where are you now: wanting to get straight back on, or rethinking whether it's worth it?"
• Watch for: Demoralisation, which can push the client into precontemplation. Watch the self-efficacy ratings [source: URI CPRC].

C6. Maintenance consultation and tapering

• Purpose: Consolidate gains and step down contact as the client becomes autonomous. Termination is reached when temptation is gone and confidence is complete [source: Norcross et al. 2011; Wikipedia].
• Steps:
  1. Space out sessions.
  2. Review triggers, especially stress [source: Wikipedia].
  3. Keep using the behavioural processes at a lower level.
  4. Agree when the client should contact you again, such as rising temptation or a lapse [synthesis].
• Example language (illustrative): "You're running this yourself now. Let's meet in two months. What signs would tell you to call sooner?"
• Watch for: Stopping all processes too early. In maintenance, process use declines but continues [source: URI CPRC].

5. Handling problems

The TTM's core rule for any problem is to re-stage the client, then check whether your processes and stance match that stage. Guidance tagged [source] comes from the cited texts; [synthesis] marks this guide's own clinical guidance.

• "Resistance" or defensiveness, often in a mandated precontemplator.
  • Treat it as a sign of a mismatch, not a client trait. Precontemplators pushed toward action tend to drop out, and therapists sometimes blame the client for their own poor fit [source: Norcross et al. 2011].
  • Respond by dropping the action agenda and taking the nurturing-parent stance (C1).
  • Use gentle consciousness raising (B1) with permission, and explore the pros of the current behaviour first (A3).
  • Set the session goal as contemplation, not change (C2).
  • Norcross et al. align this with motivational interviewing's "rolling with resistance" [source: Norcross et al. 2011].
• Demoralised precontemplator who has given up after repeated failures [source: URI CPRC describes this subtype].
  • Normalise recycling: most successful changers had several tries (C5).
  • Review earlier attempts for mismatched processes (A6). Often the action was tried without stimulus control or support.
  • Rebuild self-efficacy through small, safe steps [synthesis].
• Chronic contemplation or behavioural procrastination: years of "next month".
  • The URI CPRC names this pattern. The responses here are [synthesis].
  • Use the Socratic stance to reflect the pattern back to the client.
  • Use self-reevaluation (B5) to make the costs of waiting vivid.
  • Offer two or three concrete options (B6), since too many choices or none can stall commitment.
  • Set a small preparation step with a date, and stop adding more consciousness raising.
• Stuck in action or repeated quick relapse.
  • Check whether the client is still doing awareness work instead of behavioural work, or whether action was rushed without the decisional and commitment work of contemplation and preparation. Both are named mismatches [source: Norcross et al. 2011; Mayor 1995].
  • Respond by re-staging. If the client is really in contemplation, go back to the earlier tasks.
  • If the client is truly in action, target the high-temptation situations with stimulus control and counterconditioning (B7, B8).
• Progress stalls despite a good stage match.
  • Check whether another level is maintaining the problem, e.g. a family or interpersonal conflict, and stage that level separately [source: Piotrowski 2007].
  • Negotiate whether to shift to that level (A5).
• Non-adherence to homework or plans.
  • Read non-adherence as information about the client's stage: preparation-level tasks given to a contemplator will not get done [synthesis, applying Norcross et al. 2011].
  • Re-stage, and shrink the task to fit the client's actual stage.
  • Let the client choose among options (B6).
  • Reinforce partial completion (B9).
• Ruptures.
  • A rupture often follows a stance mismatch: coaching a client who wants to be understood, or staying Socratic with a client who wants a plan [synthesis based on C1].
  • Name the shift openly.
  • Ask what kind of help the client wants now.
  • Adjust your stance to match [synthesis].
• Overwhelm during dramatic relief or self-reevaluation.
  • Stop the exercise and ground the client.
  • Lower the emotional intensity, and always close with a route to action or relief. The URI CPRC notes that affect tends to diminish once appropriate action is available.
  • For clients with trauma histories, keep stabilisation first and avoid evocative imagery until they are ready [synthesis].
• Multiple problems at different stages.
  • Stage each problem and work first where the client is most ready [source: Norcross et al. 2011, on stage being problem-specific].
  • Don't hold an action-ready problem hostage to a precontemplation one. Revisit the others later [synthesis].
• Relapse with shame, or therapist frustration.
  • Expect recycling, and say so in advance.
  • After a relapse, re-stage the client: most return to contemplation or preparation [source: Norcross et al. 2011; URI CPRC].
  • Address therapist guilt or blame in supervision, since anticipating recycling is meant to reduce both [source: Norcross et al. 2011].
• Over-reliance on stage labels [synthesis].
  • Stages are problem-specific and can change quickly. Re-stage often, and never use a stage label to exclude a client from treatment.
  • Combine stage assessment with an ordinary clinical formulation and risk assessment.
  • The authors note there are few controlled trials of matching psychotherapy to stage, so treat matching as a guide, not a rule [source: Norcross et al. 2011].
• Risk.
  • Low readiness to change never justifies ignoring safety. With suicidality, self-harm, severe substance withdrawal, eating-disorder medical risk or child protection concerns, follow standard risk assessment and duty-of-care procedures whatever the client's stage.
  • Use the stage framing to improve engagement with safety plans, not to delay them [synthesis].
• Problems the sources do not address [synthesis].
  • Cognitive impairment or acute psychosis: simplify staging to one question about intention, use concrete options, and involve supporters.
  • Cross-cultural fit: stage distributions differ across countries [source: URI CPRC on US vs European smokers]. Explore the client's cultural meaning of the problem and of seeking help before reading low intention as precontemplation [synthesis].

