Understanding Hard to Maintain Behaviour Change

A Dual Process Approach

Ron Borland

• Publisher: Wiley
• Year: 2013
• ISBN:
  9781118572917
• Edition: 1
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

The book presents an integrative theory of hard-to-maintain behaviours, that includes hard-to-reduce or eliminate behaviours like smoking and other drug use, overconsumption of food or unsafe sex, and hard-to-sustain behaviours like exercise and sun-safe behaviours. Most of the examples come from the author's work on tobacco smoking, but it is relevant to anyone who is concerned to understand why some forms of desirable behaviour are so hard to achieve, and to those trying to help people change. It also has important implications for public health campaigns and for the development of policies to nudge behaviour in desirable ways. The book provides readers with frameworks to:

• Determine whether a "hard to maintain" behaviour is a result of the skills needed to perform it, its reinforcement history, the way the person thinks about it, the context, or some combination of these.
• Better integrate cognitive and behavioural change strategies, including emergent strategies related to mindfulness and acceptance, plus novel ways of retraining operational processes.
• Understand the different nature of challenges for behaviours where multiple attempts are typically required before the desired behaviour pattern is sustained.
• Better understand the role of feelings and emotions as influences on behaviour.
• Understand the limits of environmental factors to determine change.
• Understand the limits of self-control and will-power.

Chapter 1

An overview of the theory

Most behaviour change is unproblematic. People's behaviour changes all the time, both in response to an ever-changing environment and their increasingly refined responses to it as they learn and adapt. This book is about trying to understand those aspects of human behaviour that aren't readily brought into concordance with environmental conditions and individual desires. It develops and elaborates a theoretical framework, called CEOS theory (I will explain the acronym later), which is designed to be a new and comprehensive way of thinking about how people change habitual behaviours. This involves understanding the constraints on and the potential of volitional attempts to change behaviour patterns that are under the moment-to-moment control of non-volitional processes.

The theory also focusses on the different processes involved in the initiation and maintenance of behaviour change. It is primarily designed to understand behaviours that are hard-to-maintain (HTM behaviours); that is, ones that while seen as desirable by the individual are not spontaneously adopted or are hard to sustain and/or are seen as undesirable and hard to reduce or eliminate in the long term. These behaviours include stopping smoking, eating healthy foods to maintain a desirable weight, exercising regularly and controlling alcohol consumption. CEOS theory also encompasses easy-to-change behaviour, where it is similar to many existing theories because there is less need to consider the conflict between volitional and non-volitional forces within the individual.

The focus of this book is on health-related behaviours. The big question it attempts to answer is: Is it possible to help people to enjoy and value healthy lifestyles, to the point where there is no longer any real effort involved in avoiding unhealthy and embracing healthy behavioural alternatives? Where this is not possible, can we develop strategies to help people maintain healthy options, at least most of the time, and to minimise unhealthy choices and to break unhealthy habits, even if it requires ongoing vigilance?

Key ideas and observations that have informed the need for a new theory include the following:

• People sometimes don't act in ways that are objectively in their best interests even when they want to change; for example, they continue to smoke or continue a high-fat low-exercise lifestyle even though they want to be fit and healthy.
• Even when people try to adopt healthy behaviours, these new forms of behaviour are difficult to maintain and are thus characterised by high rates of failure. The causes of these failures are not well understood, and attempts to reduce relapse rates have a bleak record.
• Recent research has established that the determinants of deciding and trying to change are different from those of maintaining behaviour change, at least for smoking [1, 2]. (See Chapter 2 for more details.) Some of the things that motivate smokers to try to quit, and which quitting improves, are associated perversely with reduced chances of success. It is not yet known whether similar perverse relationships are present for other HTM behaviours.

CEOS is a biopsychosocial theory, in that it postulates that behaviour is co-determined by the interaction between biological factors, modifiable aspects within the individual (psychological factors) and aspects of the environment, especially social factors. Which of these influences is most important for any particular kind of behaviour, or as is the case here, which make it difficult to maintain desirable behaviours, is an empirical question.

