Developed by Prochaska and DiClemente, the Transtheoretical Model (TTM) posits that health behavior change is not an event, but a process that unfolds over time through a series of stages. In pain medicine, we use this model to assess a patient’s readiness to adopt active coping strategies, taper opioids, or engage in psychological treatments like CBT.

1. The Five Stages of Change

I. Pre-contemplation (“Not Ready”)

The patient has no intention of changing their behavior in the foreseeable future (usually the next 6 months).

• Clinical Presentation: They may be defensive or “in denial.” They often believe the solution is entirely external (e.g., “Just give me the surgery/pill”).
• Physician Goal: Validate their pain, but provide gentle education on the risks of current behaviors and the benefits of change.

II. Contemplation (“Getting Ready”)

The patient is aware that a problem exists and is seriously thinking about overcoming it but has not yet made a commitment to take action.

• Clinical Presentation: They are ambivalent. They see the “pros” of changing but are heavily weighed down by the “cons” (e.g., “I know I should exercise, but it’s so hard to start”).
• Physician Goal: Tip the “decisional balance” by highlighting the personal values that change would support.

III. Preparation (“Ready”)

The patient intends to take action in the very near future (usually within the next month).

• Clinical Presentation: They have started taking small steps, such as researching a physical therapist or buying a gym membership.
• Physician Goal: Help them develop a concrete, realistic action plan and set a “start date.”

IV. Action (“Moving”)

The patient is actively modifying their behavior, experiences, or environment to overcome their problems.

• Clinical Presentation: They are attending PT, practicing pacing, and using their CBT skills. This is the stage with the highest risk for relapse.
• Physician Goal: Provide social support, help with problem-solving barriers, and reinforce self-efficacy.

V. Maintenance (“Staying”)

The patient has sustained the new behavior for more than 6 months and is working to prevent relapse.

• Clinical Presentation: The “new” behavior (e.g., a daily walking routine) has become a habit.
• Physician Goal: Focus on long-term sustainability and “relapse prevention” strategies for future flares.

2. Motivational Interviewing (MI)

MI is the clinical communication style used to move patients through these stages. It is based on “OARS”:

• Open-ended questions.
• Affirmations.
• Reflective listening.
• Summarizing.
• Board Pearl: The goal of MI is to elicit “Change Talk” from the patient themselves, rather than the doctor lecturing them.

3. Decisional Balance

This is the “mental scale” where a patient weighs the pros and cons of a behavior.

• For a patient to move from Contemplation to Action, the perceived “pros” of the new behavior must outweigh the “pros” of the old behavior (e.g., the benefit of being able to play with grandkids must outweigh the “benefit” of the sedentary “protection” of the back).

4. Application to Interventions

• Spinal Cord Stimulation (SCS): Most psychological clearances for SCS look for patients who are at least in the Preparation or Action stage. If a patient is in Pre-contemplation regarding their role in their recovery, the device is more likely to fail.
• Opioid Tapering: A patient in Pre-contemplation is likely to experience high levels of distress and perceived “withdrawal” pain. Tapering is much more successful when the patient has reached the Preparation stage.

5. Meeting the Patient Where They Are

We do not treat all patients the same.

• For Pre-contemplators: We focus on “Harm Reduction” and building rapport.
• For Action/Maintenance: We focus on high-level functional goals and advanced strengthening.
• Relapse is Normal: The TTM is often a “spiral,” not a straight line. Patients may fall back to Contemplation during a flare; the goal is to get them back into Action as quickly as possible.

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High-Yield Board “Fast Facts”

• Pre-contemplation: No intent to change; solution is seen as external.
• Contemplation: Ambivalence; weighing pros and cons.
• Preparation: Small steps taken; intention to act within 30 days.
• Maintenance: Behavior sustained for >6 months.
• Motivational Interviewing: The primary tool for moving a patient between stages.