SEE ARTICLE ATTACHED

You will be required to submit a paper analyzing an article provided in the Reading & Study folder of Module/Week 6. The article is a collection of brief commentaries about the Stages of Change model (also known as the Transtheoretical Model). Your paper should be 2–4 pages, double spaced (not including the title page and reference page).

 

After reading the article, write a synopsis that includes the following 4 components. Each section should begin with the heading that is provided below in bold type:

  1. Thesis

Outline the main thesis, objective, or “opinion” of the article.

  1. Rationale

Select at least 2 authors from the article and provide an explanation of their perceptions of the Stages of Change model. You must also provide supporting rationale to explain the authors’ perceptions.

  1. Response

Provide a clear explanation of your response to the commentaries. (Do not just agree or disagree. Please state why you feel specific findings were or were not legitimate.)

  1. Strengths

 

Outline 2–3 strengths of the model. You must also reference a professional journal article which support these findings and observations.

Attachments

You will be required to submit a paper analyzing an article provided in the Reading & Study folder of Module/Week 6. The article is a collection of brief commentaries about the Stages of Change model (also known as the Transtheoretical Model). Your paper should be 2–4 pages, double spaced (not including the title page and reference page).

 

After reading the article, write a synopsis that includes the following 4 components. Each section should begin with the heading that is provided below in bold type:

  1. Thesis

Outline the main thesis, objective, or “opinion” of the article.

  1. Rationale

Select at least 2 authors from the article and provide an explanation of their perceptions of the Stages of Change model. You must also provide supporting rationale to explain the authors’ perceptions.

  1. Response

Provide a clear explanation of your response to the commentaries. (Do not just agree or disagree. Please state why you feel specific findings were or were not legitimate.)

  1. Strengths

 

Outline 2–3 strengths of the model. You must also reference a professional journal article which support these findings and observations.

