Life-style intervention: A conceptual framework

29

LIFE-STYLE INTERVENTION: A CONCEPTUAL FRAMEWORK* MARYALICE JORDAN-MARSH, R.N., Ph.D., JOANNE GILBERT, R.N., JULIAN D. FORD, Ph.D., and CHARLES KLEEMAN, M.D. UCLA Center for Health Enhancement Education and Research, Los Angeles, California ABSTRACT

Improving one’s life-style may improve one’s health. However, there is a lack of consensus on how to promote compliance with newly adopted health habits. This paper presents a conceptual framework that individuals can learn to assess their life-styles and plan for healthbehavior changes. It can also be used by professionals from different disciplines who are developing programs to teach healthy life-style choices. The framework is organized into three ideas: (1) Health status to a large extent reflects the individual’s styles of living (a composite of beliefs, emotions, and action patterns). (2) These styles can be encouraged or sabotaged by the individual’s support structures (relationships, environments, and equipment). (3) The change process can be seen as a series of steps that cycle through phases of readiness appraisal, decision making, experimentation, and reevaluation. Clinical examples and documentation from relevant theory and research illustrate and substantiate the framework. INTRODUCTION

There is increasing evidence that the chance of premature death, chronic disease, or disability can be reduced through proper nutrition, exercise, control of emotional stress, weight reduction, abstinence from cigarette smoking, and controlled alcohol intake.le3 In the past health-care practitioners assumed that their instructions were “orders” to be followed by their patients.4,5 It has *Thisand other researchat the Center cation and Researchis fundedin part

for Health Enhancement Eduby grants from the Ahmanson Foundation, Los Angeles; Blum Kovler Foundation, Chicago; Helena Rubinstein Foundation, New York; and the Committee on Research of the Academic Senate, University of California, Los Angeles.

VOLUME G/NUMBER1

become increasingly evident, however, that the relationship between receiving a prescription and changing health status is an uncertain link at best.5-7 We have discovered that health-care practitioners know little about the extent to which individual patients adhere to therapeutic regimens and what influences patients to follow through with all or part of the recommendations. A number of reviewers are now critical of the evidence for the effectiveness of traditional patienteducation approaches.6e8-10 Qualities of the relationship between the practitioner and the patient, knowledge of the regimen (how to carry out the expert’s advice), social support available, the power base of the practitioner, awareness of the change process, and the nature of the regimen and related side effects seem more powerful than knowledge of treatment rationales or of related anatomical and physiological facts in predicting adherence.5*6,8*‘o,11 Research has focused primarily on the extent to which the patient follows through on one component of a regimen, such as taking medicine, wearing a splint, or doing exercise.10,12*13Relatively little is known about fostering compliance with more complex regimens that involve many different behaviors. Consider the problems faced by individuals when simultaneously taking one or more medications, using new stress-management patterns, exercising regularly, and reducing dietary intake of sodium or saturated fats. This array of goals can be overwhelming. The diverse languages and strategies of the specialists in each area may create further confusion or frustration. Adopting a conceptual framework (ie, a means of organizing information relevant to plans for health-behavior change) may reduce these problems. The framework serves as a means of simplifying vocabulary among experts and addresses the problem of setting priorities for alternatives. We collaborated with colleagues at the Center for Health Enhancement, Education, and Research to develop the following conceptual framework. (The Center is the outreach arm to the community in health promotion and disease prevention.14) The framework was designed: (1) to provide guidelines for patients to maintain and initiate health-behavior changes; (2) to facilitate the delivery of a systematic and meaningful curriculum for learning life-style or health-behavior change

30 at the Center; (3) to provide a structure for research and evaluation; and (4) to provide for continuity as staff members are added or replaced. FRAMEWORK

OVERVIEW

Three main ideas characterize this framework (1) One’s health to a large extent reflects the individual’s style of living (a composite of beliefs, emotions, and actions). (2) These styles can be encouraged or sabotaged by the individual’s support structures (relationships, environments, and equipment). (3) The process of changing one’s life-style comprises a series of steps that cycle through phases of readiness appraisal, decision making, experimentation, and reevaluation (Figure 1). There are several assumptions underlying the framework. First, it is assumed that the practitioner is working with an individual, couple, or family who have at least minimal motivation to begin changing their lifestyle for better health. Second, it is assumed that participants are willing to accept shared decision-making for health-behavior change. The patient and other members of the health-care team must be willing to accept that individuals learn and apply problem-solving strategies in a fashion and at a pace that is meaningful to the individual. Finally, we assumed that individuals are motivated by increasing their sense of self-efficacy and that this is fostered by experiencing a problem-solving approach to health-behavior change.

