EXCI252-CSEP-PATH-Section-3-BehaviourChange-F2023.pptx
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CSEP-PATH Section 3 Behaviour Change EXCI 252 1 Exercise Program Adherence Almost 50% of individuals who start an exercise program will drop out within 1 year (ACSM, 2006). As an exercise specialist, you also need to understand & implement psychological theories related to successful beha...
CSEP-PATH Section 3 Behaviour Change EXCI 252 1 Exercise Program Adherence Almost 50% of individuals who start an exercise program will drop out within 1 year (ACSM, 2006). As an exercise specialist, you also need to understand & implement psychological theories related to successful behavior change. EXCI 252 2 Behaviour Change Theories & Models To be effective at guiding clients to make regular physical activity part of their lives, qualified exercise professionals must recognize that there are many facilitators and considerable barriers when it comes to changing complex behaviours like physical activity. Health behaviour change refers to a replacement of health-compromising behaviours, such as physical inactivity & sedentary behaviour, by health-enhancing behaviours like regular physical activity & reduced sedentary time. EXCI 252 3 Behaviour Change Theories & Models 1) Social Cognitive Theory (SCT) 2) Self-Determination Theory (SDT) 3) Transtheoretical Model of Behaviour Change (TMBC) 4) Health Action Process Approach (HAPA) 5) Theory of Planned Behaviour (TPB) 6) Schema Theory (ST) 7) Psychological Continuum Model (PCM) 8) Social Support Model (SSM) 9) Enjoyment Model (EM) 10) Health Belief Model (HBM) 11) Integrated Behaviour Change Model (IBCM) 12) Identity Theory (IT) EXCI 252 4 Behaviour Change Theories & Models These theories and models of behaviour change (SCT, SDT, TMBC, HAPA) reflect 2 distinct approaches. 1. The cognitive-based approach: Behaviours are controlled by rational cognitive activity. 2. The stage-based approach: Individuals go through stages to adopt new behaviours. EXCI 252 5 Behaviour Change Theories & Models Furthermore, these theories and models of behaviour change emphasize slightly different constructs, but they generally reflect the same broad ideas: Behaviour change is a process not an event, Effective change must come from within the individual, Intervention strategies must be carefully tailored to each individual’s unique set of circumstances, and Planning is a critical factor in change management. EXCI 252 6 Social Cognitive Theory Proposes that people learn through their experiences. Includes the notion of reciprocal determinism, which refers to the dynamic interaction between: an individual (who has a particular set of learned experiences), their environment (social context), & their behaviour (response to stimuli). Considers behaviour change & maintenance to be a function of: an individual’s expectations about their ability to engage in or execute a specific behaviour (self-efficacy) & the outcomes that will result (perceived benefits). EXCI 252 7 Social Cognitive Theory 4 Constructs at the Core of SCT that Affect Behaviour Self-efficacy Outcome expectations One’s belief in the positive & negative consequences that will occur from engaging in the specific behaviour. Self-regulation e.g., Goal-setting, self-monitoring, and planning. Barriers and facilitators e.g., Social support EXCI 252 8 Social Cognitive Theory Self-Efficacy is the belief in one’s ability to succeed in specific situations. is an individual’s perception of his or her ability to perform a task. is one of the most powerful factors to consider when predicting behaviour. has been shown to influence goals people set, their ability to persist in the face of obstacles, & their capacity to cope with setbacks and stress. directly influences behavioural engagement. EXCI 252 9 Social Cognitive Theory Self-Regulation involves the ability to monitor & control one’s thoughts, actions, & emotions. also consists of the avoidance of temptations that distract individuals from long-term goals. also consists of persistence in the face of obstacles. lessens the likelihood of a lapse escalating into a relapse. Self-Regulatory Skills Self-monitoring Scheduling & planning Setting short- and long-term achievable & measureable goals Positive self-talk EXCI 252 10 Social Cognitive Theory 4 Sources of Self-Efficacy Mastery Experiences Performance Mastery Vicarious Experiences Modeling Social Persuasion Positive Reinforcement Emotional State Emotional Arousal EXCI 252 11 Social Cognitive Theory Mastery Experiences Successful experiences boost self-efficacy, while failures erode it. Most robust source of self-efficacy. Teach clients scientifically sound & safe exercise principles & techniques & allow them to practice these techniques. e.g., completing a 5.0 km run. Vicarious Experiences Observing a peer succeed at a task can strengthen beliefs in one’s own abilities. Provide clients the opportunity to observe role models who are performing exercise successfully. e.g., observing a peer succeed at a task. EXCI 252 12 Social Cognitive Theory Social Persuasion Credible communication & feedback can guide someone through a task or motivate them to make their best effort. Compliment clients when they perform activities correctly or improve a specific physical fitness component. e.g., encouragement from a personal trainer. Emotional State A positive mood can boost one’s self-efficacy, while anxiety can undermine it. A certain level of emotional stimulation can create an energizing feeling that can contribute to strong performance. EXCI 252 13 Self-Determination Theory Focuses on the degree to which an individual’s behaviour is self-motivated & self-determined, & the processes through which an individual acquires the motivation to initiate new behaviours & maintain them over time. Assumes that individuals are inherently motivated to seek out new challenges & are eager to succeed. Recognizes the importance of one’s social environment on behavioural engagement. Recognizes that individuals can be alienated or disaffected from their inherent nature as a result of being immersed in social environments that do not support that nature. EXCI 252 14 Self-Determination Theory Contends that individuals have 3 basic psychological needs: Independently solve problems (autonomy), Master tasks (competence), & Interact socially (relatedness), which are present to varying degrees as individuals work through various stages of change. The 3 basic psychological needs foster volition, motivation, & engagement in a person resulting in enhanced performance, persistence, & creativity. EXCI 252 15 Self-Determination Theory SDT Stages of Change Amotivation The individual has no intention or desire to engage in the new behaviour. External Regulation The individual is motivated by external forces such as pressure from others. Introjected Regulation The individual takes on the behaviour without fully accepting it as their own. Identified Regulation The individual consciously values a goal as personally important. Integrated Regulation The goals are fully assimilated with self, so they are included in a person’s selfevaluation & beliefs about personal needs. Intrinsic Motivation The individual values and participates in the new behaviour for the sheer enjoyment of it. EXCI 252 16 Self-Determination Theory Examples of How a Qualified Exercise Professional can Bolster a Client’s Autonomy, Competence, & Relatedness for Regular Physical Activity: Promote the client’s sense of ownership & control over their physical activity. Guide the client through an active examination of their own reasons for becoming physically active. Encourage choice & self-initiation by providing a menu of options for physical activity. Encourage clients to find activities they enjoy the most & are more likely to integrate into their lives. Help the client to identify realistic goals & provide positive feedback as they achieve success. EXCI 252 17 Transtheoretical Model of Behaviour Change is also known as the: Stages of Change Model, Stages of Readiness Theory, or Readiness for Change Theory. was developed by psychologists James O. Prochaska & Carlos DiClemente. was 1st developed for smokers. EXCI 252 18 Transtheoretical Model of Behaviour Change is one of the most popular & contentious stage-based models of behaviour change in relation to physical activity. is based on the basic premise that people change habitual behaviours slowly, passing through a series of specific stages, each characterized by a particular pattern of psychosocial & behavioural changes. classifies individuals by their readiness to change into 1 of 5 stages. EXCI 252 19 Transtheoretical Model of Behaviour Change The Basic Concepts of the TMBC Clients progress through 5 stages of change at different rates. In this process, clients may move back & forth through the stages of change. Clients use different cognitive & behavioural strategies in this process. Clients weigh the costs & benefits of the health behaviour change. EXCI 252 20 5 Stages of the Transtheoretical Model of Behaviour Change # Stage Description 1. Precontemplation No intention of changing behaviour. Not intending to make changes. 2. Contemplation Intending to take action within 6 months. Considering a change. 3. Preparation Planning to take action within 1 month. Making small changes or ready to change in the very near future. 4. Action Successful behaviour change for less than 6 months. Actively engaging in the new behaviour. 