The present essay is a critical analysis of the client’s profile based on the therapeutic approaches using the transtheoretical model (TTM) as a framework of change. Particularly, I met this client in order to complete the first component of this lesson. Here it is worth noting his presenting problems. In the first place, he told me that he worries about the future. To be more specific, he believed that he does not have the skills to keep his job. He recognized that this situation makes him feel anxious, sad and unworthy. Moreover, an other important issue is that his father has abandoned him when he was a child. Therefore, his mother had to do two jobs in order to raise him. He described his mother as a cold and distant person. Also, he feels like his mother has abandoned him as well, therefore, he recognizes that he feels lonely and unworthy. Loneliness is a feeling that he experiences in his current life because he considers that he has noone to share his problems with.
The present essay is a critical analysis of the transtheoretical model (TTM) which is based on my client’s profile. To be more specific, in the first place, the TTM is presented briefly. Next, the transtheoretical model is critically discussed as a model for integration of theories as well as the strengths and limitations of this approach. Then, the TTM’s stages, levels, and processes in relation to my client’s presenting problems are presented (Prochaska, & Norcross, 2010). Finally, this essay concludes by describing the knowledge that was received using the TTM as a framework for integrative practice, and give some suggestions for future studies (Glanz, Rimer, & Viswanath, 2008).
The transtheoretical model was founded by James Prochaska and Carlo DiClemente in 1982 (Prochaska & DiClemente, 1982). The transtheoretical model negotiates the behavioral change and how people modify a problematic behaviour or adopt a positive behaviour. Furthermore, the core dimensions of this model are three: a) stages of change, b) the processes of change, and c) the level of change. The stages of change are six. The processes of change are characterized by ten cognitive and behavioural activities that facilitate some change. Furthermore, the levels of change are five. Here it is worth noting that it is very important to encounter in which stage a client belongs and which one of the levels fits to him better. In this way, taking in mind the level(s) and the stage of his presenting issues, one can choose which of the ten processes can use in order to help client change. The model also describes a series of concepts that are dependent variables, ie the decision balance (clients weighs the pros and cons of adopting the new behavior) and self-efficacy (self-confidence and temptation). Self confidence refers to the thought like that he/she may be able to achieve behavioral changes. Finally, temptation is not treated as failure, but as a knowledge that can help the client be improved (Prochaska, & Norcross, 2010).
The transtheoretical model of change (TTM) has both strengths and limitations. In the first place I discuss the strengths of this approach. Broad, open, and deep are some characteristics of TTM. Specifically, TTM is deep because it contains a conceptual framework of how (processes), when (stages), and what (levels) changes. It is broad because it provides a range of theories and techniques. Also, it is open to modification in areas such as stages, levels, and processes of change. Strength of this model is that TTM is an integrative model that makes predictions about which one of the different approaches can be successful in change, taking in mind the levels and the stages of change. This prediction is not anti-scientific but valid. In addition, TTM’s research results can be generalized to the population (Norcross & Newman, 1992).. Moreover, TTM combines the stages and levels of change, in this way, allows the interventions. These interventions are not only focus on symptom relief, but they also are evaluated according to their efficacy. For instance, Barolow and Wolfe’s (1981) study showed that clients with phobias can be helped through the modification of the situation that creates his/her phobias. However, 50% of phobic patients drop out or fail to progress at the situational level. According to Prochaska & Norcross (2010), that psychodynamic therapy is ineffective to relief people suffering with manic symptoms, but it can motivate clients with bipolar disorder, who are at the precontemplation stage, and it can also motivate them consider of a psychopharmacotherapy treatment. Finally, the TTM is an integrative and not eclecticism model. To be more specific, eclecticism is a cousellor who choose to use a range of techniques from different approaches (Hollanders, 2007). However, the integration model struggles to surpass the idea of eclecticism bringing together elements from different approaches (includes theories and models) into the transtheoretical model (Prochaska & Norcross, 2010)
On the other hand, criticizers support that there is no many evidence in order to prove that the trenstheoretical model is related with changes in health behaviours (Bridle, et al., 2009). To be more specific, according to Riemsma’s et al. (2009) systematic review of the effectiveness of stage, there is limited evidence for the effectiveness of stage based interventions in changing smoking behaviour (Aveyard et al., 2006, Cahill, Green & Lancaster, 2011) and for the prevention of pregnancy, sexually transmitted diseases (Horowitz, 2003), to dietary interventions for people with diabetes (Aveyard et al., 2009) and to help obese and overweight people lose weight (Tuach, et al., 2011). However, a series of studies suggested that the TTM’s interventions had some significant influence on the change of the behaviors (Johnson et al., 2006, 2008, Noar, Benac, & Haris, 2007). Furthermore, Prochaska (2006) and Spencer et al. (2002) supported that the studies which found TTM ineffective are poorly designed (they have small sample sizes, poor recruitment rates, or high loss to follow-up).
