The Transtheoretical Model (aka Stage of Change Model)
Transtheoretical Model (aka Stages of Change)

Sheri Kirshenbaum, Ph.D.

Prochaska & Diclemente’s Transtheoretical Model (1994) or Stage of Change Model is a very helpful framework that can guide our thinking about assisting clients to make behavior changes. The model is based on the assumption that intentions are the primary determinant of behavior change. Thus clients must have a want to make changes in their lives. In our practical work with clients we also integrate skills building because we know that many clients may want to change, but may not know how.

Precontemplation – In the Precontemplation Stage there is no want or motivation for change because the behaviors in question are believed to be acceptable. This may be due to a lack of information, a lack of consequences of behavior or an individual may have attempted change in past without success resulting in feeling hopeless or demoralized regarding the ability to change. There is an avoidance of thinking or talking about the behavior. Clients in this stage are often characterized as resistant, unmotivated or not ready for health promotion programs by providers. Reframing as precontemplative makes work easier with these clients.

Contemplation – This stage is characterized by ambivalence – knowledge of the pros and cons of the behaviors. There is an awareness that problems may exist and thoughts regarding change, but without firm commitment to change. Clients in this stage are often characterized as procrastinators by providers. Reframing as contemplative makes work easier with these clients.

Preparation – In the Preparation Stage there is intention to take action and make changes in the immediate future. Typically these clients have taken some significant action in the past year and have a current plan of action in place.

Action – In the Action Stage specific overt modifications in life-style have been made.

Maintenance – In this stage, clients are maintaining changes in lifestyle, working to prevent relapse and strength building.

Relapse – In this stage clients revert to the behavior they were trying to change.

Movement between stages is typical. The goal is to keep individuals moving forward to higher stages of change and to help them develop tools and abilities to maintain changes made and/or get back on track if stage of change shifts.

Exercise – Identifying a Client’s Stage of Readiness for Change
This exercise presents various vignettes that illustrate the different stages of change, and gives the reader the opportunity to guess the client’s stage before the answer is revealed.

Click to View Vignette 1
Keith is a 19-year-old male who is close to completing an outpatient program for the primary addiction of meth. He has been abstinent from meth for 6 months and has recently returned to college. So far he has been able to handle his course load and has not felt triggered to use meth due to the stressors of school or a want for increased energy for studies. He has been seeing a therapist since he returned to school in order to gain support around his continued abstinence from meth and prevention of relapse; and to explore family issues that arose within his drug treatment program that he feels contribute to his substance abuse. He drinks alcohol on occasion, when going out with friends on the weekends. He has been doing well in school and has been consistent in his program, school and therapy attendance.

Which stage of change do you think Keith is in?
Pre-contemplation | Contemplation | Preparation | Action | Maintenance | Relapse

Answer: Maintenance
Click to View Vignette 2
Steve is a 28-year-old gay male. He moved to San Diego three years ago from Arizona to open a small design firm. His entrance to the gay community was through the bars/clubs. He began using crystal at annual party events and became tight with a crowd of men who enjoy partying. Over the past year, his use has increased to almost every weekend. He has a main sexual partner and a number of friends with whom they party and play frequently. He has had a few weekends that have turned out to last longer than planned, but once he’s back to work he feels confident in his grasp of the lifestyle. He’s never had a drug problem in the past.

Which stage of change do you think Steve is in?
Pre-contemplation | Contemplation | Preparation | Action | Maintenance | Relapse

Answer: Pre-contemplation
Click to View Vignette 3
Tim is a 48 year old gay male who has been using meth for the past 12 years. He is a successful real estate broker who has definitely enjoyed the spoils of his hard work. He is a savvy salesman who has developed an elite client base. His work has entailed travel, parties and more parties and Tim’s use of crystal has fit in and at times facilitated his work and lifestyle, especially his sex life. Over the years, he’s gone through spells where he’s felt depressed and somewhat paranoid, but he’s pushed through these to stay on track. Six years ago Tim contracted HIV. He wasn’t that surprised and reacted by taking control, gathering information and getting hooked up with a great doctor. He cut down on his drug use to give his body a bit of a break. Many of his friends are HIV-positive and he has confided in a few of them for support. Tim’s health had been quite stable and he had not needed medication. Recently however he has been feeling weak - his t-cell count has been dropping slowly and his viral load is no longer undetectable. His mood is more frequently depressed than not. He has been in a relationship for the past year and his partner has begun to voice concerns about Tim’s health and mood. His partner uses meth infrequently and has suggested that they stop all together. Tim’s initial reactions were angry, however he has made an appointment with a psychiatrist and he is talking with his partner about getting support around stopping his drug use, however he does have concerns about how this will influence his sexual life and his work success.

