Stages of Change Worksheet PDF and Motivational Interviewing

Most results for a stages of change motivational interviewing PDF are one-page handouts: five boxes, a sentence under each, and nothing about what to say to the person sitting in front of you. This page gives you the part a handout leaves out. You'll find the transtheoretical model explained with its history (including why some lists have five stages and others six), how it relates to motivational interviewing and where the two differ, what to do at each stage with example therapist responses, what the research supports and where it has been criticized, and how to record stage of change in a progress note.

For your client there is a printable worksheet in plain words: where am I now, the pros and cons of changing and of staying the same, and what would move me one step. Print this page or save it as a PDF.

Every client in this article is invented. Any resemblance to a real person is a coincidence.

How to print this page or save it as a PDF

The stages of change at a glance

The time frames below are the ones the model's authors use to measure each stage. They are research conventions, not rules a client has to fit.

What the transtheoretical model is

The transtheoretical model (TTM) is James Prochaska and Carlo DiClemente's model of how people change a behavior on purpose, with or without treatment. Its best-known part is the stages of change, but the model has more in it: ten processes of change, the pros and cons people weigh (decisional balance), confidence (self-efficacy) and temptation (Prochaska and Velicer, 1997).

The name comes from its origin. In 1982, Prochaska and DiClemente compared 18 leading systems of therapy and pulled out processes of change that cut across them, which is why the model is "transtheoretical" (Prochaska and DiClemente, 1982). They then studied how people changed on their own. Their 1983 study of 872 people quitting smoking without treatment found that people used different processes at different stages: the fewest in precontemplation, consciousness raising in contemplation, and behavioral processes such as rewarding themselves, replacing the habit and changing their surroundings in action and maintenance (Prochaska and DiClemente, 1983).

Two other parts of the model matter in a session:

Five stages or six?

Lists disagree because the model changed over time. Here is the sequence:

Many clinical guides, including SAMHSA's TIP 35, use the five stages from 1992 and show "relapse and recycle" as a loop rather than a stage. Handouts that list "six stages" often mean those five plus relapse. Both are fair summaries; just don't present relapse as a stage everyone must pass through, or termination as a finish line you promise a client.

Not a straight line: relapse and recycling

People rarely move through the stages in one direction. The University of Rhode Island's Cancer Prevention Research Center, home to much of the model's research, describes relapse as one form of regression, a move from action or maintenance back to an earlier stage, and says relapse "tends to be the rule when action is taken for most health behavior problems." The same page adds that for smoking and exercise only about 15% of people go all the way back to precontemplation; most return to contemplation or preparation (CPRC, Detailed Overview).

TIP 35 frames a return to use as normal and as "a learning opportunity," and prefers the words "recurrence" or "return to substance use" because "relapse" can carry negative connotations. Those words are worth borrowing in session and in your notes.

Stages of change and motivational interviewing: how they relate and how they differ

Motivational interviewing (MI) and the TTM grew up together in the early 1980s, so they are often taught as one thing. They aren't. Miller and Rollnick, who developed MI, put the first item on their list of ten things MI is not: "MI was never based on the TTM. They are, in essence, kissing cousins who never married" (Miller and Rollnick, 2009). In the same paper they describe the TTM as a comprehensive model of how and why change happens, and MI as a specific clinical method for strengthening a person's own motivation. They add: "It is not necessary to assign people to a stage of change as part of or in preparation for MI."

SAMHSA's TIP 35, which abbreviates the stages of change as SOC, says the same in its list of misconceptions about MI: "MI is not the SOC. MI is not an essential part of the SOC and vice versa. They are compatible and complementary."

How they differ:

Where they meet is practical. The stages give you a map of where the conversation is; MI gives you the conversation. Miller and Rollnick's fourth edition describes four tasks of MI: engaging, focusing, evoking and planning (Miller and Rollnick, 2023). Engaging matters at every stage. Evoking does most of the work in precontemplation and contemplation. Planning belongs to preparation and action. TIP 35 is organized the same way, with chapters on moving from precontemplation to contemplation, contemplation to preparation, preparation to action, and action to maintenance.

For the questions themselves, see our motivational interviewing questions, sorted by task with example exchanges. For the four core skills, see OARS in motivational interviewing, with weak and strong examples and a printable card.

How to tell which stage a client is in

Ask, then listen. A stage is a working guess about one behavior, not a label for the person.