Another criticism is from West (2005). West claimed that the dividing lines between the stages are subjectively decided and the TTM makes predictions that are incorrect. Prochaska (2006) responded by saying that the stages are flexible and the dividing lines needs to help the client. In addition, Velicer’s et al. (2007) study showed that the stage of change is descriptive rather than predictive. Besides, Littell & Girvin (2002) argued that TTM describes the movement between the stages as linear without allowing the individual differences. But, in fact, the TTM does not claim that a client moves through the stages is a linear way, but there is the probability for a client to go back in a previous stage. Moreover, the probability of relapse is greater than the probability of two-stage progression (Prochaska, 2006).
The central concept of the thanstheoretical model of change is the changing stages and all the other concepts run around it. The stages are six (precontemplation, contemplation, preparation, action, maintenance, and termination). Individuals who are classified in the precontemplation stage have no intention to change in the future (usually about in the next 6 months). Moreover, they may be at this stage because they either do not have any information or have incomplete information about the consequences of their behavior. Another case is the people who have tried many times to change in the future but did not succeed in, thus, they do not believe that they have the ability to change (low confidence). Both groups tend to avoid reading, talking or thinking about their behavior and risks. In other approaches, they usually characterized as resistant or as individuals who have no incentive to change, or unprepared for health promotion programs. The other stage is called contemplation. At this stage, the classified people intend to change within six months. In addition, they want to change, but they have not taken action yet. Furthermore, they are thinking of the pros and cons of changing. This relationship between pros and cons of change can cause high levels of ambivalence that can keep the client stuck in this stage for very long periods. This phenomenon is often characterized as a chronic concern or chronic procrastination. The name of the next stage is preparation. This is the stage in which they want to change in the near future, usually for the next month. They usually took some significant action in the past, and try to make a plan of action. They recognize that they have to do something in order to change. Thus, they gather information to find available strategies and resources to help them in their attempt. Usually, when clients skip this stage in order to change directly, they fail because they have not sufficiently accepted that they are going to change their lifestyle. The next stage is called action. At this stage, people have made significant modifications in their lifestyle of the past six months. The change which usually occurs at this stage is referred to other approaches as behavioral change, as it is observable change. However, according to the transtheoretical model this change refers to only one step in the overall process. In addition, they try to change their behaviour by using a variety of different techniques. Also, clients at this stage tend to receive help and support by others. Besides, another characteristic of this stage is that people depend most on their own willpower. In addition, they develop plans to deal with both external and personal issues that make them feel pressure. Here it is worth mentioning that in order for a client to pass the stage of action, it is important the action which is used to meet one criterion commonly accepted by the counsellors and it should be sufficient to reduce risks. However, now, as a criterion change is considered only the complete abstinence from smoking. At this stage it is very important to the lookout to avoid the relapse (DiClemente et al., 1993). The next stage is called maintenance. People in this stage are still working to avoid relapse by developing new skills and formulate the rules of their lives, but they do not apply change processes as frequently as those in the stage of action. People usually reach this stage after six months. Their temptation to relapse is less, and the confidence that they can continue to change constantly enhanced. The main goal of this stage is to maintenance the desirable conduct. Another characteristic of this stage is that they believe that their change is meaningful and worthwhile. Here it is worth mentioning the concept of relapse and recycling. Relapse is a secondary stage of change. Relapse happens when people have failed to maintain a kind of behaviour, thus, they return to any other previous stage of change. Moreover, the term recycling refers to people who believe that they are ”recycling” via the stages. In fact, that happens before they established their desirable behaviour. Unfortunately, both of them tend to be the norm for most of the cases. The last but not least stage is called termination. Termination occurs when the clients have not returned to previous behavior. Furthermore, they have absolute confidence in the ability to maintain the new behaviour forever in any situation. In fact, many times psychotherapy ends before clients terminate entirely. Thus, people tend to return for booster session when they believe that they may return back to the problematic behaviour (Cassidy, 1997) .
