2012. Vol.3, No.6, 494-499
Published Online June 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.36070
Copyright © 2012 SciRes.
Relationships between Stages and Processes of Change for
Effective Stress Management in Japanese College Students*
Satoshi Horiuchi1, Akira Tsuda2, Janice M. Prochaska3,
Hisanori Kobayashi4, Kengo Mihara5
1Cancer Prevention Research Center, University of Rhode Island, Kingston, USA
2Department of Psychology, Kurume University, Kurume, Japan
3Pro-Change Behavior Systems, Inc., Kingston, USA
4Department of Psychology, University of Rhode Island, Kingston, USA
5Cognitive and Molecular Research Institute of Brain Diseases, Kurume University, Kurume, Japan
Received March 5th, 2012; revised April 3rd, 2012; accepted May 4th, 2012
With a primary prevention focus, it would be important to help populations engage in stress management.
The Transtheoretical Model of Behavior Change is one of potentially useful models to formulate inter-
ventions. The model describes behavior change as progression through five stages: precontemplation (not
ready), contemplation (getting ready), preparation (ready), action, and maintenance. Processes of change
(strategies and techniques to enhance the progression) facilitate stage transition. Their use is hypothesized
to depend on stage of change. The processes tend to be used the least at the precontemplation stage. Use
of experiential processes (affective and/or cognitive strategies such as seeking information) increase over
time and tend to peak at the contemplation or preparation stage and then decease. In contrast, behavioral
processes (behavioral strategies such as seeking social support) tend to be used most at the action and/or
maintenance stage. This study examined relationships between stages and processes of change for effec-
tive stress management. Effective stress management is defined as any form of healthy activity such as
exercising, meditating, relaxing, and seeking social support, which is practiced for at least 20 minutes.
Four hundred and five Japanese college students participated in this study. A paper-pencil survey was
conducted at colleges in Japan. The process use was least in precontemplation. Experiential processes
peaked in preparation. Except for one experiential process, no significant difference was found between
preparation and maintenance. Behavioral processes peaked in preparation, action, or maintenance. Most
of these inter-stage differences of processes are in line with the prediction from the model. This study
represented an initial but important test of validity of applying processes of change to stress management.
The results partially supported its application.
Keywords: Processes of Change; Stage of Change; Effective Stress Management; Transtheoretical Model
Psychological stress inversely affects both health (Kopp,
Skrabski, Székely, Stauder, & Williams, 2007) and productivity
(Watts & Robertson, 2011). Relatively high portions of people
who are stressed have been reported in countries such as Japan
(Japan Health Promotion & Fitness Foundation, 1996), the
United States (Anderson et al., 2010), and European countries
(European Foundation for the Improvement of Living and
Working Conditions, 2006). With a primary prevention focus, it
would be important to help populations engage in healthy stress
management activities such as exercise, talking with others, or
regular relaxation to manage stress (Evers, Prochaska, Johnson,
Mauriello, Padula, & Prochaska, 2006; Prochaska et al., 2008).
For designing such interventions, it is first necessary to find
theories of behavior change to understand people’s readiness to
initiate and maintain stress management.
The Transtheoretical Model (TTM) (Prochaska & DiCle-
mente, 1983) is one of the leading theories of behavior change.
It has received international attention from health promotion
practitioners for modifying health behaviors (Redding et al.,
1999). The TTM extracts and integrates elements from major
theories of psychotherapies and social-cognitive models (Pro-
chaska, DiClemente, & Norcross, 1992). According to the TTM,
behavior change is described as progression through five stages:
precontemplation (not ready), contemplation (getting ready),
preparation (ready), action, and maintenance. Additional con-
structs such as processes of change, decisional balance, and
self-efficacy are found to facilitate stage transitions.
Processes of change refer to the covert and overt activities
that individuals are encouraged to perform in order to progress
to the next stage. The five experiential processes include con-
sciousness-raising (increasing awareness), dramatic relief (re-
acting emotionally to warnings about the unhealthy behavior),
environmental reevaluation (considering how the practice or
lack of healthy behavior affects others), self-reevaluation (rea-
lizing that the behavior change can enhance one’s identity), and
social liberation (acknowledging how society is changing to
encourage the healthy behavior). The five behavioral processes
include self-liberation (making a commitment for behavior
change), stimulus control (restructuring one’s environment to
facilitate the healthy behavior), counter conditioning (substitut-
*This work was supported by Grant-in-Aid for Scientific Research (A)
(18203035) and (B) (22330196) to A. T.
