Frameworks for Understanding and Attaining Behavior Change

1. Frameworks for Understanding and Attaining Behavior Change Chapter 2

2. Key Terms • Behavior Change • Behavior Change Models • Theories • Concepts • Constructs • Models • Motivation • Self Efficacy • Self Motivational Statements

3. Benefits of Behavior Change Theories and Models • Historically, nutrition counselors and educators attempted to change food choices by facts and diets only • Results were unsuccessful/disappointing • 1980s – focus was on behavior modification which stemmed from food related research and social psychology • 1990s – The Transtheoretical Model and Motivational Interviewing were implemented

4. Benefits of Behavior Change Theories and Models • Present a road map for understanding health behaviors • Highlight variables to target in an intervention • Supply rationale for designing nutrition interventions that will influence knowledge, attitudes, and behavior • Guide process for eliciting behavior change • Provide tools and strategies to facilitate behavior change • Provide outcome measures to assess effectiveness of interventions

5. Behavior Change Models Health Belief Model (HBM) The Transtheoretical Model (TTM) Theory of Planned Behavior (TPB) Social Cognitive Theory (SCT) Cognitive Behavior Therapy (CBT) Motivational Interviewing (MI)

6. Self-Efficacy • The concept of self-efficacy as a basic component of behavior change was developed by Albert Bandura • Defined as: “the confidence to perform a specific behavior” • Incorporated into numerous behavior change models • Attainment of behavior change correlates to a strong self efficacy • A person’s confidence in his/her ability to accomplish a behavior change may be more important than actual skill

7. Health Belief Model • Proposes that cognitive factors influence decisions to make and maintain change • Central to making this decision, a person needs to: • Perceive personal susceptibility to a disease or condition • Perceive the disease or condition as having some degree of severity, or consequence • Believe that there are benefits in taking action • Perceive no barriers to interfere with change • Be exposed to a cue to take action • Have confidence in personal ability to perform behavior: self efficacy

8. Health Belief Model

9. Transtheoretical Model • Developed by Prochaska and DiClemente – The Transtheoretical Model (TTM), or Stages of Change Model, crosses over many behavior change models • Provides a guide for explaining behavior change • Supplies effective intervention designs and strategies • Evaluates dietary change interventions

10. Transtheoretical Model • Describes behavior change as a process • Includes 5 motivational stages • Process that occurs over time • An individual can begin at any one of the motivation levels or stages

11. Transtheoretical Model

12. Transtheoretical Model • Precontemplation: • No intentions of changing within the next 6 months • Resists any efforts to modify the problem behavior • Has no awareness that a problem exists or • Is in denial of the problemor • Is aware, but unwilling or experiencing feelings of hopelessness after attempting change • Cons outweigh pros

13. Transtheoretical Model • Contemplation: • Recognize need to change, but are ambivalent • May have perceived barriers • May be in this stage for many years without change • Will usually say they intend to change in next 6 months if asked • Pros and cons balance each other out

14. Transtheoretical Model • Preparation: • Preparers believe the advantages of change will outweigh the disadvantages • Committed to taking action in near future (within next 30 days) • Prepares may have taken small steps to prepare for the change

15. Transtheoretical Model • Action: • Clients in this stage have altered the behavior to an acceptable degree at least1 day andup to 6 months and continue to work at the changes • Changes are not yet permanent • Most common time of relapse is the first 3 to 6 months

16. Transtheoretical Model • Maintenance: • Person has been practicing new behaviors for greater than 6 months • Must continue to work to modify the environment to maintain changes and prevent relapse • “Perhaps most important is the sense that one is becoming more of the kind of person one wants to be” (Prochaska and Norcross)

17. Transtheoretical Model • Decision to move from stage to stage is based on client’s view of the pros and cons of the change • Pros are anticipated benefits of change • Cons are the cost of behavior change • A shift in the balance of pros/cons will contribute to advancing or backsliding through the stages • Forward and backward movement through stages is normal • Relapses are expected

18. Transtheoretical Model • As an individual moves forward, the pros tend to outweigh the cons • As nutrition counselors, we must emphasize the “pros” of behavior change • Self-efficacy is integrated into the model • Self-efficacy tends to decrease between precontemplation and contemplation stages • As individual progresses through action and maintenance stages, self-efficacy increases