Attachments

Commentaries WHEN POPULARITY OUTSTRIPS THE EVIDENCE: COMMENT ON WEST (2005) Robert West (2005) has taken the bold step of asserting that the Transtheoretical Model (TTM) is so flawed that it should be discarded. Whether one agrees with West’s conclusion or not, his editorial should stimulate longoverdue debate about the TTM. A sharp divide of opinion about the TTM has surfaced in recent years. On one side the model enjoys substantial popularity in the form of a voluminous research literature and a large following among clinicians. On the other side there is discontent among many scholars (e.g. Sutton 2001) who have closely scrutinized the scientific rigor of the model. There can be no questioning the popular success of the TTM: it is established fact. But the scientific merit of the model can be questioned, and West has furthered the debate with his provocative editorial. Consistent with West, this commentary will focus on smoking as the model addiction because smoking has been the primary focus of the TTM. The TTM became popular because it brought attention to the intuitive notion that some smokers are more ready to quit than others. For this, the originators of the TTM deserve credit, though as West and others (e.g. Bandura 1998) have pointed out, the observation that some smokers are riper for change than others is a con- firmation of the obvious. As a scientific model, however, the TTM got off to an inauspicious start. The lynchpin of the TTM is, of course, the stages of change. Thus it would seem essential to take great care in formulating how the stages were to be conceptualized and measured. However, there has never been a peer-reviewed account of the developmental research that led to the creation of the stages of change algorithm. In fact, it is not clear that any systematic developmental research took place at all, and the consequences of this omission plague the model to the present time. Instead, the authors of the TTM essentially decreed that readiness to quit smoking should be measured using the stages of change. For the most part, the addictions research community then adopted the stages of change, with few questions asked. There would be little consequence to the omission of developmental data on the stages of change if the stages had subsequently been proved to be valid and effective. However, as West (2005) and others (e.g. Etter & Sutton 2002) point out, this is not the case. The stage of change algorithm is a magpie collection of questionnaire items that do not cohere particularly well. Two of the questionnaire items rely on arbitrary timeframes and binary yesno response options. One need not be an expert in questionnaire development to detect potential problems with this instrument. After a time the stages of change became something analogous to a ‘brand name.’ Virtually all addictions researchers became familiar with the stages of change model, and it became common to include the stages as a basic sample characteristic in studies. A pattern emerged in the TTM literature whereby success was declared on behalf of the TTM regardless of research outcomes. Exuberant interpretations of modest results became commonplace. Grandiose conclusions were extrapolated from unremarkable findings. The popularity of the TTM had come to outstrip the scientific evidence. The popularity of the TTM came at the cost of reduced scientific and clinical progress. Alternative models of motivation to quit smoking were not pursued because the TTM had ‘cornered the market’ on the topic. Research on tailored interventions for smoking cessation became dominated by the TTM, which diverted resources and attention that could have been devoted to more promising methods of tailoring. Twenty years after the introduction of the TTM, West (2005) has concluded that the TTM should be discarded, and this commentator concurs. However, the larger topic of motivation to quit should not be abandoned. Rather, researchers should renew efforts to understand and measure motivation to quit smoking. West has done precisely this by introducing his new model of behavior change. There’s much to be learned from the case of the TTM. Commentaries 1041 © 2005 Society for the Study of Addiction Addiction, 100, 1040–1050 First and foremost, researchers should insist that scientific models are judged according to the standards of scientific merit and not by popular trends or intuitive appeal. THADDEUS A. HERZOG Tobacco Research and Intervention Program H. Lee Moffitt Cancer Center and Research Institute 4115 East Fowler Avenue, Tampa FL 33617 USA E-mail: herzogta@moffitt.usf.edu References Bandura, A. (1998) Health promotion from the perspective of social cognitive theory. Psychology and Health, 13, 623–649. Etter, J.-F. & Sutton, S. R. (2002) Assessing ‘stage of change’ in current and former smokers. Addiction, 97, 1171–1182. Sutton, S. R. (2001) Back to the drawing board? A review of applications of the transtheoretical model to substance use. Addiction, 96, 175–186. West, R. (2005) Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction, 100, 1036–1039. Blackwell Science, LtdOxford, UKADDAddiction0965-2140© 2005 Society for the Study of Addiction 100 Original Article Commentary C t THEORETICAL TOOLS FOR THE INDUSTRIAL ERA IN SMOKING CESSATION COUNSELLING: A COMMENT ON WEST (2005) With over 1400 citations (according to http://www. scopus.com [accessed 12 April 2005]), Prochaska’s paper summarizing the transtheoretical model is one of the most widely cited papers in the psychological literature (Prochaska, DiClemente & Norcross 1992). Astonishingly, this success was achieved in spite of the early recognition of major problems affecting this model (Davidson 1992). The concept of ‘stage of change’ is a haphazard mixture of current behaviour, intention to change, past quit attempts and duration of abstinence. As West (2005) points out, stages are defined by setting arbitrary cutpoints on continuous variables (time and intention) and, contrary to what is often believed, this theory says nothing about the time people spend in the first three stages. Furthermore, there is little empirical evidence of progression through the entire stage sequence (Littell & Girvin 2002). It is therefore hard to believe that these stages reflect reality. It makes little sense to classify in the same category (e.g. precontemplation) people with different levels of dependence, or people who have never tried to quit with those who achieved long periods of abstinence. Similarly, using only abstinence criteria to define Action is too reductive, and neglects important steps that people take on their way towards abstinence (e.g. cutting down, non-daily smoking). Finally, the model does not take into account dependence level, withdrawal symptoms and other key determinants of smoking, in particular environmental and social factors. The core of the transtheoretical model is a description of associations between variables, in particular between stages and self-change strategies that are supposed to be used in a sequential pattern, ‘doing the right thing at the right time’ (Segan et al. 2004). However, it has never been convincingly shown that distinct strategies are needed to progress across distinct stages (Herzog et al. 1999; Segan et al. 2004). In fact, stage mismatched interventions, where all smokers, including precontemplators, receive action-oriented advice may be as effective (Dijkstra et al. 1998) or even more effective than stage matched interventions (Quinlan & McCaul 2000), which seriously questions the basic tenets of this model. This model has been widely used to guide interventions and determine who gets what treatment. However, interventions based on this model have not been consistently proven to be more effective than control interventions or than no intervention (Riemsma et al. 2003; van Sluijs et al. 2004). Worse, labelling people ‘precontemplators’ (an awkward jargon) is stigmatizing and may lead clinicians to deprive patients of effective treatments. The risk of excluding preco
ntemplators from effective treatments is a major liability of this model. Valid measurement is the foundation of good science, but measurement of the model’s constructs is problematic. There are many, incompatible ways of measuring stages of change, and questionnaires measuring the model’s other core constructs (processes of change, selfefficacy and ‘pros and cons’) were published 15–20 years ago and have not been revised since. A constant development and adjustment of scales is nevertheless required to achieve the best possible measurement in each population subgroup, and theory should be subsequently developed according to empirical findings. But the transtheoretical model is far too rigid, it has not evolved much in the past two decades, and proponents of the model have been reluctant to take into account external criticism and to develop their theory accordingly. Rather, one has the impression that the model is often used rigidly, almost religiously. There is however, a need for an integrative, comprehensive theory on which interventions can be based. Such a theory is needed in particular for computertailored programs, which can reach huge numbers of smokers over the internet. For many smokers, the internet is the only source of information and counselling. One-to-one counselling is not cost effective on the internet, but computer-tailored programs can provide effec- © 2005 Society for the Study of Addiction Addiction, 100, 1040–1050 1042 Commentaries tive, individually tailored advice to large audiences (Etter 2005). In fact, the transition from one-to-one counselling in clinical settings and telephone helplines to mass level, individually tailored counselling on the internet is comparable to the industrial revolution, when craftsmen working in small shops were replaced by huge plants managed by engineers. To successfully handle this transition, the field needs a theory that tells us what to measure, how to measure it, what type of advice should be given to each category of smokers, when to give each recommendation, and what outcome should be expected in each subgroup. Interventions should be explicitly derivable from this new theory, in contrast with the loose and questionable links between the transtheoretical model and interventions. Researchers should join in a collaborative effort to develop a theory that reflects reality better than the transtheoretical model, and to assess whether interventions based on this theory are more effective than existing interventions. JEAN-FRANÇOIS ETTER IMSP-CMU 1 rue Michel-Servet Geneva 4 CH1211 Switzerland E-mail: Jean-Francois.Etter@imsp.unige.ch References Davidson, R. (1992) Prochaska and DiClemente’s model of change: a case study? British Journal of Addiction, 87, 821– 822. Dijkstra, A., De Vries, H., Roijackers, J. & van Breukelen, G. (1998) Tailored interventions to communicate stagematched information to smokers in different motivational stages. Journal of Consult Clinical Psychology, 66, 549–557. Etter, J. F. (2005) Comparing the efficacy of two internet-based, computer-tailored smoking cessation programs: a randomized trial. Journal of Medical Internet Research, 7, e2. Herzog, T. A., Abrams, D. B., Emmons, K. M., Linnan, L. A. & Shadel, W. G. (1999) Do processes of change predict smoking stage movements? A prospective analysis of the transtheoretical model. Health Psychology, 18, 369–375. Littell, J. H. & Girvin, H. (2002) Stages of change. A critique. Behavior Modification, 26, 223–273. Prochaska, J. O., DiClemente, C. C. & Norcross, J. C. (1992) In search of how people change. Applications to addictive behaviors. American Psychology, 47, 1102–1114. Quinlan, K. B. & McCaul, K. D. (2000) Matched and mismatched interventions with young adult smokers: testing a stage theory. Health Psychology, 19, 165–171. Riemsma, R. P., Pattenden, J., Bridle, C., Sowden, A. J., Mather, L., Watt, I. S. et al. (2003) Systematic review of the effectiveness of stage based interventions to promote smoking cessation. BMJ, 326, 1175–1177. Segan, C. J., Borland, R. & Greenwood, K. M. (2004) What is the right thing at the right time? Interactions between stages and processes of change among smokers who make a quit attempt. Health Psychology, 23, 86–93. van Sluijs, E. M., van Poppel, M. N. & Mechelen. W. (2004) Stage-based lifestyle interventions in primary care: are they effective? American Journal of Preventive Medicine, 26, 330– 343. West, R. (2005) Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction, 100, 1036– 1039. Blackwell Science, LtdOxford 100 Original Article Commentary Commentary Commentary WEIGHING THE PROS AND CONS OF CHANGING CHANGE MODELS: A COMMENT