Transtheoretical Model (Stages of Change)


When it comes to boosting health, the bottom line is that if a person is unaware of his or her need to change, nothing you do as a health coach will be effective. (This is why court-appointed rehabilitation programs have much lower success rates than voluntary rehabilitation.) The clients and groups you serve must be aware of a need for a health related change.

The Transtheoretical Model (TTM), otherwise known as the Stages of Change model, describes the process of adopting healthy habits or, conversely, abandoning unhealthy habits. Every individual goes through these stages when they are changing health related habits.

Precontemplation Stage

I have no plans to make a change or take action in the near future (usually defined as within 6 months).

In this stage, an individual is either blissfully unaware that a change needs to take place or has decided that this change is not an option for them. They may be uninformed or under-informed. They could also have reached a stage of burnout. Perhaps they have tried smoking cessation multiple times and failed, so they now believe that quitting is simply not an option.

Individuals in this stage may be defined as resistant or unmotivated (Glanz et al, 2007). They often avoid the topic and are uninterested in resources, supports, or materials related to making this change. It is important to recognize that these individuals are not ready for health promotion interventions such as rehabilitation or therapy. Interventions at this level involve the use of other theories to address the underlying concern.

Contemplation Stage

I am aware that this action is a good idea and am considering it.

In this stage, an individual is not immediately making plans to change, but is weighing the options. Contemplation is often described as an individual making plans to make a change within the next 6 months, but an individual can remain in contemplation indefinitely without ever transitioning to the next stage.

Individuals in this stage are ideal candidates for educational programs that empower them to make informed health related decisions. Caution should be exercised here, however, as individuals in this stage are not yet ready for action-oriented solutions or interventions. Those can be overwhelming and result in a setback.

Preparation Stage 

I am actively preparing to make this change.

In this stage, an individual might be making a purchase, planning a strategy, or otherwise taking actions that prepare them for the change. Preparation is usually classified as an individual preparing to make a change within a month. To achieve this stage, the individual has often already taken a step or action related to the change.

Preparation requires a plan of action, and it is at this stage that health professionals are the most useful. If the preparation is for a healthy diet, for example, a dietician is a useful resource for strategy and planning. Individuals in the preparation stage are in need of action-oriented solutions and interventions. They are ready for strategies, formulas, preparations, products, and protocols–because they plan to make use of them soon.

Change Stage 

I am making the change right now.

This could be the last time a person smokes or the first time a person takes an evening walk. Unlike the other stages, the change state is a single moment in time that reflects a shift between the preparation stage and maintenance of the new habit.

Some experts consider the change state to include the first few weeks, up to 30 days, of the behavior, habit, or activity. This accounts for the inevitable transition from old behavior to new behavior, which is rarely a one-time action. Viewing the action stage as being the first 30 days of the new habit prevents the need to label progress as being multiple repetitions of a preparation-action-maintenance-relapse cycle.

Maintenance Stage 

I have made the change and am living with different habits.

In this stage, the individual has made a change and is working to prevent relapse. The distinguishing factor between this stage and the change stage is the frequency of relapse. When the new habit becomes the norm, the individual is considered to be maintaining the habit. In this stage, there is less temptation to relapse and perceived self efficacy is improving.

Individuals in this stage still require support to prevent a relapse. Whether the change is away from toxic household products towards healthier cleaners, smoking cessation, or adopting a healthier diet, relapse into old habits is always a concern. There is no set time limit for the maintenance stage; for many health behaviors, this stage lasts indefinitely.

Termination Stage 

I am no longer at risk of relapse.

In the termination stage, there is no temptation to relapse and the individual has achieved complete self efficacy. For addictive behaviors, this stage exists as though the individual had never become addicted to the substance. Due to the strict criteria to achieve this stage, experts disagree regarding whether or not termination should be considered a construct.

For the vast majority of individuals and health behaviors, relapse is usually a permanent concern. For many health related behaviors, success is defined as prolonged maintenance phase.

Relapse is not restricted to the maintenance stage. At any stage of this model, an individual may relapse and can return to a previous stage. Relapse might mean that someone in maintenance returns to preparation or it could mean someone in preparation returns to pre-contemplation.

Transtheoretical Model in Action: CAM for Pain in Rural Populations

The Transtheoretical Model was used to assess the potential to reduce opioid dependency in Appalachian communities through the use of complementary approaches to pain relief such as herbal supplements, yoga, and massage therapy.

For this study, complementary health categories included herbal supplements, vitamins/minerals, probiotics, acupuncture, massage therapy, chiropractic, Tai chi/QiGong, yoga, meditation, other relaxation therapies, movement therapies, and other natural products.

Researchers collected data from 301 individuals in a sample of clinics and found that for all categories other than vitamins/minerals, over 60% of patients were in a precontemplation stage. Approximately 5% were using herbal supplements in the maintenance stage for pain management. For every category but massage therapy, fewer than 5% of patients were in the contemplation stage. 

These findings reveal that natural health solutions which have been found in the scientific literature to have benefits for pain management are tools which are underutilized in this population. Interventions for the precontemplation stage would be the best tools for addressing opioid dependency with integrative health.


Meet Dr Hawkins

Dr. Hawkins brings 20 years of expertise in the integrative health field to her role as Executive Director of the Franklin School of Integrative Health Sciences and the leader of our clinical research team.

She holds a Bachelor’s Degree in Environmental Health from Union Institute and University, a Master’s Degree in Health Education & Promotion from the University of Alabama, a post-graduate certificate in epidemiology from the London School of Hygiene and Tropical Medicine, a PhD in Health Research from Middle Tennessee State University, and is completing the post-doctoral Global Scholars Research Training Program at Harvard Medical School. She also holds certifications in numerous natural health fields including aromatherapy, aromatic medicine, herbalism, childbirth education, and labor support.