Much of the research on therapy and behavior change has focused on what problems people have that need changing, and why they do or do not change. Perhaps more important than what and why is "how" people go about changing behaviors. Therapists have differing views of how change happens. Usually, theories and research on therapy focus on what the therapist does and not on how the client makes changes happen. In fact, early theorists most often focused on explanations of how disorders developed. The obvious hope was that understanding etiological mechanisms would provide the key to understanding and facilitating change. For example, Freud saw the key to change was allowing clients to release misdirected energy from early childhood by raising consciousness and redirecting defense mechanisms (Freud, 1949). For Carl Rogers, the critical mechanism that would produce healthy change was helping clients gain access to their personal, internal or "organismic" valuing process that had become distorted through conditions of worth (Rogers, 1954). For Skinner, change in an individual's behavior was driven by changes in the environmental contingencies that shaped and supported either the problematic behavior or a new adaptive pattern of behavior (Skinner, 1953). Although these theorists advanced our understanding of the origin of problems and some mechanisms that maintained the problematic behaviors, a more eclectic view and understanding of the change process was needed. The field also needed a perspective that would describe not only psychopathology and problem behavior change but also how people change positive healthy behaviors.
These considerations led to the search for principles of change (Goldfried, 1980) and trying to see how different views of change could be integrated (Wachtel, 1977) or different parts of the change process like decision making (Janis & Mann, 1973) and Relapse and Maintenance of behavior change (Marlatt, 1985; Brownell et al., 1986) could be understood. They also led to the development of a number of more pragmatic models of change for health and addictive behaviors, like the theory of reasoned action or planned behavior (Ajzen, 2002, Ajzen & Fishbein, 1980), Self Efficacy Expectations (Bandura, 1977), the Health Belief Model (Becker & Maiman, 1975), and the Transtheoretical Model of Intentional Behavior Change (Prochaska, DiClemente & Norcross, 1992).
All these attempts to build a more complete view of how people change included both a cognitive or motivational component and a behavioral component and included concepts like intentions, motivation, readiness to change, decision making, planning, commitment, and both initiating and sustaining behavior change.
In the Prime Solutions program, developers used this broader perspective on change, the concentration on how people change, and the belief in the power and responsibility of the client for change as guiding principles. More specifically, the program uses the perspectives of the Transtheoretical Model of Intentional Behavior Change and Motivational Interviewing as templates for understanding and intervening to promote the client's personal process of change.
The Transtheoretical Model of Intentional Behavior Change offers a way to view human behavior change that is intentional in contrast to changes that are imposed, manipulated, or mandated wherein intention and cooperation can be minimized. Sometimes individuals under pressure from courts, family, or other controlling interests will stop particular behaviors for a period of time but not really change. For example, individuals will stop drinking while on probation for a DWI or DUI only to resume problematic pattern once the probation is over. This model proposes a way of understanding the process of behavior change that individuals experience and participate in as they create new behaviors, modify existing behaviors, or stop problematic patterns of behavior. The dimensions of change, the stages, processes, context, and the markers identified in the model are all designed to assist in picturing and developing a better understanding of the process of how people change (Prochaska & DiClemente, 1984; DiClemente & Prochaska,, 1998; DiClemente, 2003). It clearly comes from a learning perspective and incorporates elements of various theories of therapy, learning, and behavior change. Hence, the name "Transtheoretical." However, the model does not try to resolve all the conceptual issues and conflicts among the various theories incorporated in the model. Instead, it simply tries to identify and describe important elements of the process of intentional behavior change (DiClemente, 2005; 2008).
The core critical insight leading to the creation of the model was that the process of change is not simply a collection of activities or experiences, but a differentiated personal pathway that individuals traverse that includes a distinct series of tasks that individuals need to accomplish in order to create, modify, or stop a habitual pattern of behavior. The dimensions of the model describe important elements of the personal process of change and offer a blueprint for possible interactions among the dimensions of change (particularly the interaction between the stages of change and the processes of change). This extensive intentional behavior change is a lengthy process that can take months (or even years) to accomplish.
Stages and Tasks of Change
The stages of change describe steps in the process of change. The tasks identify things that, once accomplished, help the person resolve that stage and move to the next. We can think of the tasks as the foundation for movement forward in the process of change and, thus, more vital than the stage itself. The tasks build on each other so that the end product of this process is a new sustained pattern of behavior that is supported by the adequate accomplishment of each of the preceding tasks.
Arousal of concern about the status quo and/or an emerging interest in a new behavior is the task that begins the process of change and moves an individual from Precontemplation to Contemplation. The person is then considering the possibility of change. However, that process also creates ambivalence which is the hallmark of Contemplation. Concern, interest, and vision are what allow someone to begin to engage in the second task - a risk/reward analysis of both the current status quo and the potential new behavior. If this cost/benefit analysis is favorable, it leads an individual to a decision to make a change in the status quo and acquire a new behavior. Once this contemplation stage work is completed, the individual must complete the tasks of the preparation stage - developing a plan that would enable the change to occur and creating commitment to it. The action stage is the beginning of the shift from the status quo to the new behavior wherein the change plan is implemented, revised, and reformed in order to begin a new pattern of behavior that can remain stable over a significant period of time (3 to 6 months). The final task of the change process, the maintenance stage, is the integration of the new behavior into the individual's lifestyle such that it becomes habitual and the new normative pattern of behavior. Unless each of these tasks is done well enough to support the action (and ultimately the maintenance of change), the behavior change process will fail, often represented by relapse or a poorly established pattern of change. The individual will then have to redo or re-cycle through the tasks (especially those inadequately accomplished) in order to make behavior change happen.
The path leading to any behavior change involves the accomplishment of a series of tasks that have been identified in a sequence of stages of change (DiClemente, 2003). When specifically focused on recovery form substance abuse, they represent what the individual would need to do to move forward in the process of making and sustaining changes in drinking and/or drug use. Substance abusers must become concerned about the need to change, convinced that the benefits of change outweigh the costs (thereby provoking a decision to change), create and commit to a viable and effective plan of action, carry out the plan by taking the actions needed to make the change, and consolidate the change into a lifestyle that can sustain it. These tasks parallel the five identified stages of change that have been assessed in both self-change and treatment-assisted recovery. Adequately accomplishing these tasks is necessary to produce change and evidence indicates these tasks are important both in recovery for self-changers as well as for those attending treatment to overcome their substance abuse and dependence.