ON WEST (2005) West (2005) challenges researchers and clinicians to abandon the transtheoretical model (TTM) and to revert to common sense ideas about motivation for change or to develop new models that better account for the complexities of the change process. Part of West’s argument is based upon the continuing popularity of the model despite the healthy debate about its theoretical and empirical shortcomings that has occurred in this journal and others. As Whitelaw et al. (2000) point out, the need for critique is the greatest at the point that an idea becomes ‘accepted’ and the TTM has gained this accepted status. An example of this acceptance is the influence of the model on service delivery. There is little empirical evidence that TTM stage-based interventions lead to superior outcomes over non-stage based interventions (Riemsma et al. 2003; van Sluijs, van Poppel & van Mechelen 2004; Adams & White 2005). Nonetheless, and despite our pledge toward evidence-based practise, many jurisdictions are developing and implementing stage based interventions in a variety of problem areas despite the lack of a strong evidence-base. Such interventions have the false appearance of being evidence-based because they are based upon scientific models although, in reality, the appeal of TTM for this purpose appears intuitive. A related unfortunate effect of the wide acceptance of the model’s validity is the potential that decisions about who gets what type of service are made on stage of change assessments (Piper & Brown 1998). People assessed as precontemplators might be excluded from service or offered less action-oriented interventions than those deemed to be more ready to change. The evidence, at least in the area of smoking cessation, is inconsistent with this stance. In a recent study, smokers, regardless of their stage of change, were offered a smoking cessation group (Pisinger et al. 2005). Only 16% of those who were ultimately successful had serious intention to quit prior to the intervention. The authors argue that cessation support needs to be offered to all smokers regardless of their stage of change. Clearly, intentions or readiness are highly fluid (Hughes et al. 2005). Commentaries 1043 © 2005 Society for the Study of Addiction Addiction, 100, 1040–1050 For these ethical reasons, I agree with one aspect of West’s argument. A moratorium on the uncritical use of the TTM model in clinical service delivery is warranted. However, I disagree that the flaws of the model are so large that it should be entirely abandoned. The purpose of model building is to stimulate testable hypotheses that will lead to enhancements of our understanding of complex phenomena. The sheer bulk of the research conducted on the TTM is evidence that it provides such a focus. The model can continue to direct interesting research queries that presumably will lead to model refinement. For example, one facet of the model that has empirical support is the predictive validity of the stages—people who are further along the continuum are more likely to have changed their behaviour at a future follow-up point than those who are at an earlier stage. It is reasonable to hypothesize that therapeutic efforts that result in forward stage movement will result in a greater likelihood of future change than interventions that do not result in forward movement. This fe
ature of the TTM accounts for part of its appeal to clinicians working with addictive behaviours—if I can’t get action from my clients then at least I can improve my clients’ readiness for change . . . Alas, this hypothesis has not been empirically tested. We don’t know whether these ‘soft outcomes’, as West describes them, are ultimately helpful for our clients (perhaps clients shift back to their initial stage post intervention) or whether these outcomes simply help the therapist cope with the limited success we have getting actual behaviour change from our clients. Surely researchers need to attend to this gap in our understanding before the TTM is abandoned. Another interesting but understudied clinical development has been the use of the model as therapeutic tool with clients. Littell & Girvin (2002) note that the model is based upon a rational actor assumption of behaviour change, the notion that change is based upon a rational cognitive self-examination by the individual. This feature is undoubtedly another part of the model’s appeal to clinicians. Many of us have started to provide our clients with a description of the stages of change portion of the model with the request that clients determine where they fit. Perhaps this process of education and self-staging provides a helpful change schema for our clients that helps organize their ambivalent thoughts about and actions toward change. West argues that self-labeling is an important aspect of maintaining behavioural change. Perhaps, a cognitive understanding of change as a process is important in initiating the change. In short, the model continues to be an important stimulus to theory and practise development and it will ultimately be usurped by reformulated models. I look forward to learning more about West’s alternative model (West, in press), a model that he admits has been inspired by the current body of research and critique of the TTM. DAVID C. HODGINS Department of Psychology Program in Clinical Psychology University of Calgary 2500 University Drive NW Calgary Alberta Canada T2N 1N4 E-mail: dhodgins@ucalgary.ca References Adams, J. & White, M. (2005) Why don’t stage-based activity promotion interventions work? Health Education Research, 20, 237–243. Hughes, J., Keeley, J. P., Fagerstom, K. O. & Callas, P. W. (2005) Intentions to quit smoking change over short periods of time. Addictive Behavior, 30, 653–662. Littell, J. H. & Girvin, H. (2002) Stages of change. A critique. Behavior Modification, 26, 223–273. Piper, S. & Brown, P. (1998) Psychology as a theoretical foundation for health education in nursing: Empowerment or social control? Nurse Education Today, 18, 637–641. Pisinger, C., Vestbo, J., Borch-Johnsen, K. & Jorgensen, T. (2005) It is possible to help smokers in early motivational stages to quit. The Inter99 study. Preventative Medicine, 40, 278–284. Riemsma, R. P., Pattenden, J., Bridle, C., Sowden, A. J., Mather, L., Watt, I. S. et al. (2003) Systematic review of the effectiveness