Sources

Sources

• Transtheoretical Model: Overview – URI Cancer Prevention Research Center
• Transtheoretical Model: Detailed Overview – URI Cancer Prevention Research Center. Adapted from Velicer, Prochaska, Fava, Norman & Redding (1998), Homeostasis, 38, 216–233.
• Norcross, Krebs & Prochaska (2011). Stages of change. Journal of Clinical Psychology: In Session, 67(2), 143–154 (copy hosted by ISPA clinic)
• Stages of change – URI DigitalCommons record (Norcross et al. 2011)
• In search of how people change – URI DigitalCommons record (Prochaska, DiClemente & Norcross 1992). Abstract only.
• Mayor S., L. I. (1995). El cambio en las conductas adictivas. Revista de Psicología de la PUCP, 13(2). A Spanish-language secondary review.
• Piotrowski, N. A. (2007). Practical approaches to staging change in dual diagnosis (slides)
• Transtheoretical model – SAGE Encyclopedia of Theory in Counseling and Psychotherapy (Prochaska; intro only)
• Transtheoretical model – Wikipedia. Secondary source, used only to fill gaps.
• Enhancing Motivation for Change Inservice Training (CSAT/SAMHSA, 2006). Only the table of contents was readable; no content was used.

Further reading (not drawn on)

• Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390–395.
• Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change. American Psychologist, 47, 1102–1114.
• Prochaska, J. O., & Velicer, W. F. (1997). The Transtheoretical Model of health behavior change. American Journal of Health Promotion, 12, 38–48.
• Prochaska, J. O., & DiClemente, C. C. (2005). The transtheoretical approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of Psychotherapy Integration (2nd ed.).
• Prochaska, J. O., & Norcross, J. C. (2014 and later editions). Systems of Psychotherapy: A Transtheoretical Analysis.
• Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994). Changing for Good.
• Prochaska, J. O., Velicer, W. F., DiClemente, C. C., & Fava, J. L. (1988). Measuring the processes of change. Journal of Consulting and Clinical Psychology, 56, 520–528.

Not drawn on [uncertain]: URI CPRC processes-of-change page and SAMHSA TIP 35. Also not drawn on: the primary texts on named strategies for intervening across levels of change, and the expert-system algorithms.