Developed by James Prochaska and Carlo DiClemente in the 1970s, the transtheoretical model (often referred to as the “stages of change”) recognizes that clients can be at different levels of readiness in the behaviour-change process. The model suggests that changing a person’s health behaviours involves moving through five cognitive stages (i.e., precontemplation, contemplation, preparation, action and maintenance) and provides direction on how to adapt treatment based on the client’s stage of change (Norcross et al., 2011; Prochaska, 1979; Prochaska & DiClemente, 1982).
One of the strengths of this model is that it recognizes that change is rarely linear; people move forwards and backwards through the different stages (Prochaska & DiClemente, 1982). According to the model, relapse is understood as a common and useful part of the behaviour change process, more a “rule” rather than an exception. In addition, relapse is seen as a learning opportunity and part of the move toward creating long-lasting change (Petry, 2005).
The stages of change represent both the points in time and sets of tasks that are needed to achieve behaviour change (Norcross et al., 2011). Determining a client’s readiness for change is essential to choosing the appropriate strategies and effectively supporting them. 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 (Norcross et al., 2011).
This page 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, problem gaming, and problem technology use.
The following video describes each stage in detail and offers clinical strategies appropriate for clients living with problem gambling.
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 (Norcross et al., 2011). The client’s stage of change at the start of treatment is correlated with the severity of their gambling problems and their level of psychosocial functioning (Petry, 2005). Findings from a 2016 meta-analysis suggest that clients with gambling problems are significantly more likely to have successful treatment outcomes if they are in the action stage (Merkouris et al., 2016). Another meta-analysis of interventions for health behaviour change found that adapting the intervention to the client’s stage of change resulted in significantly greater likelihood of success (Krebs et al., 2010).
- Reducing drop-out rates in mental health therapy. Understanding a client’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 client’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 were more likely to drop out of psychotherapy than those in the other stages (Callaghan et al., 2005; Derisley & Reynolds, 2000). Conversely, studies show that clients who are in the maintenance stage are more likely to complete their course of psychotherapy (Henderson et al., 2004; Joe et al., 1998).
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 for smoking cessation (Anatchkova et al., 2006; Anatchkova et al., 2007; Charkazi et al., 2012; Sarbandi et al., 2013), physical activity (Benitez et al., 2017; Geller et al., 2012) and weight loss treatments (Chae et al., 2010; Kjøllesdal et al., 2011; Sbrocco et al., 2012). However, no research has emerged regarding cultural adaptation of this model for problem gambling.
How do I put the evidence to 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 will indicate which stage of change they are likely in: contemplation (“some day”), preparation (“in the next month”), and action (“now”) (Prochaska et al., 2013).
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. Consider these external factors when discussing how the client feels about change.
Motivational interviewing can be a useful technique to guide clients through the stages of change (DiClemente & Velasquez, 2002). 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 (DiClemente & Velasquez, 2002).
The following are considered best practices in using the stages of change for clients who have gambling problems:
- Assess your client’s current stage of change and tailor treatment accordingly. For example, focus on insight and motivation if clients are in the earlier stages; focus on action planning if clients are in the later stages (Norcross et al., 2011).
- 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 (Velicer et al., 1995).
- Work with your client to set realistic goals and 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 (Norcross et al., 2011).
- 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 (Norcross et al., 2011).
- 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/contingency planning work best during the later stages of change (Norcross et al., 2011).
- Acknowledge and work with ambivalence. There is always some ambivalence around change, even with clients in the action stage, and motivational interviewing techniques can assist with resolving this ambivalence (DiClemente & Velasquez, 2002).
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.
CL: I’m not really sure what I’m doing here or what the point even is.
T: Well, I see from your intake documents that you are here because your partner, Jon, wants you to get treatment to address your gambling.
CL: I do gamble, but so what? It’s not that bad, and he just has zero tolerance.
T: Even though you don’t agree with your partner, you care enough about him to come in to check out the program. I’m impressed you made the effort to get here.
CL: I really just want to get Jon off my back. He’s been on me about closing all my online poker accounts. I thought that if I started coming to see someone, he would relax a bit, and we could get back to how things used to be.
T: Sounds like your relationship with Jon is really important to you.
CL: Yeah. I just hate all the fighting.
