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A PREMATURE OBITUARY FOR THE TRANSTHEORETICAL MODEL: A RESPONSE TO WEST (2005)

2005; Wiley; Volume: 100; Issue: 8 Linguagem: Inglês

10.1111/j.1360-0443.2005.01138.x

1360-0443

Carlo C. DiClemente,

Psychotherapy Techniques and Applications

The editorial by Robert West eulogizing the Transtheoretical Model (TTM) offers a provocative perspective (West 2005). However, it is not clear why Dr West feels the need to bury something that still has life or why he cannot create a new model from his insights that would make the old one obsolete, dying a natural death rather than what I consider a premature interment. Although his critique offers some valid concerns, essentially he repeats ongoing criticisms that have been addressed previously in this journal and in more recent publications (Prochaska & DiClemente 1998; Connors et al. 2001; DiClemente & Velasquez 2002; DiClemente 2003; DiClemente, Schlundt & Gemell 2004) and continues to overreact to exaggerated claims that have been made about the utility and scope of the model. I would agree that some claims have been exaggerated and that there are challenging data and anomalies that need to be examined, explored and explained. However, the basic premise of the editorial is flawed. A balanced assessment would be more useful for advancing our understanding of the human change process and for exploring both the stage and state aspects of this process. Dr West's critique is really a criticism of the stages of change and not the entire model. As is true of many previous critiques, he focuses on assessment of the stages of change and issues about time frames and labels. Although they are closely related, it is important not to confuse construct with assessment and confound operationalizing a construct with the phenomenon that the construct is supposed to help explain. The dimensions of the Transtheoretical Model offer a framework that makes explicit elements of a human intentional behavior change process and answers the question: what does it take for individuals to accomplish successfully sustained behavior change? In contrast to a prior view of change as an on/off phenomenon (unmotivated or motivated; action or inaction), the original insight underlying stages of change was that there appear to be a series of identifiable and separable tasks involved in changing a specific behavior. Stages were a way to segment the process into meaningful steps related to critical tasks, namely concern about the problem and consideration of the possibility of change, risk reward analysis and decision making, planning and prioritization, taking action and revising action plans, and integration of the behavior change into the person's life-style. The terms ‘precontemplation’, ‘contemplation’, ‘preparation’, ‘action’ and ‘maintenance’ were an attempt to identify specific steps or stages in the process and isolate subsets of people who had similar tasks to accomplish as they move forward in the process of change. Stages have always been considered states and not traits so they are quite unstable and individuals can move between them quickly, engaging and abandoning some of these tasks even within a single session of intervention. The exception seems to be the action to maintenance shift, which appears to need the passage of time for the task of consolidation of change. Individuals can also become stuck in a task, such as considering change for long periods of time before taking action. The labels and attempts at making stages operational for assessment were thoughtful but arbitrary ways of labeling these sets of tasks and subgroups of people. Early work with the model followed large numbers of smokers for 2 and 3 years with and without interventions tracking their progress or lack of progress through the process of change. This extensive research supported stage differences and the importance of processes of change in the transitions from one stage to the next (DiClemente & Prochaska 1998). Making a concept operational so that one can assess the phenomenon is always arbitrary, and simply an attempt to create a dividing line that could be useful in isolating a concept or construct. This is true for all our psychological concepts such as stress, depression, anxiety, addiction, etc. Constructs always differ from the phenomenon and operationalizing and assessing are always challenging. Although few would deny the existence of anxiety or depression, there are many different ways of operationalizing these constructs, assessing individuals who may or may not have these conditions, and understanding the phenomenon. Problems of operationalization make it more difficult to study the phenomenon but should not be confused with the value of the concept or construct. The objective of the TTM and the research examining the model has been to enhance our understanding of the process of change and our ability to intervene in this process and not to identify a rigidly defined set of stages and prove the existence of those stages. The key questions are whether these tasks are definable and separable to some degree, whether it is helpful to separate these tasks in order to better conceptualize and manage change, and whether we can identify and assist individuals or groups who seem to be engaged in these similar tasks. These separate tasks are not unique to the TTM and have been identified in many current theories of health behavior change. Both the health belief model and Bandura's social cognitive theory describe decisional considerations and self-evaluations that precede taking action (Bandura 1986). The theory of planned behavior identifies implementation planning as an important dimension of change that precedes action. Early action appears to be different from successfully sustaining change, as is discussed in Marlatt's relapse prevention model (Marlatt & Gordon 1985). What the stages do is to organize these tasks into a logical sequence of activities that seem to build upon one another. Individuals uninterested in change or unconcerned about a current behavior