Within the individual, engagement with the environment is maintained by a complex multi-level processing system that relates environmental inputs to need states of the individual, leading to behaviours designed to reduce those needs [3, 4]. Emerging from the higher levels of this system is the unique human capacity to represent the world outside of the moment and to operate on conceptualisations of it using language and rules. This representation of the world can encompass aspects of the individual doing the representing, and thus becomes self-referential, and it has the power to influence behaviour in novel ways. The capacity to influence behaviour based on a conceptual understanding of the world is a top-down process, unlike the bottom-up process of dynamic adaptation to the environment that characterises other aspects of behaviour.

The core-characterising feature of CEOS theory is that these two processes (Figure 1.1) constitute two fundamentally different ways of relating to the world, and many of the problems of human behaviour can be better understood by considering them as co-occurring and in some cases competing systems within the individual. The base system that is reactive to environmental conditions I call the Operational System (OS) because it is the system that operates directly on the world to maintain homeostasis. The term is used in computing to cover those routine functions that are automated, that is, are done without executive (external governing) input. The emergent, reflective, self-referencing system that acts on conceptualisations of the world I call the Executive System (ES) because it operates in much the same way as the executive of an organisation works; that is, by setting the goals for an organisation that can only be achieved if the organisation is sufficiently prepared to work towards them. The name CEOS is an acronym for Context, Executive and Operational Systems, which are the core elements of the theory. CEOS is one of a class of dual-process theories [5, 6], which make similar, but not identical distinctions between volitional and non-volitional processes.

Figure 1.1 Simple diagram showing the three main influences on behaviour change.

The OS is where all behaviour is generated and controlled. The OS is reactive to the environment of the moment, its current states and inputs from the ES. It adapts through associative mechanisms typified by habituation and conditioning. By contrast, the ES uses inputs from the OS and from language-based representations of the world to evaluate ongoing behaviour, and to either resolve conflicts between OS tendencies to act or pursue articulated goals that emerge from its conceptualisation of the world or of possible futures.

Reframed in dual-process terms, the challenge that this book addresses is why, once the ES decides that behaviour needs to change, it is sometimes so difficult to enact that change and to maintain it. CEOS postulates that this is because the OS tends to favour or revert to well-learnt routines when not being explicitly directed to do otherwise, and indeed will not respond to ES directives unless suitably primed. Priming involves acting to generate affective associative links to ES ideas so they also become action tendencies within the OS, and thus if strong enough, compete with other operational action tendencies to be enacted. This priming is necessary because the ES cannot act without the OS accepting the behavioural schemata or script from the ES as ‘its own’. The capacity of ES processes to inhibit action tendencies is easier to achieve than building the strength for action tendencies to impel action as inhibition requires lower levels of activation than for exciting action.

Emerging out of the characteristics of the two systems, and central to this book, CEOS postulates that different processes are involved as a person progresses from unconcerned acceptance of one behavioural pattern to the stable adoption of a more desirable alternative; in particular, the determinants of the initiation of change are quite different from those involved in maintenance and this is most clearly manifested in HTM behaviours.

CEOS is a framework (or meta-theory) for integrating a range of micro-theories that help us understand the key component tasks involved in complex behaviour change and how they interrelate. As such, it encompasses descriptive theory (taxonomy), theories of mechanisms and theories of how to intervene. As part of the theory of how to intervene, it includes a model of how a person might best conceptualise a problematic behaviour to optimise his/her chances of successfully changing it.

The theory is designed to explain why some behaviours are hard to reduce or eliminate and others are hard to sustain. It is argued that while there are some similarities with both hard-to-reduce behaviours (such as smoking) and hard-to-sustain behaviours (such as dietary change), there are some important differences, particularly in the role of cues and the role of negative experiences.

The theory was developed with the persisting problem of tobacco smoking as the primary focus. As a result, most of the examples used come from the challenges associated with smoking cessation. However, it has been conceptualised to apply to all HTM behaviours.

Before beginning to elaborate, I provide some background on the conceptual and empirical underpinnings, which together justify the need for a new overarching framework.

Context

Science-based approaches to understanding HTM behaviours are by no means the first societal efforts to encourage us collectively to do what the society sees as desirable—it is one of the enduring projects of human civilisation, involving governments, religions, communities and families. A lot can be learnt from the successes, part successes and failures of the past.