19. Transtheoretical Model The Relationship b/w Stage and both Self-Efficacy and Temptation The Relationship b/w Stage and the Decisional Balance for a Healthy Behavior

20. Transtheoretical Model • Prochaska and Norcross identified the following effective strategies to assist with client’s progression from one stage to the next: • Assessing a person’s readiness for change assists with determining treatment interventions • As individuals move through stages, interventions needs to be adjusted • Cognitive (thinking) and affective (feeling) strategies are more effective in early stages • Behavioral strategies are more effective in latter stages • Counselors need to re-assess client’s stage periodically

21. Theory of Planned Behavior • Originally known as “Theory of Reasoned Action” • An individual’s health behavior is directly influenced by intention to engage in that behavior • 3 factors affecting behavioral intention are: • Attitudes • Subjective norm • Perceived behavioral control

22. Theory of Planned Behavior • Attitudes: • Can be favorable or unfavorable • Strongly influenced by our beliefs about the outcomesof our actions (outcome beliefs) and • How important the outcomes are to the client (evaluation of outcomes) • Ex/ “Eating whole grain foods will increase my energy levels” and “having high energy levels is extremely important to me”

23. Theory of Planned Behavior 2. Subjective norm: • “Perceived social pressure” • Determined by 2 factors: • Normative beliefs - the strength of our beliefs that significant people approve or disapprove of the behavior • Motivation to comply - the strength of the desire to comply with the opinion of significant others

24. Theory of Planned Behavior 3. Perceived behavior control: • The overall measure of an individual’s perceived control over the behavior • Control beliefs are influenced by presence or absence of resources and barriers • Control factors are internal or external • Internal - i.e. skills and abilities • External - i.e. social or physical environmental factors • The impact of each resource to facilitate or impede the desired behavior is “perceived power of the variable”

25. Theory of Planned Behavior

26. Social Cognitive Theory (SCT) • Formerly known as “Social Learning Theory” • Provides a basis for: • Understanding and predicting behavior • Explaining the process of learning • Designing behavior change interventions • A dynamic interaction of personal, behavior, and environmental factors, with a change occurring in one, that is capable of influencing the others • Known as reciprocal determinism

27. Behavior Change Theories and Models: Social Cognitive Theory • Personal factors can include values and beliefs regarding outcomes and self efficacy • Behavior changesmay occur by observing and modeling behaviors, and/or using self-regulating techniques, such as journaling • Environmental changes may include buying new cooking equipment or altering types of food available in the home

28. Client-Centered Counseling • Founded by Carl Rogers • Referred to as “nondirective” or “person-centered” • Based on the theory that humans are basically “rational, socialized, and realistic and that there is an inherent tendency to strive toward growth, self-actualization and self-direction” • Clients participate in clarifying needs and exploring potential solutions

29. Client-Centered Counseling • Counselors totally accept clients without passing judgments • Total acceptance is very important for a level of trust to develop so that clients feel comfortable to express feelings • Can help guide nutrition counselors by stressing the importance of respect and acceptance for developing a counseling relationship

30. Cognitive-Behavioral Therapy (CBT) • Incorporates components of both cognitive therapies and behavior therapies • Includes a wide range of treatment approaches • Based on the assumption that behavior is learned and can be changed by altering environmental or internal factors

31. Cognitive-Behavioral Therapy (CBT) • Cognitive Therapies • Based on the premise that negative self talk and irrational ideas are self defeating learned behaviors and frequently the source of one’s emotional problems • Clients learn to: • Distinguish between thoughts and feelings • Analyze trueness of thoughts • Develop skills to interrupt harmful thoughts • Identify, eliminate and replace harmful thoughts

32. Cognitive-Behavioral Therapy (CBT) • Behavioral Therapy • Based on the premise that behaviors are learned, so it is possible to learn new ones • 3 approaches: • Classical conditioning: focuses on stimuli and cues that affect food behavior • Operant conditioning: based on the law of effect, which states that behaviors can be changed by their positive or negative effect • Modeling: observational learning • Ex/ video, demonstration, observing an associate, etc.

33. Solution-Focused Therapy • Therapist works with clients to focus on solutions and strengths that have worked in the past • Aim is for clients to use solution-oriented language to speak about what they can do differently, resources they possess, and what they have done in the past that worked for them

34. Solution-Focused Therapy • Examples of questions a solution-focused counselor may ask: • What can I do that would be helpful to you? • Was there a time when you ate a whole-grain food? • When was the last time you ate fruit? • Has a family member or friend ever encouraged you to eat low-sodium foods?