In my case, a client with all of his presenting issues is at the contemplation stage. To be more specific, he is not at the precontemplation stage because he wants to change. Furthermore, he is not at the preparation stage because he has not any strategies to change and he is not ready to try changing his problematic behaviour. Moreover, he is not at the action, maintenance or termination stage because he has not tried to change something yet. He is at the contemplation stage because he wants to change, but he has never tried to change his behaviour and he has not any strategies to face his problems. However, he did not negotiate the pros and cons of the change (Prochaska, & Norcross, 2010).
Thus far, TTM seems to classify people into categories and select some specific processes in order to replace the problematic with the desirable behaviour. However, the process of change is not so simple. Thus, it is essential the third core dimension of the transtheoretical model, which is the level of change, to be discussed. The levels of change are consisted of five different, but connected with each other levels of psychological problems that are addressed in psychotherapy. Therefore, a changing in a specific level can cause a change at other level. These levels are a) symptom/situational problem, b) maladaptive cognitions, c) current interpersonal conflicts, d) family/systems conflicts, and finally, intrapersonal conflicts. To be more specific, the first level refers to the client’s symptoms and the situation which the symptoms support. Here it is worth mentioning the follow example. Symptoms may be advocated by maladaptive cognitions (counter-productive cognitions), which create interpersonal conflicts that are experienced in childhood in the framework of family conflicts, which appear in the form of intrapersonal conflicts. Furthermore, it is an important point in treatment when both therapist and client agree on the level (or levels) during which they assign the problem. Besides, the further down of the scale is someone’s level, the more unconscious and historical the conflict is. Therefore, the more historical is a client’s problem, the more resistance to some change the client tends to have. Thus, the further down is the level that has to be changed, the longer and more complex the psychotherapy would be (Prochaska, & Norcross, 2010).
There are three strategies that can be used to intervene at multiple levels of change. The first one is called shifting. At first, psychotherapists tend to focus on symptoms and situations that create the client’s symptoms. If the client successfully completes each stage, then the psychotherapy could be finished without another level of change being examined by the counsellor. If the treatment could not be effectively, the psychotherapist shifts his/her focus on the very next level of change. The second category that focuses on the key levels is the certain idea of the second category. In some certain cases if the available evidence is clear and points to one key level of causality, then the psychotherapist can first work in this level of change with the corresponding processes. The last but not least category is the maximum impact strategy. In some cases, there is a specific level of change which appears as cause, consequence, or a maintainer of the client’s problems. In this case, counsellors intervene in a way that engage the patient at each and every level of change. This creates a chain among the interventions (Prochaska, & Norcross, 2010).
In my case, my client feels some fear due to his belief that he is going to lose his job because he does not have the skills to keep it. Thus, he believes that he is worthless. He experiences this maladaptive cognition during his workplace, also in other environments too, like in his family system. Moreover, he feels loneliness. He has also experienced this emotion earlier in his life when his father abandoned him. Therefore, his mother has to do two jobs in order to raise him. As a result he was not seeing her many times. So he felt lonely again. Summarizing, the two client’s presenting issues are a) fear of losing his job and b) his father has abandoned him, both of these issues have their roots in his childhood. Hence, taking in my mind the three ways of intervention, I chose the second one (focus on key levels). In this way, I can work with the fourth level of change ”family/systems conflicts” because I believe it is the cause of his problems (Prochaska, & Norcross, 2010).