What to do at each stage, with example therapist responses

The responses below follow one invented client so you can see the conversation change. Dana is 41 and manages a busy restaurant. She sees you by video for work stress. She drinks four to six glasses of wine most nights after closing, and her doctor recently mentioned her blood pressure and liver tests.

Treat the lines as examples to adapt, not scripts. The "what helps" lists draw on TIP 35's counseling strategies for each stage (Exhibits 4.1, 5.1, 6.1 and 7.1), in our own words, with a few additions from MI practice.

Precontemplation: not thinking about changing

The client isn't intending to change this behavior soon. They may not see a problem, may feel pressured by someone else, or may have tried before and given up. TIP 35 describes five styles you'll hear here, often called the five Rs: reveling (still mostly enjoying it), reluctance (not knowing enough about the problem, or doubting they could manage without the behavior), rebellion (resisting being told what to do), resignation (feeling hopeless after past attempts) and rationalization (having an answer for every concern).

What helps:

Example responses with Dana:

What tends to backfire: arguing, warning, listing consequences, labels such as "denial," and making a plan the client didn't ask for.

Contemplation: thinking about it, not sure

The client intends to change at some point and sees reasons on both sides. Ambivalence is strongest here, and people can stay in this stage for a long time; the Rhode Island researchers call it "chronic contemplation" (CPRC). Your aim is to help the client resolve ambivalence, usually toward change, without pushing.

What helps:

Example responses with Dana:

What tends to backfire: pressing for a decision, spending most of the session on what's good about drinking, and moving to planning before the client is ready.

Preparation: decided, getting ready

The client intends to act soon and may already be taking small steps. Commitment can still be fragile. Your job is to turn the decision into a plan that is the client's own.

What helps:

Example responses with Dana:

That fourth line matters. Alcohol withdrawal "may range from a mild and uncomfortable disorder to a serious, life-threatening condition" (MedlinePlus), and TIP 35 says tapering off opioids, benzodiazepines or several substances should be done under medical supervision. A change plan for any of these needs a medical provider in it.

What tends to backfire: a plan you wrote, a goal that's too big, and skipping the question of what might get in the way.

Action: making the change

The client has made specific, visible changes within the past six months. They are working hard, and this is the stage where, in the Rhode Island researchers' words, "vigilance against relapse is critical." Your job is to support the effort and adjust what isn't working.

What helps:

Example responses with Dana:

What tends to backfire: assuming the work is done, ignoring ambivalence that's still there, and cutting back support too soon.

Maintenance: keeping it going

The client has kept the change going and works to prevent a return to the old pattern. They are usually less tempted and more confident than in action (CPRC), but some situations remain risky for a long time. Your job is to help the change become part of a life the client wants.

What helps:

Example responses with Dana:

What tends to backfire: treating maintenance as the end, and ending contact abruptly.

Relapse and recycling: a return to an earlier stage

The client has gone back to the old pattern, briefly or for longer. In smoking and exercise research, most people who return to an old behavior go back to contemplation or preparation, not to the beginning. Your job is to take the shame out of it, learn from it together and help the client decide where they are now.

What helps:

Example responses with Dana:

What tends to backfire: "back to square one," moralizing, and treating a return to use as a reason to end treatment.

How to use the worksheet in session

The worksheet below is written to the client. A few points before you hand it over.

Parts 3 and 4 are a full decisional balance, so decide how you'll use them. Miller and Rose found that with ambivalent people a balanced pros-and-cons exercise tends to decrease commitment to change, while evoking change talk tends to increase it; once a person has decided, a pros-and-cons exercise may strengthen commitment (Miller and Rose, 2015). TIP 35 advises you to "carefully consider your own intention and the client's stage in the SOC before using a structured DB that explores both sides of client ambivalence equally" (DB is decisional balance). In practice:

Other tips:

Worksheet: Where I am with change

Before you start

This sheet is for you. It isn't a test, and there are no right answers. Pick one change to think about. If there's more than one, use a separate sheet for each. Your answers can change from week to week, and that's normal.

Part 1: The change I'm thinking about

Part 2: Where am I now?

Circle the one that fits best today.

My numbers

Part 3: Staying the same

Part 4: Making the change

Part 5: What matters most

Part 6: What would move me one step

You don't have to jump to the end. One step forward from where you are is enough.