S. HORIUCHI ET AL.
ing new and positive behavioral choices), helping relationships
(listing and utilizing support), and reinforcement management
(using positive reinforcement and reward). These ten processes
were initially identified in smoking cessation (DiClemente &
Prochaska, 1982; Prochaska & DiClemente, 1983), and then
were modified and applied to many other behaviors including
exercise (Marcus, Rossi, Selby, Niaura, & Abrams, 1992), ma-
mmography use (Pruitt, McQueen, Tiro, Rakowski, Diclemente,
& Vernon, 2010), medication adherence (Johnson, Driskell,
Johnson, Prochaska, Zwick, & Prochaska, 2006), and stress
management (Evers, Evans, Fava, & Prochaska, 2000; Evers et
The TTM proposes systematic relationships between stages
and processes of change (Prochaska et al., 1992). The processes
tend to be used the least at the precontemplation stage. Use of
experiential processes increases over time and tend to peak at
the contemplation or preparation stage, and then deceases in the
action and maintenance stages. In contrast, behavioral pro-
cesses tend to be used most at the action and/or maintenance
TTM-based intervention studies have been successful in
guid-ing populations to initiate and maintain stress management
(Evers et al., 2006; Prochaska et al., 2008). Despite such TTM
potential, there is limited information on inter-stage differences
for the use of the ten processes of change with a reasonable
sample size. Relationships between stage and processes of
change vary across health behaviors to some extent (Rosen,
2000). To validate the application of processes of change to
stress management, it is first necessary to examine whether re-
lationships between stage and processes of change are consis-
tent with the predictions from the TTM (Velicer, Prochaska,
Fava, Norman, & Redding, 1998).
Only three studies have been reported which have applied the
processes of change to stress management (Evers et al., 2000;
Padlina, Aubert, Gehring, Martin-Diener, & Somaini, 2001;
Riley, Lewis, Lewis, & Fava, 2008). Evers et al. (2000) found
that six of the ten processes significantly differed across the
stages, but results of post-hoc tests were not reported. Padlina et
al. (2001) examined two higher-order processes (experiential
and behavioral). Among the three previous studies, only the
study of Riley et al. (2008) examined inter-stage differences of
all ten processes’ use, but found that no process differed across
the stages. Predicted relationships from the TTM were not su-
pported. The results of Riley et al. (2008), however, seem to be
largely affected by a small sample size (N = 42). Examination
of the inter-stage differences of all ten processes with a reason-
able sample size will provide an initial but important test to va-
lidate the application of processes of change construct to stress
The purpose of this study is to examine the relationship be-
tween stage and processes of change for stress management
with Japanese college students. The authors chose these stu-
dents as a sample due to the following two reasons: stress ma-
nagement represents a high public health priority for students;
they are a convenient sample.
In this study, effective stress management is defined as any
form of healthy activity such as exercising, meditating, relaxing,
and seeking social support, which is practiced for at least 20
minutes. Unhealthy activities include those such as using alco-
hol and other drugs, overeating, or smoking. This definition is
applied from the stage-based manual for adopting stress man-
agement (Pro-Change Behavior Systems, Inc., 2003). The mi-
nimum length of time (20 minutes) was added since it was as-
sumed to be helpful to give people a time frame. One may think
that a more clear definition should be applied. The authors be-
lieve, nevertheless, that it is suitable to use such a flexible defi-
nition when focusing on daily self-care activity from a primary
prevention focus, since there is large variation on what kind of
activity people engage to manage stress (Horiuchi, Tsuda, Kim,
Hong, Park, & Kim, 2010). Furthermore, Horiuchi et al. (2010)
reported that college students who are carrying out effective
stress management for more than six months are less stressed
than those who do not, supporting the validity of this definition.
Based on the TTM, it is predicted: 1) Use of the processes is
least in the precontemplation stage; 2) Experiential processes
are more frequently used at the contemplation or preparation
stage compared to the precontemplation stage, and are lower in
the action and maintenance stages than in the preparation stage;
and (3) Behavioral processes are most frequently used at the
action and/or maintenance stages.
The least use of the processes in the precontemplation stage
is predicted, since those in precontemplation do not have the
intention to initiate stress management, and are least motivated
to take action. The most frequent use of experiential processes
in the contemplation and/or preparation stage is predicted, since
individuals in those stages need to increase readiness to act and
these processes are useful to increase such motivation. Most
frequent use of behavioral processes by individuals in the ac-
tion and/or maintain stage is predicted, since they need to use
the behavioral processes for maintaining and increasing fre-
quency of effective stress management and behavioral proc-
esses are effective for doing so.