5. Maintenance Successful behaviour change for 6 or more months. Sticking with the behaviour change. EXCI 252 21 Stage 1: Precontemplation No Intention of Changing Behaviour An individual is not intending to make a change. “My Dad never exercised & he lived to 100, so I can too.” Others may not believe they can change. “I can’t, I’m not an athlete.” Others may be demoralized by past failed attempts. “I’ve tried , but nothing works.” The cons (barriers) of changing > the pros (benefits) of changing. Denial is very common at this stage. EXCI 252 22 Stage 2: Contemplation Intending to Take Action Within 6 Months An individual is planning to make a change. While aware of the benefits of change & increasingly dissatisfied with the results of not changing, they have not yet resolved their ambivalence. “I really should exercise, but I never seem to get in gear.” The cons are still > the pros. They can remain in this stage for years. EXCI 252 23 Stage 3: Preparation Planning to Take Action Within 1 Month An individual has decided to take action & is actively planning to do so in the immediate future. “I’ve been planning to start walking in the mornings. I have holidays next week & thought it would be a good time to start.” “I purchased a treadmill & am going to start a walking program.” The pros of changing are > the cons. The client is making a commitment to change. The client takes small steps to promote change. EXCI 252 24 Stage 4: Action Successful Behaviour Change for < 6 Months The individual: is committed to the new behaviour & consistently engaging in it. overtly takes action to change a behaviour. implements his/her plan for change. uses strategies to resist temptation, cope with everyday challenges, & prevent relapse. “I’m bicycling 3 times/week. I have way more energy & sleep better. What a feeling!” EXCI 252 25 Stage 4: Action Successful Behaviour Change for < 6 Months This stage is most visible to others who see the new behaviours taking place. Rewards & incentives are important elements in this stage. This is the busiest stage of change. A strong belief & confidence in the ability to change is a key element in this stage. EXCI 252 26 Stage 5: Maintenance Successful Behaviour Change for ≥ 6 Months The individual has adopted the new behaviour & done it for many months. “My day isn’t complete without my evening workout.” The new behaviour is firmly established & the individual is confident in their ability to stick with it. The person sustains his/her new behaviour, usually for 6 months to 5 years. Actions or patterns are becoming automatic. The main goal in this stage is to prevent relapse. EXCI 252 27 Transtheoretical Model of Behavior Change Setting up an exercise program for contemplators is fruitless. An exercise program can be prescribed for individuals in the Preparation, Action, & Maintenance stages. In fact, most programs with the goal of increasing physically activity are designed for individuals in the Preparation and Action stages. EXCI 252 28 Algorithm for Determining Your Stage of Change Do you perform resistance exercise at least 2 to 3 times per week? Yes No Have you done this consistently over the last 6 months? Yes Do you plan to adopt this practice within the next 6 months? Yes No No Within the next month? Yes Maintenance Action Preparation EXCI 252 No Contemplation Precontemplation 29 Adapted Readiness for Exercise Questionnaire (Strength Training) Stage Precontemplation Statement I do not participate in ST exercise & I do not plan to begin a ST program in the next 6 months. Contemplation I do not participate in ST exercise, but I am thinking about starting a ST program in the next 6 months. Preparation I do not participate in ST exercise, but I am planning to begin a ST program in the next month. Action I am currently performing ST regularly, & have been training for < 6 months. Maintenance I have been performing ST regularly for ≥ 6 months. EXCI 252 30 Sample Behaviour Change Contract EXCI 252 31 Health Action Process Approach Provides a framework of motivational & volitional constructs that help explain & predict individual changes in health behaviours. Suggests that the initiation, adoption, & maintenance of health behaviours such as physical activity is a structured process that includes: a Motivation Phase & i.e., deliberation that leads to the formation of intention, a Volition phase i.e., during which intentions foster planning. EXCI 252 32 Health Action Process Approach Includes the notions of self-efficacy & outcome expectancies as predictors of behaviour change. Classifies individuals as pre-intenders, intenders, & those who are already in the action phase (changing). Postulates that intention & volitional factors (e.g., action planning) are more proximal predictors of behaviour change. Good intentions are more likely to be translated into action when individuals plan when, where, & how to perform the desired behaviour. EXCI 252 33 Health Action Process Approach Intenders who are in the pre-action stage are motivated to change, but may not act if they feel they do not have the right skills to translate their intention to action. Planning is a key strategy at this point & serves to connect intentions & behaviour. is needed to translate an individual’s intentions into action. can be divided into: Action Planning & Coping Planning. EXCI 252 34 Health Action Process Approach Action Planning pertaining to the when, where, & how to carry out the intended behaviour. is considered more important for the initiation of health behaviours. Coping Planning includes the anticipation of barriers and the design of alternative actions that help to attain one's goals in spite of the impediments. is more important for the maintenance of the behaviour over time. EXCI 252 35 Health Action Process Approach Self-Efficacy is required throughout the entire behaviour change process. nature changes from phase to phase: Goal setting, planning, initiation, & maintenance. types include: Pre-actional self-efficacy Coping self-efficacy, & Maintenance self-efficacy. EXCI 252 36 Putting Theory into Practice Commonalities Between the Behavioural Theories & Models 1) The individual is in control of their own behaviour & that behaviour change must come from within. 