T: You don’t like that there’s so much disagreement about the gambling, and coming to talk to me is one way to show you’re making an effort. Do you have a sense of what you’d like us to focus on?
CL: If I could figure out a way to better explain to Jon that a lot of people gamble and that it’s not really that big a deal, I think he would lay off a bit.
T: So, discussing how to talk to Jon about your gambling and the difference between typical and harmful gambling might be helpful?
T: We can definitely do that. To start, I wanted us to talk about what counselling will look like and review your rights to confidentiality and the limits of confidentiality. Then, we can spend the rest of our time today talking about how to talk to Jon about your gambling. Does that sound okay?
T: How’s your week been?
CL: It was okay. Jon and I are fighting a lot still . . . he tells me I need to stop the gambling cold turkey.
T: What do you think of that?
CL: I know that if I close my online poker accounts, he’ll be happier, and things between us will get better, but I’m worried about what it would be like not to play poker at all anymore.
T: Poker has been a big part of your life, and closing the accounts would be a pretty significant change.
CL: I started doing some research. I looked into that website you gave me—Gamblock.com.
T: That’s great that you looked into that! Would it be a tool you might want to consider trying?
CL: I think so. It would help me keep away from the online poker sites.
T: Okay. So, it sounds like that’s something you might try out in the future. I’m wondering—have you given any thought to joining the group I mentioned?
CL: Yeah. I think it’s a good idea to try it out.
T: A lot of people have found that having the support of others who are going through a similar situation is very helpful.
CL: When did you say the next group starts, again?
Use these handouts and worksheets depending on which stage of change your client is in.
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.
- 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 recognize the 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.
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.
- 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.
Anatchkova, M.D., Redding, C.A. & Rossi, J.S. (2006). Development and validation of decisional balance and temptations measures for Bulgarian adolescent smokers. Addictive Behaviors, 31 (1), 155–161. Available: https://doi.org/10.1016/j.addbeh.2005.04.015. Accessed February 8, 2021.
Anatchkova, M.D., Redding, C.A. & Rossi, J.S. (2007). Development and validation of transtheoretical model measures for Bulgarian adolescent non-smokers. Substance Use & Misuse, 42 (1), 23–41. Available: https://doi.org/10.1080/10826080601094140. Accessed February 8, 2021.
Benitez, T.J., Tasevska, N., Indiana, K.C. & Keller, C. (2017). Cultural relevance of the transtheoretical model in activity promotion: Mexican-American women’s use of the process of change. Journal of Health Disparities Research & Practice, 10 (1), 20–27. Available: https://digitalscholarship.unlv.edu/cgi/viewcontent.cgi?article=1452&context=jhdrp. Accessed February 8, 2021.
Callaghan, R.C., Hathaway, A., Cunningham, J.A., Vettese, L.C., Wyatt, S. & Taylor, L. (2005). Does stage-of-change predict dropout in a culturally diverse sample of adolescents admitted to inpatient substance-abuse treatment? A test of the transtheoretical model.
Addictive Behaviors, 30 (9), 1834–1847. Available: https://doi.org/10.1016/j.addbeh.2005.07.015. Accessed February 8, 2021.
Chae, S.M., Kwon, I., Kim, C.J. & Jang, J. (2010). Analysis of weight control in Korean adolescents using the transtheoretical model. Western Journal of Nursing Research, 32 (4), 511–529. Available: https://doi.org/10.1177/0193945909355996. Accessed February 8, 2021.
Charkazi, A., Shahnazi, H., Ghourchaei, A.B. & Mirkarimi, K. (2012). Smoking behaviors in Iranian male students: An application of transtheoretical model. Journal of Education and Health Promotion, 1, 22–27. Available: https://doi.org/10.4103/2277-9531.99954. Accessed February 8, 2021.
Derisley, J. & Reynolds, S. (2000). The transtheoretical stages of change as a predictor of premature termination, attendance and alliance in psychotherapy. British Journal of Clinical Psychology, 39 (4), 371–382.
DiClemente, C.C. & Velasquez, M.M. (2002). Motivational interviewing and the Stages of Change. In W.R. Miller & S. Rollnick (Eds.), Motivational Interviewing: Preparing People for Change (2nd ed.) (pp. 201–221). New York: Guildford Press. Available: http://www.well- coach.com/memberships/images/MI_DiClemente_Stages.pdf. Accessed February 8, 2021.