Thranstheoretical model includes a number of concepts which function as independent variables; they called change processes (which cause the change, ie the movement from one stage to another). Moreover, these concepts are derived from a variety of psychotheraputic models. To be more specific, there are five experiential and five behavioral processes that facilitate the change. The experiential processes are used primarily for the earlier stage of change and the behavioral processes for the later stage of change. The five experiential processes are the followings: a) consciousness raising, b) dramatic relief, c) environmental re-evaluation, d) self re-evaluation, and e) self liberation. On the other hand, the five behavioural processes are: a) social liberation, b) stimulus control, c) helping relationship, d) counter-conditioning, and finally, e) contingency management. In the next paragraphs, the interrelation between the stages and processes of change is presented . Moreover, it is discussed which one of the processes is more appropriate for my client according to his stage and level of change (Patten et al., 2000).
The first of the experiential process is the consciousness raising and it can be achieved by increasing client’s awareness of the causes, consequences and cures for a particular problem behaviour, finding and learning new facts and information which supports the change. It is very important for a counsellor (who use this process) to start by revealing client’s defenses before they become more conscious to him/her. Client’s awareness can be increased through feedback, education, confrontation, interpretation, bibliotherapy, and media campaigns. Second, during the second processes dramatic relief (or catharsis), the client initially experiences and expresses negative feelings for the problem, such as anxiety and fear which are followed by the reduction of their feelings if the counsellor takes an appropriate action. Psychodrama, role playing, grieving, personal testimonies, and media campaigns are examples of techniques that can stimulate the client emotionally. Moreover, both of the above processes can be applied at the pre-contemplation stage and help clients move at the next stage. However, consciousness raising methods (psychodrama etc.) can be applied easier to people in the contemplation stage. People at the precontemplation stage tend to use change processes less frequently than at any other stage (Prochaska, & Velicer 1997).
When clients become more aware about themselves and their unhealthy behaviour, they have to reevaluate both their environment and themselves. This reevaluation can be achieved through from both environment and self re-evaluation process. Firstly, the process of environmental re-evaluation combines an emotional and a behavioral assessment of how the presence or the absence of a person’s habit affects his/her social environment. Particularly, it includes the knowledge that he/she can function as a negative or positive model for others. In addition, if the problematic behaviour is a result of their core values, client and counsellor have to work on themselves. Empathy training, documentaries, value clarification and interventions in the family can lead a client to the re-evaluation of his/her environment. Moreover, the self re-evaluation process combines cognitive and affective assessments of the individual’s image of his/her self-image, with and without this problematic behaviour. The value clarification, health role model, and imagery are techniques that can motivate people re-identify themselves. Both of these two techniques above are used by the counsellors when their client is in the contemplation stage (Rodgers, Courneya, & Bayduza, 2001).
As clients are in the preparation stage, counsellors may use stimulus control and counterconditioning to reduce client’s undesirable behaviour. The characteristics of the stimulus control process are the removing stimuli that lead to problem behavior and adding stimuli that cause the desirable behavior. In addition, counsellor’s intervention includes avoidance, environmental re-engineering, and self-help groups can be set up to provide stimuli that support change and reduce the risk of relapse. Furthermore, counterconditioning process includes learning healthy behaviors that can replace the problematic behaviors. A counsellor can intervene using desensitization and relaxation techniques to reduce the client’s stress, cognitive counters to irrational thinking or assertion training can counter peer pressure. Self liberation includes the belief that a person can change, but also the commitment and re-commitment to act on that belief. When the person sets a goal and he/she has multiple options rather than a single choice, then this can enhance self-liberation or what people call willpower. Research related to motivation suggests that when individuals have two options, have greater commitment from those who have a choice. People with three options are even greater commitment, while those with four or more options have significant strengthening of will power. Here it is worth mentioning that before the clients move from preparation to action stage, they have to work on their self liberation. This process requires an increase in social opportunities or options especially for people who are deprived or oppressed. The central concept of self-liberation is that the client’s efforts play an important role in succeeding in the deal of hard situations, in other words, the idea of self-efficacy. Besides, during this process counsellor has to help the client find strategies to change his life. Defend, performance power procedures, and appropriate policies can lead to the increase of the opportunities for health promoting minorities and minority groups and groups with special characteristics, health promotion for people with low socioeconomic status, etc. The same procedures can be implemented to help all people change, eg creating non-smoking places, selling healthy food in schools (eg salad bars), easy access to condoms and other contraceptives (Velicer et al., 1998).
