By Dr Bob Montgomery FAPS
Clinical and health psychologist

All professional psychology is about helping people to make and sustain successful changes in their behaviour, to prevent, solve or at least alleviate problems. This is particularly true in the field of health promotion and illness prevention. Most people do have some idea of changes they should make to their lifestyle to enjoy and protect better health (although there is an abundance of misinformation, typically peddled by snake oil sales people). The problem for most people is not a lack of information but of motivation.

This problem does plague all areas of professional psychology. We may have the best evidence-based procedures for solving an anxiety disorder, or improving cooperation within an organisation, or achieving best athletic performance, or quitting smoking, but, unless our clients are motivated to try our suggestions, and to stick to them, we have done them little lasting good. Most university programs focus on evidence-based procedures, which certainly deserve major attention, but pay little or no attention to some of the other ingredients required for successful behaviour change.

This need for a broad approach to facilitating successful behaviour change has been increasingly recognised (Bothelo, 2004; Rollnick, Mason & Butler, 1999) and key ingredients for change have been identified (see Table 1). The keys to increasing motivation and bringing about successful behaviour change in clients involve consideration of the following issues.

  • Self-efficacy is the best predictor of engagement in health-protective behaviour so should be the main intervention target.
  • Autonomy is important to people older than two years; the more we seem to tell people what to do, the more we invite resistance.
  • People arrive at different stages of readiness for change and we should know how to tailor our approach accordingly and facilitate progress along this dimension.
  • The basic procedure for building and maintaining motivation is useful goal-setting, something most health professionals get wrong (see Table 2).
  • Relapse is what normal people usually do. Roberts and Marlatt (2004) have developed effective guidelines for preventing relapses and managing them when they inevitably occur.
  • There is strong evidence that the nature and quality of the psychologist-client relationship is a major determinant of the success or otherwise of the intervention. All professional psychologists need good counselling skills.
  • Ethically we should be using evidence-based procedures wherever available. We should be able to show that what we offer our clients is likely to work, unlikely to harm, and is cost-effective.
  • Psychoeducation respects the client's autonomy and can facilitate adherence to goals, even when they are challenging. It is not the universal panacea some hope
    for (can there be a single obese person who does not know they need to eat more sensibly and be more physically active?), but it is an important ingredient.
  • Recognition of the magnitude of successful change programs should encourage you to resist requests from clients, employers, third party payers and governments for magical, instant, low cost and undemanding interventions. Insist on your right to do a good job.

For further information, contact the author at drbob@drbobmontgomery.com.au

Table 1: Key ingredients to facilitating successful behaviour change

  • Building self-efficacy while recognising autonomy
  • Identifying and facilitating readiness to change
  • Facilitating motivation to change
  • Helping to prevent and manage relapses
  • Fostering a good working alliance
  • Using evidence-based procedures
  • Providing relevant information and advice
  • Allowing sufficient time for change

Table 2: Building self-efficacy with useful goal-setting

A client's sense of self-efficacy in making behaviour change can be greatly aided by setting useful and useable goals to build and maintain motivation. People can be assisted to enjoy success in their attempts to make desirable behaviour change by setting goals according to the guidelines below.

Goals should be clear plans for concrete actions
Goals should be expressed as behaviour/s the client intends to do, which will distinguish them from wishful thinking (e.g., "I wish I could stop smoking"), or good intentions (e.g., "I really must exercise more"), or desirable outcomes (e.g., "I'd really like to lose some weight").

Goals should be realistically challenging
If goals are too hard, the sense of self-efficacy will be lost; if they are too easy they won't inspire much effort.

Goals should incorporate the client's interests
It is difficult to be motivated to work on something that is not genuinely interesting. Exercise routines may be made more interesting by, for example, listening
to a book on CD at the same time. Healthy eating and drinking can and should be very interesting.

Goals should conform to the client's values
Some of our important basic ideas about ourselves involve a sense of personal integrity. Different people may well have different values, as do different societies and cultures, including about desirable eating and drinking.

Goals should have verifiable outcomes
Verifiable outcomes will allow clients to see themselves being successful at achieving the goals they have set. This in turn will build self-efficacy so that they will be more likely to keep achieving the goals. Verifiable outcomes provide observable evidence of achievement, as opposed to desirable outcomes which are something that is hoped for.

Goals should depend on the client's own efforts
It is important that achieving goals does not depend on the actions or reactions of things outside of the client's control. This is the aspect of goal-setting many health professionals get wrong. For example, a good goal is to eat sensibly, because that's under the person's control; a poor goal would be to lose 5 kg, because that's not under the person's control.

Goals should be achieved reasonably soon
Distant goals tend to be weaker motivators, while closer goals tend to be stronger motivators. Daunting goals can be broken into manageable steps so that they are seen as a series of sub-goals.

Goals should be set with the involvement of the client
Collaborative goal-setting is the beginning of all successful behaviour change programs and how we show practical respect for our client's autonomy.

References

Bothelo, R. (2004). Motivational practice. Rochester NY: MHH Publications.

Roberts, L., & Marlatt, G. (2004). Guidelines for relapse prevention. In G. Koocher, J. Norcross, & S. Hill (Eds.) Psychologists' desk
reference (2nd ed). NY: Oxford.

Rollnick, S., Mason, P. & Butler, C. (1999) Health behavior change. Edinburgh: Churchill Livingstone.