2) Behaviour change is a process, not an event. Motivational Interviewing & Brief Action Planning offer significant value in applying many of the behaviour change theories described in this section. EXCI 252 37 Motivational Interviewing is a way of working with clients to assist them in accessing their motivation & confidence to change behaviour. is founded on the premise that lasting change is more likely when clients discover their own reasons to change. aligns well with current lifestyle change research that identifies client-centered counseling strategies as being more effective than practitioner-centered approaches. recognizes that individuals start out at different levels of readiness to change their behaviour. EXCI 252 38 Motivational Interviewing Do not tell clients what to do & how to do it. Act as a guide who facilitates the client’s own examination of the positive & negative aspects of behaviour change. Clients are recognized as the experts on their own lives (competence) & are actively empowered to identify, evaluate, & choose (autonomy) the changes that will work for them. EXCI 252 39 Motivational Interviewing A client’s autonomy is actively cultivated by: Drawing out & acknowledging client perspectives & values, Linking change to the client’s broader goals & values, & Offering options for the client to choose from. EXCI 252 40 Motivational Interviewing Four Elements that reflect the “spirit of MI” & are essential to its practice: Partnership Work in collaboration with the client. Acceptance Respect the client’s autonomy and the right to change or not change. Compassion Act with heart when providing assistance to the client. Evocation Ideas come from the client, not the clinician, helper, or QEP. Does the QEP align with the MI perspective? • A deep well of wisdom & experience exists within your client from which you can draw. EXCI 252 41 Motivational Interviewing Basics Discover their own interest in considering and/or making a change in their life. Express in their own words their desire for change. Examine their ambivalence about change as a means to elicit & strengthen their change talk. Enhance their confidence in taking action & noticing that even small, incremental changes are important. Strengthen their commitment to change. Plan for & begin the process of change. Refer to Tips for Motivational Interviewers on page 13 in Section 3 of the CSEP-PATH manual (2021). EXCI 252 42 Motivational Interviewing To engage in MI, the qualified exercise professional will employ such skills as: Open-ended questioning, Active listening, Eliciting “change talk” from the client, Managing “sustain talk” (effectively managing a client’s resistance to change), & Developing discrepancy (guiding the client through an exploration of the gap between where they are & where they want to be in the future). The strategies & tactics underlying MI take time to master, but have been proven to be effective in helping individuals. EXCI 252 43 Skills Required for Motivation Interviewing Open-Ended Questioning To help a person find the power to change from within. The interviewer must draw out the client’s story, motivation for change, & prior history in attempting the change. Active Listening is essential to developing the insight required to facilitate clients’ exploration of motivation & options for change. tools: include Affirmations, Paraphrasing, Summarizing, & Reflection on Meaning & Feelings. are used to accurately demonstrate understanding of the information the client has shared. EXCI 252 44 Skills Required for Motivation Interviewing Eliciting ‘Change Talk’ To help clients work through their ambivalence (mixed feelings) about changing a behaviour, the interviewer seeks to elicit change talk, which refers to an individual’s discussion of their desire, ability, & need to change. Developing Discrepancy The greater the gap between where the client currently is & where they want to be in the future, the harder it is for the client to justify the current behaviour, the more attractive change becomes, & the less ambivalence the client will feel about the change. EXCI 252 45 Skills Required for Motivation Interviewing Managing ‘Sustain Talk’ Resistance to change will sometimes be evident in a client’s sustain talk as clients articulate reasons for sticking with their current behaviour patterns as part of the process of resolving their ambivalence. Instead of offering counter arguments, the skilled motivational interviewer allows clients to express the reasons for not undertaking change without feeling pressured to change or worrying about being judged for not wanting to change. EXCI 252 46 Reflection Tactics Used in Motivational Interviewing Content Reflections