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Transtheoretical Model (Stages of Change)

The transtheoretical model (also known as the stages of change) suggests that changing one's health behaviours involves moving through five cognitive stages: precontemplation, contemplation, preparation, action and maintenance. 1,2,3 

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Gambling, Gaming & Technology Use
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Stages of Change

Developed by James Prochaska and Carlo DiClemente in the 1970s, the transtheoretical model recognizes that clients can be at different levels of readiness in the behaviour-change process depending on the stage of change they are in. The model provides direction on how to adapt treatment based on the client’s stage of change.1,2,3 

This webpage looks at the evidence about the stages of change and how you can use this model when treating clients who have gambling problems. The content is based on a review of the evidence and was reviewed by an expert in the field of problem gambling, gaming, and technology use.

Click through the model below to view the key concepts for each stage of change. You will find practice tips related to clinical objectives for each stage as well as practical behavioural and cognitive interventions.


Adapted from Prochaska & DiClemente, 1982.


One of the strengths of the model is that it recognizes that change is rarely linear; people move forwards and backwards through the different stages.2 This means that rather than being a totally negative experience, relapse is seen as a learning opportunity and part of the move toward long-lasting change.

The stages of change represent both the points in time and sets of tasks that are needed to achieve behaviour change.3 To achieve behaviour change, people must engage in strategies for change.3 When using the stages of change in a clinical setting, the focus is on helping the client see the advantages of changing their harmful behaviours and guiding them through change processes so they will progress to the next stage.3 


What does the evidence say?

The stages of change model has been shown to be effective in two major areas:

  • Identifying appropriate treatments for addictive disorders. Identifying a client's current stage of change can play an integral role in treating addictive disorders and promoting behaviour change because it allows clinicians to tailor their approach based on the client's current readiness for change.3 The client's stage of change at the start of treatment is correlated with the severity of the client's gambling problems and their level of psychosocial functioning.4 A recent study also showed that being in the action stage was associated with successful outcomes in people being treated for problem gambling.4 

  • Reducing drop-out rates in mental health therapy. Understanding a person's stage of change at the start of treatment may lead to more informed clinical interventions, which in turn may reduce the likelihood of the client dropping out. A person's readiness for change can predict how long they will remain in treatment. In two studies, participants with addictions who were in the precontemplation stage dropped out of psychotherapy at higher rates than those in the other stages.5,6  Conversely, studies show that people who are in the maintenance stage are more likely to complete their course of psychotherapy.7,8 


Findings from a recent meta-analysis suggest that clients with gambling problems are significantly more likely to have successful treatment outcomes if they are in the action stage.9 Another meta-analysis of interventions for health behaviour change found that adapting the intervention to the person's stage of change resulted in significantly greater likelihood of success.10

While many studies have validated the use of the stages of change model, few have examined culturally diverse groups.  Cultural adaptations of the model have begun to emerge in smoking cessation,11,12,13,14 physical activity15,16 and weight loss treatments.17,18,19 However, no research has emerged regarding cultural adaptation of this model for problem gambling.


Putting the evidence into practice

To assess a client's stage of change, first ask whether they feel they have a gambling problem. If a client believes that their gambling behaviour is not a problem, they are in either the precontemplation or maintenance stage. If they do feel they have a problem, they are in the contemplation, preparation, or action stage. Follow up by asking when they see themselves addressing this problem. Their answers indicate their stage of change: contemplation ("some day"), preparation ("in the next month"), and action ("now").20

When assessing a client's stage of change, ask about their views on their gambling behaviour and their level of motivation to change. Based on clinical experience, although internal motivation is foundational for change to occur, external factors, such as family, friends, culture and community support are also important. For example, a lack of community support, socioeconomic barriers, and stigma can decrease a person's motivation to change their gambling behaviour. Keep these external factors in mind when discussing how the client feels about change. Motivational interviewing can be a useful technique to guide clients through the stages of change.21 Motivational interviewing is a person-centred counselling style that facilitates behavioural change by addressing the common problem of ambivalence. It can be particularly helpful for clients who are in the early stages of change.21 

For clients who have gambling problems, the following are considered best practices in using the stages of change:3