Geller, K.S., Nigg, C.R., Motl, R.W., Horwath, C.C. & Dishman, R.K. (2012). Transtheoretical model constructs for physical activity behavior are invariant across time among ethnically diverse adults in Hawaii. Psychology of Sport and Exercise, 13 (5), 606–613. Available: https://doi.org/10.1016/j.psychsport.2012.02.006. Accessed February 8, 2021.
Henderson, M.J., Saules, K.K. & Galen, L.W. (2004). The predictive validity of the University of Rhode Island change assessment questionnaire in a heroin-addicted polysubstance abuse sample. Psychology of Addictive Behaviors, 18 (2), 106. Available: https://- doi.org/10.1037/0893-164X.18.2.106. Accessed February 8, 2021.
Joe, G.W., Simpson, D.D. & Broome, K.M. (1998). Effects of readiness for drug abuse treatment on client retention and assessment of process. Addiction, 93 (8), 1177–1190. Available: https://doi.org/10.1046/j.1360-0443.1998.93811776.x. Accessed February 8, 2021.
Kjøllesdal, M.R., Hjellset, V.T., Bjørge, B., Holmboe-Ottesen, G. & Wandel, M. (2011). Intention to change dietary habits, and weight loss among Norwegian-Pakistani women participating in a culturally adapted intervention. Journal of Immigrant and Minority Health, 13 (6), 1150–1158. Available: https://doi.org/10.1007/s10903-010-9416-7. Accessed February 8, 2021.
Krebs, P., Prochaska, J.O. & Rossi, J.S. (2010). A meta-analysis of computer-tailored interventions for health behavior change. Preven- tive Medicine, 51 (3–4): 214–221. Available: https://doi.org/10.1016/j.ypmed.2010.06.004. Accessed February 8, 2021.
Merkouris, S.S., Thomas, S.A., Browning, C.J., & Dowling, N.A. (2016). Predictors of outcomes of psychological treatments for disor- dered gambling: A systematic review. Clinical Psychology Review, 48, 7–31. Available: https://doi.org/10.1016/j.cpr.2016.06.004. Accessed February 8, 2021.
Norcross, J.C., Krebs, P.M. & Prochaska, J.O. (2011). Stages of change. Journal of Clinical Psychology, 67 (2), 143–141. Available: https://doi.org/10.1002/jclp.20758. Accessed February 8, 2021.
Petry, N.M. (2005). Stages of change in treatment-seeking pathological gamblers. Journal of Consulting and Clinical Psychology, 73 (2), 312–322. Available: https://doi.org/10.1037/0022-006X.73.2.312. Accessed February 8, 2021.
Prochaska, J. (1979). Systems of Psychotherapy: A Transtheoretical Analysis. Homewood, IL: Dorsey Press.
Prochaska, J.O. & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice, 19 (3), 276–288. Available: https://doi.org/10.1037/h0088437. Accessed February 8, 2021.
Prochaska, J.O., Norcross, J.O., & DiClemente, C.C. (2013). Applying the stages of change. Psychotherapy in Australia, 19 (2), 10–15. Available: https://doi.org/10.1093/med:psych/9780199845491.003.0034. Accessed February 8, 2021.
Sarbandi, F., Niknami, S., Hidarnia, A., Hajizadeh, E. & Montazeri, A. (2013). The transtheoretical model (TTM) questionnaire for smoking cessation: Psychometric properties of the Iranian version. BMC Public Health, 13 (1), 1186. Available: https://- doi.org/10.1186/1471-2458-13-1186. Accessed February 8, 2021.
Sbrocco, T., Osborn, R., Clark, R.D., Hsiao, C.W. & Carter, M.M. (2012). Assessing the stages of change among African American women in a weight management program. Journal of Black Psychology, 38 (1), 81–103. Available: https://doi.org/10.1177/0095798411403618. Accessed February 8, 2021.
Velicer, W.F., Fava, J.L., Prochaska, J.O., Abrams, D.B., Emmons, K.M. & Pierce, J.P. (1995). Distribution of smokers by stage in three representative samples. Preventive Medicine, 24 (4), 401–411. Available: https://doi.org/10.1006/pmed.1995.1065. Accessed February 8, 2021.