Levels of Change: The Neglected Narrative-Mind Construct in the Transtheoretical Model

I have written previously about the stages of change and the processes of change, two important components of James Prochaska's transtheoretical model (TTM). The original TTM also had a third concept, the levels of change, which captures another feature that differentiates between psychotherapy schools. In this case, Prochaska was getting at the idea of a "theory of problem causation" that seen as the focus for psychotherapeutic efforts. Prochaska differentiated these theories of why people have problems from separate "theories of change," which represent the ways in which problems can be fixed. The TTM's processes of change are theories of change, while the levels represent theories of problem causation. Compared to the other two components of the TTM, the levels of change have received minimal research and have not proven strongly predictive of treatment outcomes. Perhaps for that reason, this construct has not been widely used in the health care arena. In fact, Prochaska's own website no longer mentions the levels of change as a component of the TTM.

The original TTM identified five distinct levels of change, or areas in which a psychotherapist and client could direct their change efforts:

1. Symptoms or situational problems
2. Current maladaptive cognitions
3. Current interpersonal conflicts
4. Family systems conflicts
5. Long-term intrapersonal conflicts

These levels answer the important question "where do people's problems come from?" Each one actually implies a different view of human nature: For example, a “maladaptive cognitions” focus in therapy is based on the assumption that people’s thoughts determine their behaviors -- an understanding that is consistent with Cognitive Therapy, but that Two Minds Theory implies is not true. An “intrapersonal conflicts” focus, by contrast, is based on the theory that people’s behavior is influenced by past experiences and patterns that continue to shape their perceptions and reactions without them being consciously aware of the reasons. That sounds quite a bit like Two Minds Theory, but Prochaska was almost certainly thinking of psychodynamic therapy instead, in which the source of the unconscious influences is suggested to be a person’s early life experiences and family relationships.

Each of the levels of change has historical roots in different psychotherapy traditions: Besides cognitive and psychodynamic therapy, Prochaska’s model encompasses the structural and strategic schools of Family Systems Therapy (“family systems” level of change, which emphasizes ongoing interactional patterns like treating a particular family member as the “identified patient” in order to divert attention from other problems). It also includes Skinnerian Behavior Therapy at the “symptoms” level of change, because this approach was traditionally seen to be a way of “fixing the symptom” as opposed to addressing the underlying problems that caused the symptom in the first place. And the potential level of “current interpersonal conflicts” brought in a different type of psychodynamic treatment based on the writings of Harry Stack Sullivan and Karen Horney, who focused less on early childhood experiences and more on strengthening a client’s current interpersonal relationships as an adult.

It’s important to remember something that I said on my last post about the TTM, that it was originally designed not as a tailored-messaging strategy but instead as a way of integrating competing psychotherapeutic schools. The processes of change were one way of integrating competing approaches based on the methods that a therapist might actually use with a client (what Prochaska called the “theory of change” endorsed by that school of therapy). The levels of change were a different method of integration, grouping schools of therapy based on the content or focus of the therapist’s interactions with clients - what Prochaska called the “theory of problem causation.” In line with integrative psychotherapy thinking of the time, Prochaska suggested that a school’s theory of causation and its theory of change were separable from one another. Two schools might use the same method, like exposure to a feared situation, but offer completely different explanations for why the technique was selected or how it was expected to help the client. A potential problem with the levels of change is that different causal explanations for why someone has a problem can’t all be true — many of these theories are in fact mutually incompatible. This might be why the approach to integrating different schools based on shared techniques (the process of change) was ultimately more successful than the approach to integration based on a classification of theories (the levels of change).

I actually tried to test this under-utilized component of the TTM in my dissertation research: My hypothesis at the time was that providing clients with a novel explanation might be part of why therapy works. The fact that therapy offers an explanation for problems is often identified as one of the "common factors" that explain why so many different forms of therapy work about equally well. For convenience, I recruited a group of college students who self-identified as having trouble with procrastinating on their school assignments (yes, my dissertation was about procrastination). I was pretty deep in constructivist thought at the time, and I suggested that it didn’t really matter whether a particular theory of problem causation was actually true. Instead, it seemed to me that it just mattered whether the therapist could make someone believe in the theory. Furthermore, I hypothesized that when the therapist presented a different theory from the one that the person stated with, the intervention would be more effective. I came up with a list of 10 different causal explanations for problems, which expanded on Prochaska’s levels of change, and then assessed which of them the student already believed. Next, I randomly assigned students to one of three experimental groups. In the first, the therapist agreed with the student’s pre-existing theory. In the second they offered a different theory, one that was randomly selected to emphasize one of the other levels of change. At that time I believed strongly in the power of narratives, and I thought that I could produce change by speaking to the Narrative mind. The levels of change are fundamentally a Narrative-mind construct: They are about what we believe, not about what we do. I hoped that the power of belief — even a belief selected at random — could spark a change in people’s behavior. 

If you are a regular reader of this blog, you will know that I no longer think narratives can directly affect behavior, and perhaps you will guess what happened. My clever intervention didn’t work at all. Two Minds Theory could have told me so: Narrative thinking is just too slow to have a direct effect. By the time we think “I need to move my hand 6 inches higher to catch that baseball,” the ball has already hit us in the face. I did have an interesting finding, in which my control group actually improved more than either the same-level or different-level interpretation of what caused the student’s procrastination problem: You can read more about what I actually found out here. 

The levels of change at this point seem to be a historical curiosity, but the project of identifying causes of problems is far from abandoned. Recent efforts like Susan Michie’s proposed taxonomy of behavior-change constructs seem to include a mixture of processes of change (e.g., reinforcement, persuasion) and causal factors (e.g., lack of knowledge, lack of motivation) that affect change. What we might take from the history of Prochaska’s TTM is that the things that cause problems can be divisive — they separated psychotherapy into competing schools for decades — but they actually don’t seem to matter very much at the end of the day. One of Prochaka’s enduring contributions is the insight that a psychotherapy’s theory of change, i.e. the things that therapists actually do, can be almost totally separated from that same psychotherapy approach’s theory of problem causation. The methods that we use to help people, which Prochaska called the processes of change, are likely to be a more fruitful avenue of research.