Stages of Change
The stage construct is important, in part, because it represents a temporal dimension.
In the past, behavior change often was construed as a discrete event, such as quitting
smoking, drinking, or overeating. The TTM posits change as a process that unfolds
over time, with progress through a series of six stages, although frequently not
in a linear manner.
Precontemplation is the stage in which people do not intend to take action in
the near term, usually measured as the next six months. The outcome interval may
vary, depending on the behavior. People may be in this stage because they are uninformed
or under-informed about the consequences of their behavior. Or they may
have tried to change a number of times and become demoralized about their abilities
to change. Both groups tend to avoid reading, talking, or thinking about their
high-risk behaviors. They are often characterized as resistant or unmotivated clients
or as not ready for therapy or health promotion programs. An alternative explanation
is that traditional health promotion programs were not ready for such individuals and
were not motivated to match their needs.
In contemplation, people intend to change their behaviors in the next six months.
They are more aware than precontemplators of the pros of changing but are also acutely
aware of the cons. This balance between the costs and benefits of changing can produce
profound ambivalence and keeps people stuck in contemplation for long periods
of time. This phenomenon is often characterized as chronic contemplation or behavioral
procrastination. These folks also are not ready for traditional action-oriented programs
that expect participants to take action immediately.
In preparation, people intend to take action soon, usually measured as the next
month. Typically, they already have taken some significant step toward the behavior
in the past year. They have a plan of action, such as joining a health education class,
consulting a counselor, talking to their physician, buying a self-help book, or relying
on a self-change approach. These are the people who should be recruited for actionoriented
programs, such as traditional smoking-cessation or weight-loss clinics.
People in the action stage have made specific, overt modifications in their lifestyles
within the past six months. Because action is observable, behavior change often has
been equated with action. In the TTM, action is only one of six stages. Typically, not
all modifications of behavior count as action in this model. In most applications, people
have to attain a criterion that scientists and professionals agree is sufficient to reduce
risks for disease. In smoking, for example, the field used to count reduction in
number of cigarettes or switching to low tar and nicotine cigarettes as action. Now, the
consensus is clear—only total abstinence counts as action, as these other changes do
not necessarily lead to quitting and do not lower risks associated with smoking to zero.
Maintenance is the stage in which people have made specific, overt modifications
in their lifestyles and are working to prevent relapse, but they do not apply change processes
as frequently as people in action. They are less tempted to relapse and are increasingly
more confident that they can continue their changes. Based on temptation and selfefficacy
data, it was estimated that maintenance lasts from six months to about five years.
Longitudinal data from the 1990 Surgeon General’s Report (U.S. Department of Health