Used to elicit the basic facts in the client’s story & generally entail paraphrasing what the client has said. Feeling/Meaning Reflections Often take the form of “You are feeling embarrassed about your weight.” Amplified Negative Reflections A way of exaggerating the benefits associated with the undesirable behaviour.EXCI 252 47 Reflection Tactics Used in Motivational Interviewing Double-Sided Reflections Can be used to acknowledge that the practitioner heard the client’s reasons both for & against change. Action Reflections Often used after the client has moved beyond ambivalence into action planning. Reflect possible solutions to the client’s barriers or a potential course of action. EXCI 252 48 Self-Efficacy in Motivational Interviewing Building self-efficacy is core to motivational interviewing. The qualified exercise professional should strive to bolster the clients’ confidence that they have the capacity to make regular physical activity part of their lives. EXCI 252 49 Moving from WHY to HOW A recent adaptation to the motivational interviewing model was introduced to address a challenge in determining when & how to transition from building motivation & commitment to planning a course of action. EXCI 252 50 Moving from WHY to HOW This recent adaptation conceives motivational interviewing in 3 phases: Exploring Drawing out the client’s story, building rapport, obtaining a behavioural history, & identifying what behaviours are to be discussed. Guiding Steering the conversation toward the possibility of change by asking clients to consider life with & without change to help them see the discrepancy between their current actions & their broader life goals & values. Choosing Once a commitment to making a change occurs, the conversation moves to a more pragmatic discussion of HOW to put the desired change into action. EXCI 252 51 Brief Action Planning is another tool available to help qualified exercise professionals (QEPs) . has been defined by Gutnick & colleagues (2014) as a “highly structured, stepped-care, self-management support technique.” is composed of a series of 3 questions and 5 skills. can be used to facilitate goal setting & action planning to build self-efficacy in chronic illness management and disease prevention. is grounded in the principles and practice of motivational interviewing and the psychology of behavior change. overall goal is to assist an individual to create an action plan for a selfmanagement behavior that the individual feels confident he or she can achieve. EXCI 252 52 Key Features of Brief Action Planning Relevant to QEPs Key Feature Explanation of Key Feature Delivery QEPs can be trained to use & deliver BAP. Time Trained professional: BAP may take as little as 5 minutes. BAP is easily accomplished within a 20-30 minute consultation session. Use is flexible & can be used one or more times with a client (Initial visit, Followup visits). How was BAP developed? Literature identifying the need to support the development of client selfefficacy, and the creation of appropriate action plans. Derived from motivational interviewing. Evidence supporting BAP Studies promoting physical activity for individuals with osteoarthritis, spinal cord injury, and the prevention of chronic disease. How do you do BAP? Gutnick et al.’s (2014) paper, training opportunities, & online resources. See https://centrecmi.ca EXCI 252 53 3 Questions of Brief Action Planning Question # 1 is asked to elicit ideas for change from the client. “Is there anything you would like to do for your health in the next week or two? Question # 2 is asked to evaluate the client’s confidence. “How confident or sure do you feel about carrying out your plan on a scale from 0 to 10?” Question # 3 is asked to arrange a follow-up with the client or the client’s accountability. “Would it be helpful to set up a check on how things are going with your plan?” EXCI 252 54 5 Skills of Brief Action Planning Skill 1 - Offer a Behavioural Menu 2 - SMART Planning Description A Behavioural Menu is used when a client does not have any ideas, does not know where to start, or requests ideas. A Behavioral Menu is comprised of 2 or 3 suggestions or ideas that will ideally trigger individuals to discover an idea of their own. Once an individual decides on an area of focus, the QEP partners with the client to clarify the details and create an action plan to achieve the client’s goal. The QEP works with the client to ensure that his or her goal is SMART (Specific, Measurable, Achievable, Relevant and Time-bound). EXCI 252 55 5 Skills of Brief Action Planning Skill Description 3 - Elicit a Commitment Statement Once the client has developed a specific plan, the next step is for the QEP to ask the client to “tell back” the specifics of the plan. 4 - Problem Solving for Low Confidence Collaborative problem solving is suggested as the next step when confidence is relatively low (i.e., a score below 7 for Question 2 of the BAP). 5 - Follow-up Follow-up is a feature of successful multifactorial selfmanagement interventions. Follow-up builds trust between a client and a QEP. EXCI 252 56