If I slip

A slip doesn't erase what you've done. Many people go around more than once before a change lasts. Bring this sheet to your next session.

If you feel unsafe, or think you might harm yourself, call or text 988 in the US, or call 911.

End of the worksheet.

What the evidence says, and the critiques

The stages of change are among the most widely taught ideas in counseling, and among the most debated. Here is the research in both directions, so you can decide how much weight to give them.

Readiness predicts therapy outcomes. A meta-analysis of 39 studies (8,238 psychotherapy patients) found a clinically significant association between pretreatment stage of change and outcome (d = .46): clients further along the stages tended to make more progress (Norcross, Krebs and Prochaska, 2011). An update of 76 studies (25,917 patients) found a moderate effect (d = 0.41) across substance and alcohol use, eating disorders and mood disorders (Krebs and colleagues, 2018). These are associations: they show that readiness matters, not that matching treatment to stage improves results. The 2011 review itself notes "scant psychotherapy research" on matching.

Stage-matched treatment hasn't beaten unmatched treatment. A systematic review of 23 randomized studies of smoking cessation concluded that stage-based interventions were no more effective than non-stage-based interventions or no intervention (Riemsma and colleagues, 2003). A Cochrane review of 41 randomized studies (more than 33,000 participants) found that, in the four studies that compared the same intervention with and without staging, stage-based self-help and counseling were "neither more nor less effective than their non-stage-based equivalents." Against usual care or other controls, staged programs helped about as much as unstaged ones do. The review added: "The evidence does not support the restriction of quitting advice and encouragement only to those smokers perceived to be in the preparation and action stages" (Cahill, Lancaster and Green, 2010). Both reviews are about smoking, the area where the model was born and has been tested most.

The stages may not be separate stages. Sutton's review of substance use research found staging cutoffs based on arbitrary time periods, and found that the multi-scale questionnaires (URICA, SOCRATES and the Readiness to Change Questionnaire) were not measuring discrete stages (Sutton, 2001). A review of 87 studies found the stages were not mutually exclusive and found little evidence that people move through them in sequence, while granting the model "considerable heuristic value" (Littell and Girvin, 2002).

Change can be sudden. In a national survey in England, 48.6% of smokers who had tried to quit said their most recent attempt started the moment they decided, with no advance planning, and unplanned attempts were more likely to last six months (West and Sohal, 2006). West had earlier argued in an editorial that it was time to put the model "to rest" (West, 2005). The journal published five commentaries alongside it, including DiClemente's reply, "A premature obituary for the transtheoretical model".

MI has its own evidence, independent of staging. A meta-analysis of 72 clinical studies found an average short-term effect of 0.77 for MI, falling to 0.30 at follow-ups up to a year, with results that varied widely across providers, populations and settings (Hettema, Steele and Miller, 2005).

What this means in practice:

TIP 35 takes a similar position: it calls the stages "not a specific counseling method but a framework," and notes that results on its usefulness are mixed.

How to note stage of change in a progress note

"Client is in contemplation" says little on its own. A useful note records the behavior, the stage with the evidence for it, what you did, and a plan that fits the stage:

An example in DAP format, for an invented contemplation session:

Weak and better lines:

Where it goes in other formats: in BIRP, ruler scores and the client's change talk go under Response and your stage reading under Plan or a stage line; in SOAP, the client's statements and ruler scores go in Subjective and your stage reading in Assessment. The progress notes cheat sheet has wording for MI interventions and client response, the DAP notes examples and BIRP note examples show full notes, and the treatment plan template helps you write objectives that fit the stage, such as "client will name two ways drinking affects what matters to her" in precontemplation or "client will write a change plan with a start date" in preparation.

How this works in TranqBay

TranqBay is practice software for therapists in private practice: a practice website, online booking, video sessions and session notes in one place. Here is where a stages of change conversation fits.

practice.tranqbay.health shows a practice website design with a "My approach" section and the booking page where a new client requests a first consultation, so you can see where that line about not needing to be sure would sit.

Frequently asked questions about the stages of change and motivational interviewing

Before your next session

Pick one client who seems stuck. Before the session, guess their stage for one behavior and write down why. In the session, ask them where they are, compare their answer with your guess, and use the worksheet's last part to find one step forward from there.

If you also want your practice website, booking, video sessions, client forms and session notes in one place, look at a practice website design and the booking page your clients would use. If you're deciding whether to join, this page explains how joining TranqBay works.

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