  • Assess your client's current stage of changeand tailor treatment accordingly. For example, if clients are in the earlier stages, focus on insight and motivation; if clients are in the later stages, focus on action planning.3
  • Do not assume all clients are in the action stage. One study of readiness to change a problematic behaviour found that 40 per cent of people were in the precontemplation stage, 40 per cent were in contemplation and 20 per cent were in the preparation stage.22
  • Work with your client to set realistic goalsand guide your client through stages one at a time. Make sure you and your client understand that progress will not be linear. Most clients will progress through the stages several times and in a non-linear fashion before achieving long-term maintenance.3
  • Do not impose action on people in the precontemplation stage. Doing so can drive them away. Instead, use motivational interviewing to help increase their motivation and commitment to change.3
  • Use stage-appropriate strategies for change. For example, strategies associated with developing insight or awareness work best during the earlier stages, whereas strategies associated with action therapies work best during the later stages of change.3
  • Integrate different strategies for change and relational stances to help your clients move successfully through the stages of change. Listen to these audio clips to hear how a gambling counsellor's approach changes when a client is in the precontemplation stage and, later, in the action stage. There is always some ambivalence around change, even with clients in the action stage, and motivational interviewing techniques can assist with resolving this ambivalence.21 Because the stages of change are not linear, and because a client's stage can change very quickly, include relapse prevention as part of each client's treatment plan.3

Precontemplation stage

Action stage

HANDOUTS

Winning ways to keep gambling safe.
(suitable for clients at all stages of change)

This handout provides tips on how to reduce the risks of gambling.

What factors put you at risk for gambling problems?
(suitable for clients in the precontemplation, contemplation and maintenance stages)

This handout includes a list of known risk factors for developing gambling problems as well as information about how to get support.

Decision matrix.
(suitable for clients in the contemplation stage)

This worksheet helps clients consider the advantages and disadvantages of gambling and decide whether or not they want to change their behaviour.

How will changing your gambling improve your life?
How will gambling affect your life if you don't change?
(suitable for clients in the contemplation and preparation stages)

These worksheets help clients identify the benefits of stopping or minimizing their gambling and drawbacks of continued gambling. Clients can also develop an impact statement that will help them visualize their future goals.

Ways to boost your motivation
(suitable for clients in the contemplation, preparation and action stages)

This worksheet highlights key areas for clients to brainstorm ways they can boost their motivation.

Monitor your gambling & urges
(suitable for clients in the contemplation, preparation, action and maintenance stages)

This worksheet is a self-monitoring tool that can help clients gain a better understanding of their urges to gamble. For this tool to be effective, it should be used every time your client feels an urge to gamble, regardless of whether or not they did gamble.

This tool is also available online and as a mobile application for iOS, Blackberry, and Android devices. Both versions allow the client to monitor wins and losses if they continue to gamble.

Quitting or cutting back
(suitable for clients in the preparation stage)

This worksheet encourages clients to set a behaviour change. It describes three options for the behaviour change: (1) abstaining; (2) quitting only problematic forms of gambling; and (3) cutting back. It includes a questionnaire to help clients determine if cutting back will work for them.

Smarter goal worksheet
(suitable for clients in the preparation stage)

This worksheet helps clients identify what is important to them and what goal they may want to focus on. Engaging in smarter goal setting can support your clients to:

  • clearly define their goals
  • stay focused
  • track their progress.

Dealing with Debt
(suitable for clients in the preparation and action stages)

This handout provides clients with information about debt repayment options, including debt consolidation, consumer proposals, and bankruptcy. This can be a helpful handout for clients looking to learn more about repayment options and how to get started.

Stages of change exercise
(Most suitable for clients in the action and maintenance stages)

This worksheet provides clients an opportunity to reflect on their progress and identify the key factors that have contributed to their success. However, it can be given to clients at any point in the gambling treatment process.

Meaningful activities for a healthier lifestyle
(suitable for clients in the action and maintenance stages)

This handout provides a list of healthy non-gambling activities that clients can engage in during their leisure time.

Repairing relationships
(suitable for clients in the action and maintenance stages)

This worksheet describes the importance of working to repair relationships hurt by gambling problems and provides some practical strategies for doing so. It encourages clients to make a list of what they did—or did not do—in their relationships hurt by gambling. It also encourages clients to think about what they can do to make it up to the other person.

Dealing with urges
(suitable for clients in the action and maintenance stages)

This worksheet helps clients in the action and maintenance stages identify their gambling triggers and situations that put them at risk for gambling. It explains the central role of coping strategies in overcoming urges to gamble and helps clients systematically examine and record the coping strategies that work for them.

How do I help someone change their gambling?

This handout is for family members and friends wishing to better understand and support someone who has a gambling problem.


References

Last modified: January 16, 2019

This information is intended to help clinicians in their use of evidence-informed practice (EIP) when screening, assessing, and treating clients with behavioural addiction(s). Evidence-informed practice, sometimes called evidence-based practice, is a client-centred approach to clinical decision making. It’s a way to solve problems by integrating the best available research evidence with the clinician’s experience, the client’s preferences and values, and the organizational and cultural context.1,2,3,4