of stage based interventions to promote smoking cessation. BMJ, 326, 1175–1177. van Sluijs, E. M., van Poppel, M. N. & van Mechelen, W. (2004) Stage-based lifestyle interventions in primary care: are they effective? American Journal of Preventive Medicine, 26, 330– 343. West, R. (2005) Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction, 100, 1036–1039. West, R. (in press) Theory of Addiction. Oxford: Blackwell Publishing. Whitelaw, S. S., Baldwin, S., Bunton, R. & Flynn, D. (2000) The status of evidence and outcomes in Stages of Change research. Health Education Research, 15, 707–718. Blackwell Science, LtdOxford, UKADD 100 Original Article Commentary Commentary Commentary ANOTHER NAIL IN THE COFFIN OF THE TRANSTHEORETICAL MODEL? A COMMENT ON WEST (2005) In a series of publications (Sutton 1996; 2000a, 2000b, 2001, 2005), I have critically examined the transtheoretical model (TTM) and its associated assessment instruments and evaluated the evidence for the model. I came to the conclusion that the TTM cannot be recommended in its present form and that we need to go ‘back to the drawing board’ (Sutton 2001). Thus, I reached a similar © 2005 Society for the Study of Addiction Addiction, 100, 1040–1050 1044 Commentaries conclusion to West (2005) but by a somewhat different route. Although I endorse West’s conclusion, I disagree to some extent with his analysis of what the Rhode Island group calls stage effects (Prochaska et al. 2004) and with what he says about intervention studies. STAGE EFFECTS A stage effect is observed when initial pre-action stage of change predicts being in action or maintenance at followup: those in the preparation stage at baseline are more likely to be in action or maintenance at follow-up than those in contemplation, and those in contemplation at baseline are more likely to be in action or maintenance at follow-up than those in precontemplation. We need a meta-analysis to quantify these effects, but my reading of the literature on the TTM is that stage effects are a highly consistent finding. Of course, this is not surprising, because the pre-action stages are defined in terms of intentions and past behaviour, and there is ample evidence that these predict future behaviour. Stage effects mean that stage measures may be of practical value, for example in measuring progress towards smoking cessation. This may or may not be ‘common sense’, but it is not trivial. However, as West points out, other measures may do better. It is important to appreciate that stage effects do not necessarily provide strong evidence for a stage model because ‘pseudostage’ models may yield similar effects. For example, continuous measures of intention predict future behaviour and if such an intention measure were categorized into, say, three categories, one would expect to find a (pseudo)stage effect. Stage models make specific predictions about the probabilities of different stage transitions that can be tested using longitudinal data (Weinstein et al. 1998; Sutton 2000a). INTERVENTIONS West states that ‘Where interventions have been developed that are based on the model these have not proved more effective than interventions which are based on traditional concepts’. Unfortunately, the systematic reviews of stage-based interventions that have been published to date (e.g. Riemsma et al. 2003; van Sluijs et al. 2004) have included studies that were not proper applications of the TTM. For an intervention to be labelled as TTM-based, it should (1) stratify participants by stage and (2) target the model’s ‘independent variables’ (pros and cons, con- fidence and temptation, and processes of change), focusing on different variables at different stages. There is a need for more focused reviews of TTM-based intervention studies. The interventions that come closest to a strict application of the TTM are those developed by the Rhode Island group. The group’s studies of smoking cessation interventions (e.g. Prochaska et al. 1993, 2001a, 2001b; Pallonen et al. 1998)—none of which were cited in West’s (2005) editorial—have yielded mainly positive findings. However, adaptations of these interventions evaluated by research groups in the UK and Australia have yielded mainly negative results (Aveyard et al. 1999, 2001, 2003; Borland et al. 2003; Lawrence et al. 2003). Process analyses showing that TTM-based interventions do indeed influence the variables they target in particular stages and that forward stage movement can be explained by these variables have not been published to date. There have also been few experimental studies of matched and mismatched interventions, which could potentially provide the strongest evidence for or against the model (Weinstein et al. 1998; Sutton 2005). West states that ‘the model is likely to lead to effective interventions not being offered to people who would have responded’. This consequence would not be in the spirit of the model. The TTM implies that everyone, regardless of which stage they are in, should receive the a
ppropriate stage-matched intervention designed to move them to the next stage; this includes precontemplators. The issue of whether health professionals should deliver interventions to ‘all-comers’ or to subgroups selected on the basis of higher risk, greater motivation or some other criterion is a complex one that deserves much more detailed consideration than could be given to it in the editorial. ALTERNATIVE MODELS Discarding the TTM does not necessarily mean abandoning the idea that behaviour change, including smoking cessation, involves movement through a sequence of discrete stages. Two promising alternatives to the TTM are the precaution adoption process model (Weinstein & Sandman 2002; Sutton 2005) and the perspectives on change model of smoking cessation (Borland, Balmford & Hunt 2004). In contrast to the TTM, both these theories are based on a thoughtful analysis of the process of behaviour change, but neither has been tested extensively. Among existing non-stage models, the theory of planned behaviour (Ajzen 1991, 2002) has several attractive features: (1) it is a general theory; (2) it is clearly specified; (3) there exist clear recommendations for how the constructs should be operationalized; (4) it has been widely used to study health behaviours as well Commentaries 1045 © 2005 Society for the Study of Addiction