CHAPTER 4 Motivation and cognitive-behavioral intervention strategies
General considerations
Health care practitioners frequently find that patients react skeptically to advice. Sometimes we need to persuade patients into behavioral change, such as taking more exercise. Patients seem not to like being told what to do. Despite this, public health campaigns often try to increase individual risk perception through emotional messages based on fear appeal theory, for example, the graphic warnings on cigarette packs. Such warnings are rarely successful – although fear is an important factor in human perception, we need strategies to deal with this fear. Practical research has demonstrated that, although some patients react favorably when given advice, success rates are not very high, according to brief intervention studies (Mason & Butler 1999; Marcus et al. 2000; Lawlor & Hanratty 2001).
This leads to the question: which type of intervention would be successful in therapeutic practice? A word of warning: studies researching the effectiveness of different interventions have found inconsistent results. For instance, in their review Lewis et al. (2002) state that definitive conclusions could not be reached, because of measurement error, lack of importance of a particular variable, or unsuccessful interventions with changing variables.
Useful strategies for motivational counseling were originally developed to treat addiction (Prochaska & DiClemente 1983, Rollnick et al. 2008). These tactics can be applied to change other forms of behavior.
As shown by everyday experience as well as empirical research, it is difficult to develop the ability to suppress strong habitual or situational impulses in favor of new needs that have been rationally recognized. For instance, your intention to diet stalls when you are faced with your favorite food. By the same token, patients may accept rationally their therapist’s advice for daily practice of certain exercises but be unable to carry it out. One reason for this is because we prefer small short-term gains over greater long-term rewards (Ainsli 2005).
This impulsive, unwholesome behavior can be explained by the existence of multiple competing evaluation and control systems (McClure et al. 2004). Because of their attitudes and subjective norms, people do not always do what they intend to do. In social psychology this is called the intention–behavior gap (Bandura 1986, 2000; Sniehotta et al. 2005). Therefore, we need special self-control strategies in order to achieve long-term objectives in the face of passing emotions or proven habitual reactions.
Self-control techniques recommend learning to influence your individual motivation level. This means selectively focusing your attention on information that will help you achieve your goal while ignoring stimuli that distract you from that goal (Kuhl 1985). For example, if an eagerly awaited vacation starts with a dawn flight, a traveler will motivate himself to get up in time by imagining the expected pleasures of the trip. Rising early then becomes the lesser evil compared with missing the plane.
A factor that is important in achieving a desired behavior is the difference between goal intentions (i.e., “I want to go on vacation”) and implementation intentions (“Tomorrow at 5 a.m. I will take a taxi to the airport”) (Gollwitzer 1999). Studies have shown that participants who try to smoke less, achieve healthier eating habits, or follow an exercise program are more successful if they have set out their specific intentions (Abraham & Sheeran 2000).
It has been repeatedly demonstrated that patients’ physical activity patterns can improve through short, one-off cognitive-behavioral interventions. In a review of studies published between 1966 and 2006, Smitherman et al. (2007) give the following general recommendations:
These ideas are similar to a technique called motivational interviewing, presented by Rollnick & Miller (1995). According to the authors, this method is determined by its “spirit” and its “interpersonal style.” Here, different cognitive and personality variables are taken into account, and there is a conscious attempt to avoid reactance (the strengthening of a contrary attitude).
Practical measures
Small steps
Changing your lifestyle is always difficult because an old, tried and tested position has to be given up. Depending on our own personal experience with changes, this triggers fears. The bigger these steps towards change, the more likely it is that fear will be aroused. Thus any change is hampered. As Maurer (2004, p. 21) notes, “fear of change is rooted in the brain’s psychology, and when fear takes hold it can prevent creativity and change. The brain is designed that any new challenge triggers some degree of fear.” As a result, it is best to suggest that patients take small, individually appropriate steps, to help them reach their goal. These steps should be so small that they avoid triggering the fight or flight response. Of course, everyone’s reaction will be different. The therapist and patient should work together to define the patient’s goals, the steps needed to reach these goals, and an appropriate exercise program. In the process, the therapist asks about previous changes that the patient has achieved. From the starting point of these personal experiences, the exercise program is planned.
Asking questions
The first step is the decision to change something, and patients will already have taken this decision before they choose a therapist. They really want to change their state of health. In other words, they already have some risk awareness, even if this does not effectively predict future health behavior change by itself (Weinstein 2003). In addition patients need appropriate strategies. You can reinforce patients’ decisions to change by asking what resources they used to solve other problems and talking about role models in similar situations.
The next step is to identify the setting and the specific exercises. Ask questions about realistic times and places and discuss how long the patient is willing to practice and how success can be measured. This kind of exchange supports the decision to exercise (Gollwitzer 1999). Through the questioning process, patients visualize a context for exercise and become familiar with it.
Appropriate questions could be:
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