Which stage of change do you think Tim is in?
Pre-contemplation | Contemplation | Preparation | Action | Maintenance | Relapse

Answer: Preparation
Click to View Vignette 4
Doug is a 34 year old heterosexual male. He just completed a short term residential drug treatment program and has been attending ongoing outpatient care for individuals with co-occurring conditions. Doug has struggled with methamphetamine abuse since his discharge from the Marines four years ago due to a diagnosis of bipolar disorder. He is currently living with his brother and sister-in-law and recently began working part time as a computer programmer for an electronics company. Doug has just started to get himself back out there, going out with his buddies and trying to meet women. He’s been feeling bored, overly medicated, and insecure about his job performance and his ability to attract a sexual partner. He’s been driving past his drug dealer’s house on nights he goes out with his friends, but has not found him at home, until tonight. Doug bought an eighth and smoked a bit with his connect before going to meet his friends. He’s continued this pattern for the past 2 weeks now and has missed treatment appointments. He went in to his program yesterday to talk about what has been going on.

Which stage of change do you think Doug is in?
Pre-contemplation | Contemplation | Preparation | Action | Maintenance | Relapse

Answer: Relapse
Click to View Vignette 5
Shelly is a 32-year-old male to female transgender. She has been living with some friends for the past three months but prior to that had lived on the streets for two years. She began using meth when living on the streets. She began hustling to make some money to purchase hormones, and in exchange for food and shelter. Meth became a part of this life for her. Although she has a roof over her head now she continues to engage in sex work as her source of income and to use meth while working. She worries about her appearance – seeing the impact of her drug use on her face and body and she fears that this will have an impact on her ability to earn money. She also doesn’t like the feeling of coming off a run (what she calls her “hag days.”) During these bad days she has contemplated getting some assistance kicking her meth habit, but after a few days she’s back in her element. At these times she’s tried to imagine a different life, but these thoughts turn to frustration and sadness. She believes she’s doing the best that she can working with the resources she has. She thinks of her drug use as temporary as she builds up her nest egg and then she’ll make some real changes.

Which stage of change do you think Shelly is in?
Pre-contemplation | Contemplation | Preparation | Action | Maintenance | Relapse

Answer: Contemplation
Click to View Vignette 6
Julia is a 40-year-old single mother of 2 school-aged children. She began using meth after having her second child to increase her energy and help her to take off the weight she had gained. She started out using just a bump in the morning and on some days, another just before the kids came back from school. Over about 6 months she lost 15 pounds and was feeling great. Her use increased, as she wasn’t feeling the same level of get-up-and-go. Julia began to feel the impact of her use on her interactions with her kids. She decided she wanted to make some changes when the weekends rolled around and she found herself sleeping all day, allowing the kids to entertain themselves in front of the television. Parents of her children’s friends had stopped calling for play dates and her eldest child began doing poorly in school. Julia has taken steps to cut back her use and has been a regular attendee at a CMA meeting across town and has been adherent with her antidepressant medication. She has noticed a positive impact on her parenting which she feels proud of. She is having more difficulty than she thought staying completely off meth, but feels she would really like to find some other alternatives to increase her gains.

Which stage of change do you think Julia is in?
Pre-contemplation | Contemplation | Preparation | Action | Maintenance | Relapse

Answer: Action

Stage Specific Interventions
To maximize chances for success, interventions must be matched to the client’s stage of readiness for change.

Precontemplation - Clients in this stage don’t think that they have a problem – even if those around them think so. These clients usually don’t show up at your door asking for help. The main goal in this phase, if you even see client at this stage, is to engage clients and establish a trusting rapport with them so that in the future – if they come to the conclusion that they want some help – you may be one of the people that they call.

Engaging a client doesn’t have to mean telling them that they should do something about their use and when they are ready to call you, but to get to know the client and what is important to them, what is going on in their lives and what issues they are dealing with. You can inform these clients of the work that you do. And give your contact information.

Very often you meet these clients in other contexts – they attend groups, trainings, presentations, they may have friends who receive services from you, they may be receiving other services from your agency not related to drug use.

Contemplation – Clients in this stage are characterized by ambivalence – a tricky scale that could be easily upset with the wrong intervention. The intervention goal at this stage is to engage the client in discussion of his/her ambivalence and to slowly and gently uncover discrepancies in you client’s own goals and behaviors. THAT’S IT!!!