Addiction, 100, 1040–1050 as other kinds of behaviours; and (5) meta-analyses of observational studies show that it accounts for useful amounts of variance in intentions and behaviour (Sutton 2004). The theory is able to capture the moment-tomoment balance of motives mentioned by West and to take account of situational influences (because different sets of beliefs may be salient in different situations). It is also consistent with the idea that the processes involved in the formation and modification of beliefs, attitudes and intentions may be largely automatic (Ajzen & Fishbein 2000). However, there have been few experimental tests of the theory (Sutton 2002) and few intervention studies (Hardeman et al. 2002), and it has not been widely applied to smoking cessation. Concluding comment The TTM has proven remarkably resilient to criticism. The Rhode Island group has not so far responded to my own critiques of the model or to those by Carey et al. (1999), Joseph et al. (1999), Littell & Girvin (2002) and Rosen (2000) among others. The model is still accepted uncritically by many in the health promotion field. I hope that West’s (2005) editorial does finally put the model to rest, but I am not optimistic. STEPHEN SUTTON University of Cambridge Institute of Public Health Forvie Site Robinson Way Cambridge CB2 2SR E-mail: srs34@medschl.cam.ac.uk References Ajzen, I. (1991) The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179–211. Ajzen, I. (2002) The theory of planned behavior. http:// www.people.umass.edu/aizen [accessed 13 April 2005]. Ajzen, I. & Fishbein, M. (2000) Attitudes and the attitudebehavior relation: Reasoned and automatic processes. European Review of Social Psychology, 11, 1–33. Aveyard, P., Cheng, K. K., Almond, J., Sherratt, E., Lancashire, R., Lawrence, T., Griffin, C. et al. (1999) Cluster randomized controlled trial of expert system based on the transtheoretical (‘stages of change’) model for smoking prevention and cessation in schools. BMJ, 319, 948–953. Aveyard, P., Griffin, C., Lawrence, T. & Cheng, K. K. (2003) A controlled trial of an expert system and self-help manual intervention based on the stages of change versus standard self-help materials in smoking cessation. Addiction, 98, 345– 354. Aveyard, P., Sherratt, E., Almond, J., Lawrence, T., Lancashire, R., Griffin, C. et al. (2001) The change-in-stage and updated smoking status results from a cluster-randomized trial of smoking prevention and cessation using the transtheoretical model among British adolescents. Preventive Medicine, 33, 313–324. Borland, R., Balmford, J. & Hunt, D. (2004) The effectiveness of personally tailored computer-generated advice letters for smoking cessation. Addiction, 99, 369–377. Borland, R., Balmford, J., Segan, C., Livingston, P. & Owen, N. (2003) The effectiveness of personalized smoking cessation strategies for callers to a Quitline service. Addiction, 98, 837– 846. Carey, K. B., Purnine, D. M., Maisto, S. A. & Carey, M. P. (1999) Assessing readiness to change substance abuse: a critical review of instruments. Clinical Psychology Science and Practice, 6, 245–266. Hardeman, W., Johnston, M., Johnston, D. W., Bonetti, D., Wareham, N. & Kinmonth, A. L. (2002) Application of the theory of planned behaviour in behaviour change interventions: a systematic review. Psychology and Health, 17, 123– 158. Joseph, J., Breslin, C. & Skinner, H. (1999) Critical Perspectives on the Transtheoretical Model and Stages of Change. In: Tucker, J. A., Donovan, D. M. & Marlatt, G. A., eds. Changing Addictive Behavior: Bridging Clinical and Public Health Strategies, pp. 160–190. New York: Guilford. Lawrence, T., Aveyard, P., Evans, O. & Cheng, K. K. (2003) A cluster randomized controlled trial of smoking cessation in pregnant women comparing interventions based on the transtheoretical (stages of change) model to standard care. Tobacco Control, 12, 168–177. Littell, J. H. & Girvin, H. (2002) Stages of change: a critique. Behavior Modification, 26, 223–273. Pallonen, U. E., Velicer, W. F., Prochaska, J. O., Rossi, J. S., Bellis, J. M., Tsoh, J. Y. et al. (1998) Computer-based smoking cessation interventions in adolescents: description, feasibility, and six-month follow-up findings. Substance Use and Misuse, 33, 935–965. Prochaska, J. O., DiClemente, C. C., Velicer, W. F. & Rossi, J. S. (1993) Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychology, 12, 399–405. Prochaska, J. O., Velicer, W. F., Fava, J. L., Rossi, J. S. & Tsoh, J. Y. (2001a) Evaluating a population-based recruitment approach and a stage-based expert system intervention for smoking cessation. Addictive Behaviors, 26, 583–602. Prochaska, J. O., Velicer, W. F., Fava, J. L., Ruggiero, L., Laforge, R. G., Rossi, J. S. et al. (2001b) Counselor and stimulus control enhancements of a stage-matched expert system intervention for smokers in a managed care setting. Preventive Medicine, 32, 23–32. Prochaska, J. O., Velicer, W. F., Prochaska, J. M. & Johnson, J. L. (2004) Size, consistency and stability of stage effects for smoking cessation. Addictive Behaviors, 29, 207–213. Riemsma, R. P., Pattenden, J., Bridle, C., Sowden, A. J., Mather, L., Watt, I. S. et al. (2003) Systematic review of the effectiveness of stage based interventions to promote smoking cessation. BMJ, 326, 1175–1177. Rosen, C. S. (2000) Is the sequencing of change processes by stage consistent across health problems? A meta-analysis. Health Psychology, 19, 593–604. van Sluijs, E. M. F., van Poppel, M. N. M. & van Mechelen, W. (2004) Stage-based lifestyle interventions in primary care: are they effective? American Journal of Preventive Medicine, 26, 330–343. Sutton, S. R. (1996) Can ‘stages of change’ provide guidance in the treatment of addictions? A critical examination of © 2005 Society for the Study of Addiction Addiction, 100, 1040–1050 1046 Commentaries Prochaska and DiClemente’s model. In: Edwards, G. & Dare, C., eds. Psychotherapy, Psychological Treatments and the Addictions, pp. 189–205. Cambridge: Cambridge University Press. Sutton, S. (2000a) A critical review of the transtheoretical model applied to smoking cessation. In: Norman, P., Abraham, C. & Conner, M., eds. Understanding and Changing Health Behaviour: From Health Beliefs to Self-Regulation, pp. 207–225. Reading: Harwood Academic Press. Sutton, S. (2000b) Interpreting cross-sectional data on stages of change. Psychology and Health, 15, 163–171. Sutton, S. (2001) Back to the drawing board? A review of applications of the transtheoretical model to substance use. Addiction, 96, 175–186. Sutton, S.