should differ from those convinced of the need to change and preparing for action both in their view of change and what they are doing to create change. However, simply because specific tasks can be identified as distinct does not mean that they are discontinuous and dichotomous. These tasks are part of a larger process of change and build on one another. Critical stage tasks need to be completed in a ‘good enough’ fashion to allow the individual to move forward but in reality stage tasks are not completely accomplished until successfully completed change is achieved. It seems obvious that someone can move into action without having completed the proper decision-making, planning or prioritization needed to make the change successful. Stages are not boxes from which individuals jump, one to the next, in order to make change, but represent tasks that can be accomplished to a greater or lesser degree. In fact, relapse seems to be related to the quality of the accomplishment of the stage of change tasks and not simply whether one takes action. Recycling through the stages and the multiple attempts that individuals make in order to successfully recover from addiction seem to support the role of successive approximation in completing the decision making, the commitment, the preparation, the plan and the implementation in such a manner that can support successfully sustained change. Dr West contends that this view obstructs the view of the role of ‘moment to moment balance of desire versus value’ and the role of circumstances. I would argue the contrary, that the stages offer a way of viewing and studying how the momentary and the circumstantial interact with the larger process of change. There are implicit and explicit cognitions and a host of normative comparisons and self-evaluations that are operative in the process of change. Motivations are often momentary. Change attempts can be very spontaneous looking and responsive to specific events. I remember my days as a smoker when I would wake up and say to myself that this is it and throw away the cigarettes, only to search for them later that morning and abandon my attempt. Certainly there are momentary influences and actions, but they seem part of a larger process of change. Not until I was able to be convinced and convicted about smoking cessation, created a plan that could work for me and was able to stick with that plan did I successfully quit smoking. Momentary events are not contrary to a process perspective, but complement it. There is ample evidence of significant differences among subgroups of individuals classified into different stages that do not simply mirror ‘common sense’ differences between people actively changing and those who are not as was indicated by Dr West. Across multiple behaviors (smoking, dietary behaviors, physical activity, alcohol consumption and drug abuse) there are interesting and consistent differences among subgroups on meaningful process of change dimensions. In longitudinal studies there have been consistent findings that individuals in earlier stages have less success in sustaining behavior change. Dr West ignores these data. The model has also assisted in exploring interesting phenomena, has contributed to changing how treatment professionals approach individuals referred to treatment and challenged the field to think in a more differentiated and complex manner about health and addictive behavior change (Stotts et al. 1996; Carbonari & DiClemente 2000; DiClemente et al. 2003). The claim that the model is hindering advances and exploration seems clearly erroneous. Practitioners have made interesting and creative changes in the way they offer services and approach clients. Individuals who are in the process of change have told us repeatedly that the model seems to reflect their experiences of changing a health behavior. There is increased emphasis on early interventions and how interventions can influence even people who seem to lack motivation. Although often problematic in how stages are assessed and simplistic in approach, research studies into the process of change have grown exponentially. In a recent presentation at the meeting of the Association for the Advancement of Behavior Therapy, colleagues and I examined measures of stage and process of change in a dually diagnosed sample of seriously mentally ill with cocaine dependence to see if measures looked the same and were influenced by neurocognitive status. This led to an interesting discussion of whether seriously mentally ill people accessed an intentional process of change or were more influenced by current considerations and social influences. Dr West's contention that the model must be jettisoned before alternative views can be explored is simply not true, or is true only for those treating the model as a religion and not a heuristic model to explore the change process. Interment of such a provocative and heuristic model seems premature and unnecessary. It would be a mistake to return completely to a state model resembling the on/off views of the past. Readiness to change is not a single construct but a compilation of tasks and accomplishments that can produce both momentary change and sustained change. Pitting state against stage does a disservice to the process of intentional behavior change. In fact, this process incorporates and can elucidate many of the issues that Dr West identifies in his closing paragraph. There is clearly much more to understand about the process of change and how individuals go about creating and stabilizing a new behavior or abandoning one that is well established. The process involves biological, psychological and social/environmental determinants that are momentary and more stable. However, the process of change appears to be a very productive way to try to integrate these dimensions (DiClemente 2003). Hopefully, a dialogue on how the model does or does not fit the process of change and how various new discoveries challenge the model or make it obsolete can promote a more complete and scientific understanding of human intentional behavior change.