35. Motivational Interviewing • Definition: “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” • Complements the Transtheoretical Model • Focuses on strategies to motivate clients to build commitment and make behavior changes • Motivation is viewed as a state of readiness to change

36. A state of mind in which a person has coexisting, but conflicting feelings about something Wanting to change but not wanting to change. Source: Miller & Rollnick 1991 What is Ambivalence?

37. Motivational Interviewing • Table 2.5 Overview of What is Motivational • 1. Knowledge of consequences • 2. Self-efficacy • 3. A perception that a course of action has been chosen freely • 4. Self analysis (giving arguments for change) • 5. Recognition of a discrepancy between present condition and desirable state of being • 6. Social support • 7. Feelings accepted

38. Characteristics of Motivational Interviewing • Guiding more than directing • Dancing rather than wrestling • Listening as much as telling • Collaborative conversation • Evokes from persons what they already have • Honoring of person’s autonomy Source: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care. 2008

39. Motivational Interviewing • 4 Guiding Principles with acronym “RULE”: • Resist the Righting Reflex • Understand and Explore Motivations • Listen with Empathy • Empower the Client

40. Express Empathy • Acceptance facilitates change • Shows interest and caring to understand client’s experience • Conveys unconditional positive regard

41. Empathy Starters • “You seem_____” • “In other words…” • “You feel ___ because ___” • “It seems to you…” • “You seem to be saying…” • “I gather that…” • “You sound…”

42. Motivational Interviewing Change Talk: • Objective is to resolve ambivalence by providing the client (rather than the counselor) the opportunity and encouragement to make arguments for change • When clients express the need for change, the balance of indecision shifts toward taking action • As change talk strengthens, commitment and likelihood of behavior change increases

43. Motivational Interviewing • 4 categories of change talk statements • Cognitive: Problem recognition • Ex/ “I get headaches from my high blood pressure” • Cognitive: Optimism for change • Ex/ Lots of people have to take insulin. I can do it too.” • Affective: Expression of concern • Ex/ “I’m so worried about my diabetes. I hope eating better and exercise brings down my blood sugar levels.” • Behavioral: Intention to change • “In the past, I always enjoyed eating fruit. I will eat a banana with breakfast and dried fruit with my lunch tomorrow”.

44. Motivational Interviewing • Strategies to Elicit Change Talk • Evaluate Importance and Confidence: Involves rating the importance of change and their confidence in making the change (0-10 scale) • Values Clarification - Card Sort: Involves sorting (ranking) cards based on the personal core value of the client • Change Roles: Client and Counselor change roles • Typical Day Strategy: Involves client describing day and including how health/diet are affecting their life

45. Importance Ruler How importantis it for you right now to change? On a scale of 0 to 10, what number would you give yourself? 0……………………………………………………….10 Not at all Extremely Why are you at 4and not at 1? What would it take for you to move from a 4 to a 6?

46. Motivational Interviewing • “OARS” – 4 foundation skills that are most useful for MI: • Open-ended questions • Affirmations • Reflective listening • Summaries

47. “Open Ended” Questions Closed ended questions often lead to “yes/no” or single word answers and discourage further conversation Open ended questions allow the individuals to tell their story, lead to increased understanding and help to build empathy

48. Affirmations • Statements of appreciation and understanding • Highlight a person’s strengths, personal values and goals by using compliments and encouragement • Acknowledge efforts to make changes

49. Reflective Listening • Deepens and extends the conversation • By taking time to listen, you convey empathy • Validates what clients are feeling • Creates a sense of safety for clients to talk • Can be used to develop discrepancy between a person’s stated values and present behavior • Reflective listening is more effective than questioning

50. Reflective Listening • Repeating • Rephrasing – slightly alter person’s words • Empathic reflection – provide understanding for person’s situation • Reframing – help person think differently about their situation • Feeling reflection – reflect emotional undertones • Amplified reflection – exaggerate what was said • Double-sided reflection – reflect both sides of person’s ambivalence Source: B. Borelli “Using Motivational Interviewing to Promote Patient Behavior Change and Enhance Health”