(2002) Testing attitude-behaviour theories using non-experimental data: An examination of some hidden assumptions. European Review of Social Psychology, 13, 293– 323. Sutton, S. (2004) Determinants of health-related behaviours: Theoretical and methodological issues. In: Sutton, S., Baum, A. & Johnston, M., eds. The Sage Handbook of Health Psychology, pp. 94–126. London: Sage. Sutton, S. (2005) Stage theories of health behaviour. In: Conner, M. & Norman, P., eds. Predicting Health Behaviour: Research and Practice with Social Cognition Models, 2nd edn, pp. 223–275. Buckingham: Open University Press. Weinstein, N. D., Rothman, A. J. & Sutton, S. R. (1998) Stage theories of health behavior: Conceptual and methodological issues. Health Psychology, 17, 290–299. Weinstein, N. D. & Sandman, P. M. (2002) The precaution adoption process model. In: Glanz, K., Rimer, B. K. & Lewis, F. M., eds. Health Behavior and Health Education: Theory, Research, and Practice, 3rd edn, pp. 121–143. San Francisco: Jossey-Bass. West, R. (2005) Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction, 100, 1036–1039. ction A PREMATURE OBITUARY FOR THE TRANSTHEORETICAL MODEL: A RESPONSE TO WEST (2005) 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 Commentaries 1047 © 2005 Society for the Study of Addiction Addiction, 100, 1040–1050 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 inter- © 2005 Society for the Study of Addiction Addiction, 100, 1040–1050 1048 Commentaries ventions 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. CARLO C. DICLEMENTE Department of Psychology University of Maryland Baltimore County MD USA E-mail: diclemen@umbc.edu References Bandura, A. (1986) Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall. Carbonari, J. P. & DiClemente, C. C. (2000) Using transtheoretical model profiles to differentiate levels of alcohol abstinence success. Journal of Consulting and Clinical Psychology, 68, 810– 817. Connors, G., Donovan, D. & DiClemente, C. C. (2001) Substance Abuse Treatment and the Stages of Change: Selecting and Planning Interventions. New York: Guilford Press. DiClemente, C. C. (2003) Addiction and Change. How Addictions Develop and Addicted People Recover. New York: Guilford Press. DiClemente, C. C., Carroll, K. M., Miller, W. R., Connors, G. J. & Donovan, D. M. (2003) A look inside treatment. Therapist effects, the therapeutic alliance, and the process of intentional behavior change. In: Babor, T. & Del Boca, F. K., eds. Treatment Matching in Alcoholism, pp. 166–183. Cambridge, UK: Cambridge University Press. DiClemente, C. C. & Prochaska, J. O. (1998) Toward a comprehensive, transtheoretical model of change: Stages of change and addictive behaviors. In: Miller, W. R. & Heather, N., eds. Treating Addictive Behaviors, 2nd edn, pp. 3–24. New York: Plenum Press. DiClemente, C. C., Schlundt, D. & Gemell, L. (2004) Readiness and stages of change in addiction treatment. American Journal on Addictions, 13, 103–119. DiClemente, C. C. & Velasquez, M. (2002) Motivational interviewing and the stages of change. In: W. R. Miller & S. Rollnick., eds. Motivational Interviewing, 2nd edn: Preparing People for Change, pp. 201–216. New York: Guilford Publications, Inc. Marlatt, G. A. & Gordon, J. R. (1985) Relapse Prevention. New York: Guilford Press. Prochaska, J. O. & DiClemente, C. C. (1998) Comments, criteria and creating better models. In: Miller, W. R. & Heather, N., eds. Treating Addictive Behaviors, 2nd edn, pp. 39–45. New York: Plenum Press. Stotts, A., DiClemente, C. C., Carbonari, J. P. & Mullen, P. (1996) Pregnancy smoking cessation: a case of mistaken identity. Addictive Behaviors, 21, 459–471. West, R. (2005) Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction, 100, 1036–1039. Blackwell Science, LtdOxfo 100•••• Original Article Commentary Commentary Commentary WHAT DOES IT TAKE FOR A THEORY TO BE ABANDONED? THE TRANSTHEORETICAL MODEL OF BEHAVIOUR CHANGE AS A TEST CASE I am grateful to my fellow researchers for their thoughtful comments on my editorial arguing for abandonment of the Transtheoretical Model of Behaviour Change (West 2005). Herzog (2005) notes that the popularity of the model does not seem to derive from a close analysis of its scientific merits. Etter’s (2005) commentary ela
borates on some of the major conceptual problems with the TTM. Hodgins (2005) notes limitations in the evidence base in support of the model and argues for a moratorium on uncritical use of the model. However, he argues that the model has been and could continue to be a useful stimulus to research. I have regretfully to demur for the reasons given in the editorial. Sutton (2005) has argued for many years that the model cannot be recommended and my editorial does lit- Commentaries 1049 © 2005 Society for the Study of Addiction Addiction, 100, 1040–1050 tle more than reinforce that view. However, he takes issue with me on two counts. First, he argues that the finding of ‘stage transitions’ which represents the main evidence in favour of the model, though common sense, is not trivial. Yet surely showing that individuals who at time A are thinking about doing something, or indeed trying to do something, are somewhat more likely to have done it at time B is not a major contribution to understanding of motivation. Secondly, Sutton argues that the failure to show that TTM-based interventions are more effective than more traditional interventions might have resulted from not having used the model appropriately. This kind of argument is deployed a great deal when empirical studies fail to support theories in psychology. It cannot be ruled out as an explanation in this case. The problem is that it can never be ruled out. How far should we go in allowing this kind of ‘get out clause’? There is no simple answer, but if a model has conceptual flaws and counterexamples ranged against it and if, after many years of research, independent reviews conclude that it has not led to development of more effective interventions, perhaps that is enough. DiClemente (2005) acknowledges that there are valid concerns with the model and rightly points out that my editorial says little