Power analysis showed that a sample size of 295 is required
to detect η2 = .04 with power .8. This small to medium effect
size was expected based on the study of Evers et al. (2000).
They reported medium effect sizes for six of the ten processes
which were significantly different across the stages, while no
significant difference was found for the other processes. Par-
ticipants included 405 college students, of which 52.3% were
female. They were students who were in classes one of the
research team members taught. The mean age was 19.40, with a
standard deviation (SD) of 1.56 years. The students majoring in
business, nursing or medicine, psychology, and other were
55.8%, 35.6%, 8.1%, and .5%, respectively. Freshmen in-
cluded 65.2%, sophomores 15.8%, juniors 13.6%, and seniors
For measuring processes of change, Pro-Change’s processes
of change measure for effective stress management (Evers et al.,
2006) was translated into Japanese using a back translation
procedure after receiving permission from the original authors.
It includes 30 items and consists of two higher order and 10
factors (the comparative fitness index = .85; the root mean
square error of approximation = .08) in this study. A sample
item is shown for each process in Table 1. Each participant was
asked to rate each item on a 5-point Likert scale (1 = Never to 5
= Repeatedly). Cronbach’s alpha coefficients range from .53
to .83 (Table 1). One might consider that the reliability of the
Copyright © 2012 SciRes. 495
S. HORIUCHI ET AL.
Copyright © 2012 SciRes.
Sample item and Chronbach’s alpha coefficient of each subscale of processes of change measure for effective stress management*.
Processe s of change Sample item Alpha
Consciousness raising I search for information about how to deal with stress in a healthy way. .83
Dramatic relief I react emotionally to warnings about stress. .56
Environmental reevaluation I consider how managing my stress would benefit my family and friends. .77
Self reevaluation I feel good about myself when I use healthy strategies to manage my stress. .77
Social liberation I notice that managing stress is becoming a greater concern in our society. .69
Self liberation I promise myself that I will take active steps to manage my stress. .73
Stimulus control I keep things at home that remind me to use healthy stress management techniques. .55
Counter conditioning When I start to feel stressed out, I take a short break to relax. .53
Helping relationships I have someone I can count on when I experience stress in my life. .65
Reinforcement management Friends and family say something positive when I use healthy strategies to manage stress. .71
*©2004. Pro-Change behavior systems, Inc. All rights reserved.
measure is problematic, since some of alpha coefficients are
lower than .70, indicating lower levels of internal consistency
These lower coefficients are still acceptable given that each
sub-scale consists of a small number of items and measures a
relatively broad construct. Cronbach’s alpha coefficient of a
factor is affected by the number of items and how broad a con-
struct is. Each subscale consists of three items. Furthermore,
since processes of change for effective stress management are
broadly defined, the construct measured by each scale should
be relatively broad.
Stage of change was assessed using the Japanese language
version of Pro-Change’s staging algorithm (Horiuchi, Tsuda,
Tanaka, Okamura, Yajima, & Tsuda, 2009). First, the definition
of effective stress management was provided to the participants.
Then, the participants were asked whether they practice stress
management in everyday life and were requested to select one
of the following five items representing their stage of change: 1)
“No. I have no intention to begin in the next six months.” (pre-
contemplation stage); 2) “No. But I intend to begin in the next
six months.” (contemplation stage); 3) “No. But I intend to
begin in the next month.” (preparation stage); 4) “Yes. I have
been practicing but for less than six months.” (action stage); or
5) “Yes. I have been practicing for at least six months.” (main-
tenance stage). The item “No. I have not been stressed.” served
to exclude respondents who did not experience stress. Twenty-
seven female and 25 male students said they were not stressed
and excluded from the following analyses. Stage of change for
effective stress management may vary to some extent depend-
ing on situational factors such as stressful daily events, so it is
expected that the temporal stability of stage of change is mod-
erate. A two-week test-retest reliability was moderate (κ = .40).
Construct validity was confirmed by demonstrating that rela-
tions to decisional balance were consistent with the predictions
from the TTM (Horiuchi, Tsuda, Kobayashi, & Prochaska,
An ethics committee at Kurume University reviewed this
study. The paper-pencil survey was conducted in July 2010.
During lectures, we asked 503 students to complete the ques-
tionnaire in 10 - 15 minutes. An informed consent form was
attached to the questionnaire. Eighty-two percent of the stu-
dents agreed to participate, gave informed consent, and returned
the completed questionnaire. The rest refused to participate or
quit survey, and did not give informed consent.