In the action stage, clients can be helped by behavioural processes such as counterconditionis, stimulus control, helping relationships, and contingency management. Contingency management provides consequences for the steps that lead to one specific direction. This process may include the use of punishment, but research data shows that those changes are based more on rewards rather than punishments. Furthermore, it emphasizes on aid as the philosophy of the model is to work in harmony with how people change naturally. The increasing of the aid procedures and the probability that positive changes will be repeated again include contingency contracts, reinforcements, positive self statements and group recognition that facilitate the change. In addition, helping relationships refer to a combination of care, trust, openness, acceptance and support for the new healthy behaviour. Rapport building, therapeutic alliance, counsellor calls the consultant, and groups of friends or family can be sources of social support that help establish the desirable behaviour. During this stage, therapists can provide skills training in behavioural processes to facilitate the client’s change and reduce the probability of relapse (Velicer et al., 1998).
Finally, a successfully maintenance is a consequence of the previous processes that the client has experienced and of knowing under of which conditions the client is likely to relapse. Also, clients evaluate the alternative options they have in order not to relapse. In this stage, a very encouraging common idea that clients have is that they become more of what they want to be. Therapists can use techniques such as counterconditioning, stimulus control, helping relationships, and contingency management to establish the change. Here it is worth noting that the above processes are more effective when clients strong believe in their value and in what they think they are and not in what the important others see or think about them (Velicer et al., 1998).
According to the level and the stage of change, the therapist has to decide which one of the therapeutic approaches has to follow. Generally, psychoanalytic processes are most useful in pre-contemplation and contemplation stage. Moreover, cognitive behavioural therapy is most useful at preparation, action, and maintenance stages. Furthermore, Roger’s person-centered therapy is used as basis for an effective therapeutic relationship. In this way, this approach reduces the distance between stage and level of change facilitating the client’s change.
In my case, the client’s presenting issues are both at the contemplation stage; therefore, it would be used psychoanalytic processes such as consciousness raising (methods), environment and self re-evaluation. Moreover, as it was discussed earlier, it is very important both the two presenting issues at the fourth level of change to be worked (family/systems conflict). It is important to use psychoanalytic techniques because in the forth level of change psychoanalytic and family/systems therapy tends to be more effective than the others. For instance, behaviour therapists focus on the symptoms and situational problems, cognitive therapists focus on maladaptive cognitions and psychoanalytic therapists focus on intrapersonal conflicts. To be more specific, in the first place, how aware is this client about his unhealthy behaviour and how this behaviour is interrelated with his family system has been checked, because the awareness of his problem was not very clear at the previous session. Then, processes such as environment and self re-evaluation as they were discussed in the above text can be used (Prochaska, & Norcross, 2010).
To sum up, the present essay is a critical discuss about how the processes, stages and levels are related with my client’s profile. Here it is worth noting the knowledge that was received by using the TTM as a framework for integrative practice. First, it is very important for both client and therapist to work at the same stage. For instance, if a counsellor tries to work with his/her client at the action stage but, the client is precontemplator then, the client may believe that the counselor is insensitive and coercive. Second, the meaning of the stages is the main organizational concept of theory. Stages represent the dimension of time, not by treating the change as a single event but as a process that takes time. Third, the decision of the change comes from the client. Finally, if a therapist matches the client’s stage and level of change, he/she is able to use the appropriate process(es) of change. Moreover, the transtheoretical model has both strengths and limitations. Thus, there is a need for further research (Prochaska, & Norcross, 2010).
More theoretical variables should take a part in future studies, such as processes of resistance, framing, and problem severity in order to ascertain if such variables relate with the predict process of the stage. Finally, it should be important to examine the structure or intergration of processes and stages of change through a range of bevaviours (like exercise) and extinction behaviours (like smoking cessation) (Glanz, Rimer, & Viswanath, 2008).
Na balw sto dior8omeno arxeio thn paraktw protash: Na grapsw gt to transtheoretical legetai diaewritiko, dld oti sundiazei tis alles prosegkiseis k.a. To allazw se intrapersonal.