of substance that is new. However, he believes that the basic premise of the editorial is flawed. He argues that stages have always been considered states and not traits and they are quite unstable, even changing within a session. But he also argues that the model aimed to segment people into those that could benefit from different types of intervention. These two statements seem at odds because there would not be much purpose in segmenting people on the basis of a state that is in any event unstable. He also argues that my editorial confused the operationalisation of stages with the underlying concept. In behavioural research operationalisations are needed when we cannot measure something directly; the question here is what exactly is it that we are trying to measure and whether it has any reality beyond the method of measurement. It is obvious that some smokers who, when they think about it, have some kind of intention to stop at some point in the not too distant future while others do not. It is also obvious that some smokers (we do not know how many) will make more definite plans to stop on a particular date which they may or may not put into effect. If one wishes to go beyond this and posit ‘stages’ that represent some more abstract and stable entity, the operationalisation must specifically address the core definition of a stage which involves (1) stability and (2) discontinuity. The use of arbitrary dividing lines does not do this. Using arbitrary dividing lines to put people’s motivational condition into artificial categories encourages people to make statements such as ‘xx% of smokers are in the contemplation stage’ as though the figure referred to some real quality attaching to those individuals when it does not. DiClemente argues that the stage approach provides a framework into which momentary influences and states can be understood and harnessed. He cites his own experience of stopping smoking in which the formulation of a plan to which he was committed was a precursor for lasting change. I doubt whether anyone would dispute a statement that making a plan to which one is committed can (but does not always) help to combat momentary wishes and urges. Put in those terms, it seems, again to be a statement of the obvious. Put in more rigid terms—that making a plan to which one is committed is needed for lasting change—it is contradicted by counterexamples. DiClemente says that I have ignored data showing that people in earlier stages are less likely to sustain behaviour change. But I did not ignore this data; I and other commentators have merely said that this kind of test is too weak and that where stage assessment has been compared with a simple rating of desire or an addiction model, it has been less successful. The onus is very much on the proponents of the TTM after many years and hundreds of research papers to point to evidence that their approach predicts actual behaviour better than simple alternatives. It seems like a very negative thing to call for the abandonment of something into which so much has been invested. However, I think there is an onus of those of working in the field to be rigorous and objective in our evaluation of theories and models. In the end it is selfdefeating to persist with ideas that are misconceived. The problem of theories that are developed and pursued without adequate regard to counter-examples and to whether they provide better prediction of behaviour than existing accounts is endemic in behavioural research. Perhaps the time has come for a root and branch review of our methods of theory development, testing and application. Here is a simple common sense account of healthrelated behaviour. It contains no insights derived from formal study but is merely an articulation of what any intelligent lay person might propose: ‘Engaging in or failing to engage in health-protective behaviour patterns depends on opportunities afforded by the one’s social and physical environment and the balance of motivations when those opportunities are present. These motivations include desires, urges, needs, habits, evaluations and level of commitment to any prior resolutions. The specific problem for healthpromoting behaviours is that they are often less pleasant than the alternatives on offer at the time. Inter- © 2005 Society for the Study of Addiction Addiction, 100, 1040–1050 1050 Commentaries ventions to reduce chronic unhealthy behaviour patterns involve reducing opportunities for unhealthy behaviours, increasing opportunities for healthy behaviours, reducing the actual or perceived attractiveness of or need for the unhealthy option, increasing the actual or perceived attractiveness of the healthy option, and prompts to make and keep to resolutions to make lasting changes. Addiction presents special problems because the addictive behaviour (usually a drug) causes changes to the addict’s CNS and/or social and physical environment which undermine desires to remain abstinent and/or heighten desire to continue with the activity. This means that more powerful and sustained interventions to bolster motivation to abstain and to reduce motivation to engage in the addictive behaviour are needed.’ Any supposedly scientific model of behaviour change should be able to do demonstrably better at prediction and development of interventions than an operationalisation of this model than this. It should not be hard. ROBERT WEST Health Behaviour Unit Department of Epidemiology, Brook House University College London 2–16 Torrington Place London WC1E 6BT E-mail: robert.west@ucl.ac.uk References DiClemente, C. (2005) A premature obituary for the Transtheoretical Model: a response to West (2005). Addiction, 100, 1046–1048. Etter, J.-F. (2005) Theoretical tools for the industrial era in smoking cessation counselling: a comment on West (2005). Addiction, 100, 1041–1042. Herzog, T. (2005) When popularity outstrips the evidence: comment on West (2005). Addiction, 100, 1040–1041. Hodgins, D. (2005) Weighing the pros and cons of changing change models: a comment on West (2005). Addiction, 100, 1042–1043. Sutton, S. (2005) Another nail in the coffin of the Transtheoretical model? A comment on West (2005). Addiction, 100, 1043–1046. West, R.
(2005) Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction, 100, 1036–10

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