A raw score of each subscale was converted into T-score (M
= 50, SD = 10). To test the first prediction, means were calcu-
lated and compared by stages. To test the second and third pre-
dictions, differences in the mean values of processes of change
for stress management across the five stages were examined
using an oneway multiple analysis of variance (MANOVA)
with stage of change as an independent variable. The number of
students analyzed was 166 male and 187 female students. Eta2
values of .01, .06, and .14 were interpreted as small, medium,
and large, respectively (Cohen, 1988). Data was analyzed with
The stage distribution of the participants was as follows:
31.2% in the precontemplation stage, 12.5% in the contempla-
tion, 12.7% in the preparation, 20.1% in the action, and 23.5%
in the maintenance.
Table 2 indicates the mean scores of ten subscales by the
five stages. Individuals in the precontemplation stage showed
the lowest scores in the subscales of consciousness raising,
dramatic relief, self liberation, stimulus control, counter condi-
tioning, and helping relationships. On the other hand, those of
self-reevaluation, environmental reevaluation, social liberation,
and reinforcement management were slightly higher in the
contemplation stage than in the precontemplation stage.
A MANOVA revealed a significant effect [F(40, 1287.3) =
2.10, p < .01, η2 = .06]. Table 3 shows a summary of the results
at follow-up. There were significant stage effects for all pro-
cesses (all, p < .01). Proportions of variance that were ac-
counted for ranged from .04 to .08. These effect sizes were
S. HORIUCHI ET AL.
Means and standard deviations (in parenthese) of processes of change scores across stages.
Precontemplation Contemplation Preparation Action Maintenance
Consciousness raising 48.17 (9.55) 48.22 (9.02) 54.36 (9.86) 53.45 (11.62) 48.56 (8.48)
Dramatic relief 47.58 (9.22) 49.82 (9.02) 54.91 (9.72) 51.05 (10.47) 51.30 (9.68)
Self reevaluation 48.26 (9.75) 47.71 (8.54) 54.30 (8.71) 51.42 (10.65) 51.52 (10.41)
Environmental reevaluation 47.64 (9.25) 47.18 (8.53) 53.47 (9.17) 52.40 (11.33) 51.67 (9.27)
Social liberation 48.03 (9.50) 47.74 (8.36) 53.73 (8.80) 51.83 (11.40) 50.52 (9.10)
Self liberation 47.78 (10.43) 49.08 (8.96) 53.26 (8.96) 51.71 ( 9.54) 51.46 (10.25)
Stimulus control 47.11 (9.28) 50.08 (9.58) 51.85 (8.66) 52.66 ( 9.34) 52.16 (9.84)
Counter conditioning 47.12 (10.27) 48.42 (9.77) 54.09 (8.71) 51.72 (10.27) 52.92 (8.84)
Helping relationships 48.03 (9.24) 48.69 (9.28) 52.15 (8.59) 51.61 (10.27) 52.39 (10.26)
Reinforcement management 47.13 (9.85) 47.07 (8.02) 54.39 (10.35) 52.81 (10.05) 51.51 (8.84)
Summary of the results of follow-up analysis of variance.
F(4, 348) post-hoc η2
Consciousness raising 6.25** PC, C < PR, A
PR, A > M .07
Dramatic relief 5.13** PC < PR .06
Self reevaluation 4.25** PC, C < PR .05
Environmental reevaluation 5.76** PC < PR, A, M
C < PR, A .06
Social liberation 4.16** PC < PR .05
Self liberation 3.63** PC < PR .04
Stimulus control 5.42** PC < PR, A, M .06
Counter conditioning 7.39** PC < PR, A, M .08
Helping relationships 3.55** PC < M .04
Reinforcement management 7.96** PC < PR, A, M .08
**p < .01. Note: PC = precontemplation; C = contemplation; PR = preparation; A = action; M = maintenance.
small to medium.
The results of post-hoc comparisons are also shown in Table
3. Briefly, with regard to experiential processes, the scores of
five processes were significantly higher in the preparation than
in the precontemplation stage. Those of consciousness-raising
and environmental reevaluation were also significantly higher
in the action stage. The use of only consciousness-raising was
significantly higher in the preparation and action stages than it
was in the maintenance stage. Other experiential processes did
not show significant differences between the preparation, action,
and maintenance stages.
With regard to behavioral processes, the scores of self-libe-
ration were significantly higher only in the preparation stage
than in the precontemplation stage. The processes of stimulus
control, counterconditioning, and reinforcement management
were significantly higher in the preparation, action, and main-
tenance stages than were those in the precontemplation stage.
