Understanding Hard to Maintain Behaviour Change

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.

Preface ix

Acknowledgements xi

1 An overview of the theory 1

Context 4

Limitations of the existing theories 5

Core elements of CEOS 12

Conceptual underpinnings 14

The generation of behaviour 17

Capacity of the ES 19

Initiation versus maintenance of behaviour 20

The relationships between the two systems 21

Story creation within the ES 22

Biological constraints 22

Elaboration of CEOS theory 24

References 26

2 Characteristics of hard-to-maintain behaviours 31

Types of behaviour to change 31

What makes some behaviours hard to maintain? 34

Hard-to-reduce/resist/eliminate behaviours 37

Addictions versus other HTR behaviours 38

The example of smoking 40

Hard-to-sustain behaviours 44

Examples of HTS behaviours 45

Combinations of both kinds of behaviour change 46

Replacements and substitutes 47

What is learnt in HTM behaviour change 48

References 50

3 The roles of the operational and executive systems 54

The Operational System 55

The nature of the Operational System 55

Functions of the Operational System 60

Modifying OS functions 62

The Executive System 65

Core capacities of the ES 66

Inputs to the ES 69

Stories and the roles they play 72

What the ES can do 75

Limitations of thinking 81

Self-regulation 85

The stability of change 86

Relationship of CEOS to other dual-process theories 86

References 94

4 Environmental influences: the context of change 98

The relatively stable environment 99

The social environment and social norms 102

Modelling and vicarious learning 103

Changing the broader environment 104

Regulation and legislation 106

Public education 109

The interactional environment 110

Requisites for behaviour 110

Interpersonal influences 111

References 114

5 Conceptual influences on change 117

Framing the problem 118

Message framing 120

Mechanisms of persuasion 122

Organisation of concepts about change 125

Core beliefs and values 126

The desirability of change 127

Influences on goal desirability 127

Priority 130

Decisional balance 131

Goal achievability 133

Analysis of the challenge (task difficulty) 133

Self-efficacy 135

Beliefs that can interfere with behaviour change 137

References 139

6 The structure of the change process 142

Tasks involved in behaviour change 143

Getting behaviour change on the agenda 145

Goals 146

Making an attempt to change 148

Scripts 152

Commitments to change 154

Maintaining change: perseverance 155

Determinants of maintenance/relapse 159

Drivers of relapse 160

Maintaining appropriate beliefs 161

Influences on self-control 163

Influences on reorienting the OS 164

Recovering from setbacks 165

Feedback and evaluation 166

Repeated attempts are the norm 167

Hardening: the changing nature of the population who have not changed 169

References 171

7 Interventions for behaviour change 176

Internal and external perspectives on change 177

Differences between HTR and HTS behaviours 178

Enhancing executive function: optimising understanding 180

Framing: defining the problem and options for change 180

Feedback and evaluation 182

Making relevant knowledge salient 183

The occasional value of biases 185

Enhancing self-control 186

Enhancing executive functions 187

Managing and prioritising life challenges 188

Implementation intentions 189

Enhancing self-reorientation 190

Mindfulness and awareness 190

Acceptance 191

Understanding emotions and attitudes 193

Reconditioning the Operational System 194

Targeting alternatives to the desired behaviour 196

Practice 196

Use of drug therapies 197

Creating more supportive environments 197

Changing the pattern of cues to act 197

Rewards and other motivators 198

Understanding communication 198

Externalising self-control 199

The availability of what is required 200

Advocating for change 200

Integrative strategies 201

Building a revised sense of self 201

Improving recovery from setbacks 202

Optimising a script or plan for action 202

References 205

8 Using CEOS to advance knowledge 209

Key features of CEOS theory 209

Reframing thinking 211

Key questions to answer for behaviour change 213

Contributions of different kinds of research 213

Measuring key constructs 215

Measuring ES influences on behaviour 217

Measures of OS influences on behaviour 218

Measures of context 219

Elements of a theory-driven research agenda 220

Comparisons with other theories 221

Implications for reducing inequities 226

Concluding comments 227

References 229

Index 233

“Borland has written a succinct but powerful account of hard to maintain behaviour changes and the next step is to integrate this into services so that the model can be empirically tested and refined.” (Drugs, Education, Prevention and Policy, 27 October 2015)

Ron Borland PhD is the Nigel Gray Distinguished Fellow in Cancer Prevention, at the Cancer Council Victoria, Australia where he has worked since 1986. He also has honorary appointments at the University of Melbourne and Monash University. His background is in psychology with degrees from Monash University and the University of Melbourne. Prior to joining the Cancer Council, he worked as a psychologist at a major psychiatric institution in Melbourne and in Papua New Guinea. He has over 300 publications in peer-reviewed journals, mostly related to aspects of tobacco control. He is one of the Principal Investigators of the International Tobacco Control Policy Evaluation Project: an international collaboration currently active in over 20 countries. His main research areas are studying the impact on smokers of tobacco control policies, understanding determinants of smoking cessation outcomes, and developing and evaluating mass-disseminable interventions to help smokers quit.

The book presents an integrative theory of hard-to-maintain behaviours, which includes hard-to-reduce or
eliminate behaviours such as smoking and other drug use, overconsumption of food or unsafe sex, and hardto-
sustain behaviours such as 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.

Current ways of thinking about health behaviour change are seriously limited. Simple rationality-based models
are insufficient. Advances in neuroscience are establishing the importance of affective (emotional) responses
as determinants of behaviour. However, while these can sometimes be influenced by rational processes, this
influence is only partial and, for many, insufficient to allow unconflicted pursuit of what we believe is in our
best interests.

The theory the book elaborates, CEOS theory, explains how behaviour is jointly determined by the Context
in which the person lives and two interrelated elements of internal function which it calls the Executive and
Operational Systems. The key determinants of the latter are the influences of what is called the Operational
System, which represents the parts of human functioning that we share with infrahumans. It responds to what
is happening in the moment and controls the means by which we act on the world. The Executive System is
based on linguistic models that are references to conceptual ideas of what could be; it is the well spring of our
capacity to act with foresight. The theory helps us understand why determinants of the initiation of attempts
to change behaviour differ from those that influence the long-term success of those attempts. It sees the
former as largely driven by executive processes and thus amenable to theorising around rational,
expectancy value models, while maintenance of change is more affected by particular kinds of
experiences associated with trying to adopt the new pattern of behaviour.

This book follows a recent trend in theorising about behaviour change by taking a dual-process approach.
Related theories include Nudge, a theory with which it shares several key elements around the importance of
more effective communication and targeted environmental changes as strategies for change.

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 willpower.

Thoughtful practitioners will find the book extremely useful in trying to work out better ways to help their
clients and to challenge them to review some of their current orthodoxy.