Clients in this phase often struggle with identity questions – such as “Am I an addict?” They experience changes in their own personal rules (e.g., I’ll only use on the weekends; I’ll never use when I’m alone; I’ll never use outside of my apartment; I won’t let my use interfere with my ___________ (fill in the blank e.g., job, relationship, family life, etc.). Clients test themselves in this stage. They glamorize and normalize their using/war stories. And the line of “When is enough enough” changes. It is important in this stage to “put the words of change in the client’s mouth” rather than stating for the client that changes would benefit him/her.

For example our client Shelly – she worries about her appearance and the impact on her ability to attract clients who pay her for sex, she also doesn’t like the feel of coming off meth, she’s expressed feelings of frustration and sadness regarding making changes – there is a lot to explore here. Remember to explore without jumping to making treatment suggestions!

Preparation/determination - In this stage the typical reasons that clients seek treatment is that “bad things are happening’, negative consequences (legal, job, relationships, medical, family, financial, psychiatric). Clients may focus more on solving these problems than on addressing their crystal use. They may express a feeling that their life is out of control.

There are a few key elements that may assist in maximizing clients’ engagement in treatment at this stage as well as within the Action phase

  • Maximize engagement – use all rapport building skills – convey empathy! Clients may be afraid, anxious, ashamed, depressed, irritable, fatigued & paranoid, exhibit poor concentration and memory & experience drug craving. Some of their behaviors may come across as difficult, provocative &/or manipulative.
  • Clients should be supported and receive positive feedback for seeking treatment
  • Providers should respond quickly to client requests for support and/or treatment (e.g., initial phone inquiries) because of the high level of ambivalence common regarding treatment (strike while the iron is hot)
  • Methods (e.g., daily phone calls or appointments) to screen out “those not yet ready” may be counterproductive. Authoritative approaches are discouraged. The confrontation believed to “break through denial” may be counterproductive with meth users.
  • Help clients identify expectations, fears, concerns (best to do this before you get them into a program so you can problem solve barriers before they arise) & give treatment options
  • Meetings with clients during this phase should be frequent and brief – perhaps multiple weekly short visits
  • Keep intake assessments brief and make orientations clear and client responsibilities concise
  • Providers must help clients to remediate withdrawal from meth. Clients will require adequate sleep, nutrition and exercise and should be given the opportunity and permission to partake of these restorative behaviors.

Action - Clients in this stage are/can be engaged in active treatment. They are actively setting goals to make changes in their life and are developing the skills needed to successfully carry out these goals. Structure and support are key.

Goals should be manageable (not to big or too small), measurable (so that the client can tell whether they are moving forward or not) and time limited (with a clear endpoint). Relapse prevention skills should include the following: (TIP 33)

  • How to cope with substance craving
  • Development of trigger identification and avoidance strategies (e.g., people, places & things)
  • Development of assertiveness skills around substance refusal
  • Exploration regarding how seemingly irrelevant decisions may have an impact on the probability of later use (or how to recognize the straw before it breaks the camel’s back or even gets close to the camel)
  • General coping and problem solving skills (slowing down the decision making process)
  • Getting rid of paraphernalia
  • How to apply skills in the real world
  • Ways to prevent a full relapse should an episode of use occur
  • Developing support systems

Maintenance - At this stage, clients can be engaged in the continued application of skills in order to maintain gains with a focus on relapse prevention and the identification of ongoing supports around their progress.

Work with these clients should include continued work on:

  • Relapse prevention strategies
  • Identify ongoing supports around recovery
  • Set long-term goals and problem solving around how to best accomplish them. Clients should be taught functional analysis in which they learn to identify thoughts feelings and circumstances both positive and negative that surround their drug use, triggers, cravings etc.

Relapse - If clients come to you when they have relapsed this is an opportunity. It reveals a clients trust in you to assist him/her with their addiction. As shame and guilt often strongly accompany relapse for clients, it is important to maintain a nonjudgmental and supportive stance.

The provider’s tasks with a client in this stage are to:

  • Reevaluate the client’s current stage of change – what are they ready to do?
  • Explore the relapse episode in order to learn from it – was it longer, shorter than previous relapses – was client able to reduce use, reduce harm, use less, use for a shorter period of time, think of consequences sooner…
  • If appropriate to the client’s stage of change, work with the client to continue to develop skills required to achieve their current goals.

For a more comprehensive guide to appropriate treatment approaches for meth using clients in the Preparation or Action stages, see