Finally, the score of helping relationships was significantly
higher in the maintenance stage than were those in the precon-
This is among the first studies which examines the inter-
stage differences of all ten processes with a reasonable sample
size. The sample size of this study clearly exceeded the rea-
sonable one estimated by power analysis which is 295. The
TTM assumes specific relationships between processes and
stages of change, which help design stage-matched interven-
tions. We found a number of significant inter-stage differences
in the processes which are consistent with the predictions from
the TTM. Those results indicate strong relationships between
stages and processes of change for effective stress management,
and provide initial but important support for the applicability of
processes of change to effective stress management. The results
also indicate that the Japanese translation of processes of
change measure having adequate concurrent validity.
The results of this study indicated that the use of all processes
of change significantly differ across the stages, which were
mostly in line with those of Evers et al. (2000) which reported
that the use of six processes was significantly different across
Copyright © 2012 SciRes. 497
S. HORIUCHI ET AL.
the stages. In contrast, the results of this study were not in line
with those of Riley et al. (2008) which reported that the proc-
esses’ use did not significantly differ across the stages. One of
another interpretation of Riley et al. (2008)’ study was that
whether significant differences might not be found due to the
relatively small sample size. To exclude such possibility, we
determined a reasonable sample size with power analysis. This
determination enabled us to exclude such possibility. It is sug-
gested that the processes’ use is different across the stages.
With regard to process use in the precontemplation stage, we
found that participants used six processes the least. The use of
the other four processes was at least in the contemplation stage.
No significant difference was found in processes’ use between
the precontemplation and contemplation stages. Those results
are consistent with the predictions from the TTM. Thus, the
prediction was supported.
With regard to experiential processes, it was predicted that
those processes are more frequently used in the contemplation
or preparation stage than in the precontemplation, and are lower
in the action and maintenance stages than in the preparation
stage. The difference between precontemplation and prepara-
tion was significant in the predicted direction for all five expe-
riential processes of change. Thus, the prediction was partially
In contrast, use of the other experiential processes unex-
pectedly did not differ from the preparation to maintenance
stages. These inconsistent results with the prediction may be
explained by the fact that effective stress management requires
daily behaviors to keep up the healthy activities. Individuals in
the action or maintenance stage need to continue to engage in
certain behaviors to manage stress, and they may have some
need to continue to use the processes. These results suggest that
it is necessary to consider such characteristics of stress man-
agement when applying the processes of change construct to
stress management. Further studies are needed to examine the
roles of these experiential processes through the later stages and
the plateau that may be reached.
With regard to behavioral processes, it was predicted that
behavioral processes are most frequently used at the action and
maintenance stages. Four of five behavioral processes were
higher in the action and/or maintenance stage than in the pre-
contemplation stage, as predicted. An exception is that use of
self liberation was found to be higher only in the preparation
stage. Self-liberation is a process in which people make a
commitment to behavior change, and it is assumed to be im-
portant in the preparation stage so as to progress to action.
These findings are largely consistent with the prediction.
While extensive research has supported the TTM, the TTM
has been also criticized for a linear relationships between stage
of change and other TTM variables (Armitage, Sheeran, Conner,
& Arden, 2004; Armitage, 2009; Sutton, 2000). Sutton (2000)
reported that such relationships are problematic, since they
suggest a pseudo-stage model. Non-linear patterns were found,
however, between processes and stages of change. The applica-
bility of processes of change to effective stress management
The main limitation is that this study is based on cross-sec-
tional data, and deals with inter-individual differences. Longi-
tudinal research can examine whether the use of processes
change with stage movement as predicted by the TTM, and can
provide a stronger test of the theory. Such a longitudinal study
would compliment and extend cross-sectional findings of rela-
tionships between stages and processes of change which are
consistent with the TTM. In addition, a cross-sectional study of
Prochaska and DiClemente (1983) is one of the top cited papers
in smoking control (Byrne & Chapman, 2005), showing that
even cross-sectional research can produce high-impact results
in behavior change research. Thus, cross-sectional examination
on relationships between stages and processes of change for
effective stress management is important as an initial step for
validating the application of processes of change to effective
stress management. Based on the results of this study, it will be
necessary to examine intra-individual changes of the process
use as an individual progresses from one stage to the next. A
third limitation is that only processes of change were examined
in this study. Since the effect sizes were small to medium, it is
likely that other factors could also relate to stages of change. In
future studies, it would be important to examine the other TTM
variables—decisional balance and self-efficacy—as well as
other stress-related factors such as the severity of stress of each
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