Systems of Psychotherapy: A Transtheoretical Analysis

1. Systems of Psychotherapy:A Transtheoretical Analysis 17. Comparative Conclusions: Toward a Transtheoretical Therapy

2. Developmental Model I Perry’s stages of ethical growth • Dualists: true believers who view world in polar, dichotomous terms • Multiplists: true bettors who accept diversity and uncertainty, but favor a single theory • Relativists: true eclectics who embrace pluralism and see validity as issue-specific • Committed: accept relativism but committed to mastering and improving a particular theory

3. Developmental Model II Werner’s organismic-developmental model • Stage 1: Experiences global whole with no distinctions among component parts • Stage 2: Experiences differentiation of the whole into parts, but loses the big picture • Stage 3: Differentiated parts are organized & integrated into whole at a higher level; appreciation of unity & complexity

4. Transtheoretical Model: 3 Core Dimensions • Processes of change (how people change) 2. Stages of change (when people change) 3. Levels of change (what people change)

5. Processes of Change • Covert or overt activities to alter emotion, cognition, behavior, or relationships • Therapy systems differ on what to change (content), but tend to agree on how to change (processes) • Change processes with most use/agreement are consciousness raising & therapeutic relationship • Psychotherapy systems largely ignore the impact of common factors in producing change

6. Experiential Processes • Consciousness raising: increasing awareness • Dramatic relief: emotional arousal • Self reevaluation: self reappraisal • Environmental reevaluation: social reappraisal • Social liberation: environmentalopportunities & advocacy

7. Behavioral Processes • Reinforcement management: rewarding • Counterconditioning: substituting healthier alternatives for problem • Self liberation: committing • Stimulus control: re-engineering environment

8. Experiential Processes Behavioral Processes Thinking, Feeling or Experiencing Doing Consciousness Raising Dramatic Relief Self Reevaluation Environmental Reevaluation Social Liberation Reinforcement Management Counterconditioning Self Liberation Stimulus Control

9. Stages of Change • Constellation of attitudes, intentions, & behaviors related to readiness to change problem • A temporal dimension unfolding over time • 5 stages: precontemplation, contemplation, preparation, action, maintenance • If change is unsuccessful, then recycle (relapse) back into stages • If change is complete & stable, then termination

10. Stages of Change Maintenance Action Preparation Contemplation Precontemplation

11. Spiral Pattern of Change

12. Precontemplators • Avoid reading, talking, & thinking about the behavior that needs to be changed • The least confident about ability to take action • Most resistant to public policy changes • Feel pressured by others to take action, but have developed defenses • About 40% of people are in precontemplation

13. Contemplators • Substitute thinking for acting • Often waiting for magic moment • Not confident about their abilities to change, feel unprepared or ambivalent • Typically less than 1% of those at risk participate in traditional programs • About 40% of people are contemplators

14. Preparation • More confident & less tempted • Assess the pros as higher than the cons • Most likely to participate in change programs & most likely to benefit • About 20% of people are in preparation or in early action

15. Action • Recently started to change overt problem • Consistent for less than 6 months • “Here I go!” • Apply behavioral process • Loved by psychotherapists as the most successful in treatment

16. Maintenance • Has overtly changed behavior • Consistent success for ≥ 6 months • “Keep moving forward!” • Reaping rewards of change, but also realize relapse is common

17. Stages of Change in Which Processes are Most Emphasized

18. Levels of Change • Symptom/situational problems • Maladaptive cognitions • Current interpersonal conflicts • Family/systems conflicts • Intrapersonal conflicts

19. Putting It All Together

20. Transtheoretical Relationship • Therapist is expert on process of change • Empathic, supportive, & collaborative • Relationship will be stage matched • with precontemplators, a nurturing parent • with contemplators, a Socratic teacher • with action, experienced coach • with maintenance, a behavioral consultant

21. Effectiveness of Transtheoretical • Hundreds of studies on stages of change and processes of change • Early research conducted on addictions; now applied to dozens of disorders • RCTs on smoking cessation, depression, stress, partner violence, bullying, and multiple health behaviors • Stage-matched treatments outperform conventional treatments

22. A Paradigm Shift Moving from action-oriented programs to a stage paradigm to more effectively help people change their behavior.

23. Action-Oriented Programs • 1 - 5% participation rates • ≥ 20% of people are ready for action • High drop out rates • Small impact on populations with unhealthy behaviors

24. Stage-Matched Programs • Recognize behavior change occurs in stages • Are tailored to the needs of all participants, not just those in action • Can generate 80% participation • Can produce up to 8 times more impact than action-oriented programs

25. Efficacy vs. Impact • Efficacy X Participation = Impact • Individual/Clinic: • 50% X 5% = 2.5% • Public Health/Community: • 6% X 75% = 4.5% • Stage-Matched Proactive: • 20% X 75% = 15%

26. Criticisms of Transtheoretical Model • From a Psychoanalytic Perspective (action-oriented bias) • From a Cognitive-Behavioral Perspective (need more RCTs on severe clinical disorders) • From a Humanistic Perspective (focus on behavior rather than humans) • From a Cultural Perspective (assumes change is progression, change must occur at cultural level)

27. Key Terms action stage consciousness raising contemplation stage contingency management counterconditioning dramatic relief dualism efficacy vs. impact environmental reevaluation iatrogenic key levels of strategy levels of change maintenance stage maximum impact strategy multiplism precontemplation stage preparation stage processes of change relapse and recycling relapse prevention (RP)

28. Key Terms (cont.) relativism self-efficacy self-liberation self-reevaluation shifting levels strategy social liberation stage matching stages of change stimulus control theoretical complimentarity transtheoretical

29. Recommended Websites • Society for the Advancement of Psychotherapy: www.divisionofpsychotherapy.org/ • Addictive Behaviors and Transtheoretical Solutions: www.umbc.edu/psyc/habits/ • Home of the Transtheoretical Model: www.web.uri.edu/cprc/transtheoretical-model • Pro-Change Behavior Systems: www.prochange.com • Relapse Prevention: www.pubs.niaaa.nih.gov/publications/arh23-2/151-160.pdf