Dual-process theories are also not new. Their origins go back to antiquity [7]. They include the Buddha's analogy of the rider and the elephant and Plato's analogy of the driver and the chariot. More recently in the early days of modern psychology, James [8] made a distinction between experiential and analytic processes, Pavlov [9–11] identified his first and second signalling systems as mechanisms for these two kinds of processes to work, and Freud conceived of the structures of the Ego and Id as the framework within which this interaction occurred, mediated in his case by the Superego [12]. These are all dual-process models of one kind or another. They are all about trying to understand why humans sometimes have trouble doing what they think is best, sometimes described as taming our animal selves.

Within empirically grounded (scientific) psychology, these ideas were rejected by the influential behaviourist movement (e.g. Watson and Skinner) [13–15]. Behaviourist models postulate bottom-up processes by which environmental conditions interact with motivational (drive) states of the organism to determine behaviour. However, as the limitations of behaviourism became apparent for explaining higher cognitive processes, they were replaced by a cognitivist movement that largely ignored lower level processes, implicitly or in some cases explicitly, assuming that these could be controlled in a top-down way by higher cognitive processes. It is the observed limitations of rationality-based cognitive theories that have led to CEOS, and to experimental social and cognitive psychologists re-exploring the role of lower level processes in influencing human cognition and, less researched, behaviour. I was unaware of some of this experimental work until quite late in the development of the theory (and there may be more of which I remain ignorant), but it is reassuring that it is all consistent with the broad theory proposed here, and in a couple of cases has allowed me to refine elements of it. Canvassing the experimental literature has also renewed my concern about the parochial nature of much research and the tailoring of theory to the micro, rather than looking for theories with applicability beyond any specific research stream. I believe that it is important to begin by thinking about human behaviour in totality, and to build models within each domain of enquiry that are consistent with those that are more broadly applicable. CEOS is not the only attempt to do this, other examples include the PRIME theory of West [16, 17], which does not take a dual-process approach, the dual-process approaches of Strack and Deutsch's [18] RIM model, particularly as elaborated by Hofmann et al. [19] and the Nudge theory of Thaler and Sunstein [20], which focusses on communication strategies and environmental change to influence behaviour. The relationship of these models to CEOS is illuminated at various points in this book.

Limitations of the existing theories

We need a new overarching theory of HTM behaviours because existing theories have major limitations, either in scope or in their conceptualisation of the central problem.

Three sets of theories have dominated attempts to change problem behaviours: theories of addiction that focus on biological mechanisms, including learning theories that are concerned with the malleability of biological determinants of habits; expectancy-value theories that emphasise the rational appraisal of the balance between the costs and benefits of behaving, given the existing social and environmental contexts; and social determinant models that postulate that mal-adaptive behaviours are the result of imperfect social structures (i.e. problems with the environment). Each of these focusses on one aspect of the totality, and it is apparent that each is too limited to deal with the complexity. See West [16] for an excellent review of many of these theories, including identification of their limitations). To get a better idea of the applicability of these theories, consider the three case studies given in Box 1.1 before you read on.

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Box 1.1 Case studies of obesity

Consider three cases studies of the same problem—serious obesity—and from the information given; see what you think is responsible and what sort of strategies you might consider to help the women concerned. All three are excerpts from the stories of severely obese women of early middle age, each of whom live with her husband and children.

Case A: This woman comes from a family that is also obese. She had a happy childhood but ate lots of snack foods and sweet drinks. The area of the country in which she comes from has a history of poor diet and has the highest...

Table of contents

• Cover
• Series Page
• Title Page
• Copyright
• Preface
• Acknowledgements
• Chapter 1: An overview of the theory
• Chapter 2: Characteristics of hard-to-maintain behaviours
• Chapter 3: The roles of the operational and executive systems
• Chapter 4: Environmental influences: the context of change
• Chapter 5: Conceptual influences on change
• Chapter 6: The structure of the change process
• Chapter 7: Interventions for behaviour change
• Chapter 8: Using CEOS to advance knowledge
• Index