HEALTH

STATUS

Health status (Figure 2) is the outcome by which we measure success in altering life-style. It is mediated by a host of buffering or predisposing factor@16 that explain why some people who are ill or injured function adequately while others appear to have relatively few risk indicators yet are wholly or partially disabled. Health status may be summarized by measures of the individual’s potential and liability in three areas: (1) functional (tasks and responsibilities of daily living), (2) psychological (the intellectual and emotional realm), and (3) clinical (physical/medical) components.17 While these are overlapping and interactional dimensions, for purposes of discussion we shall consider them separately. Functional status is defined as the ability to carry out the tasks of daily living and to fulfill the challenges of one’s social roles and responsibilities.” Specific indicators of functional status include work productivity, respiratory capacity, exercise tolerance, muscular tone and coordination, and communication skills. Social roles, personal plans, self-care, and health-maintenance activities also fall into this category. Psychological status involves the individual’s sense of well-being, mental and emotional state, perception of the quality of life, and integration of strengths and resources toward maximizing personal potential.‘* It is reflected in the individual’s sense of personal efficacy or mastery.lg For example, some individuals with little clinical evidence of disease may be so handicapped by their sense of “dis-ease” that they act in ways that are self-defeating or counterproductive.20*z1 In contrast, other individuals may have serious disease conditions (poor clinical status) yet feel and act remarkably well and astound health experts and friends by their ability to maintain a normal life (high functional status) and even

PSYCHOLOGICAL

CHANGE PROCESSES

Figure 1. Conceptual framework for life-style change.

Figure 2. Three dimensions of the individual’s status.

health

PATIENTEDUCATIONANDCOUNSELING

31 to move beyond their own health concerns to the needs of others. Clinical status encompasses the physical and biochemical dimensions of health. These consist of (1) risk indicators (eg, cigarette intake, blood lipid levels, obesity), and (2) pathological abnormalities with characteristic signs and symptoms permitting a medical diagnosis (eg , hypertension, atherosclerosis, tumors). Physical handicaps, genetic abnormalities, and the presence of illness or bodily malfunctions are potential causes. Functional, psychological, and clinical assessments provide for a holistic approach to the individual. An obese, poorly controlled diabetic with low self-esteem presents far different challenges than a well-controlled diabetic with a meaningful career, for example. At the beginning of a life-style intervention program, the assessment of health status serves as a baseline for later comparisons that assess progress. For some individuals there may be changes in either functional or psychological health status that may not yet be reflected in clinical status. With cardiac patients, for example, sense of well-being may have to be strengthened by demonstration of functional capacity to exercise and to engage in sex or other daily living routines before the patient is willing to undertake the changes necessary to alter cardiac prognosis (clinical status). STYLES OF LIVING Styles of living are defined as the individual’s current health-action beliefs, feelings, and patterns (Figure 3). These represent the individual’s characteristic responses to health problems or challenges or their broader patterns of living that reciprocally influence health status. One’s style of living affects health status and is in turn

a” HEALTHACTION BELIEFS HEALTHACTION FEELINGS HEALTHACTION PAlTERNS

Figure 3. Three components of the individual’s style of living.

VOLUME G/NUMBER1

influenced by health status. In some instances, lifestyles can serve as a resource. For example, an individual who manages the stress of multiple demands at work by listing and establishing priorities can utilize this strategy to deal with dietary changes. Menu planning, diet diaries, and other aids are compatible strategies. Others may find that they have developed responses that create obstacles to their change plans. The individual who believes that pills, surgery, or health gimmicks are a fast way to health enhancement may have great difficulty giving up this dependence on things or people outside themselves to take responsibility for their own well-being. The extent to which styles of living influence health status reflects one’s willingness to take responsibility for one’s own health. Diagnosing these styles in living is an essential component of planning changes that will lead to improved health status. These diagnoses are compatible with behavioral** and nursing 23 diagnoses in that beliefs, feelings, and behavior patterns are all included. Health-Action Beliefs Health-action beliefs refer to the explanations individuals use to make sense of their health actions. These are personal theories or schema that serve to organize health-related experiences.24 These cognitive selfstatements develop as a result of information seeking and other health-related experiences. People may vary in the degree to which their beliefs are differentiated:25 “I am good at exercising, but not at dieting,” versus “I just can’t seem to do anything about my health.” Individuals may also vary in the extent to which these beliefs or cognitions are accessible to awareness.25 The clinician’s task is to help people recognize the messages they are giving themselves about their health habits. Some experts emphasize understanding the individual ‘s sense of vulnerability to the consequences of not undertaking life-style changes.26p27 This orientation is based on a threat-and-fear model. Others have suggested that it may be more productive for patients to view stressors as problems to be solved rather than as The ability to take this perspective personal threats. 2N*2s is influenced by the patient’s previous success or failure in solving health-related problems. ~9I9 The individual’s expectations that one’s efforts will be rewarded affect whether health-related coping behavior will be initiated, how much effort will be expended, and how long patients will persist when they experience difficulty. I9 This sense of “self-efficacy” is described by Bandural as a judgment of how well one can carry out the actions needed to produce the desired outcomes. Knowledge and skill may be necessary, but they are not sufficient. The sense of personal efficacyls is determined by information from four sources: (1) performance or action,

32 (2) learning from observing others as role models, (3) verbal persuasion, and (4) physiological responses, including emotions. Changing the information that the individual receives from these sources is critical to changing behaviors and ultimately health status. Health-Action Feelings The individual’s gut-level reactions to health-related incidents and expectations are important indicators of sources of resistance or enthusiasm for changes in health-related behaviors. Furthermore, these emotional responses are increasingly recognized as related to and possibly increasing the risk of disease.30*31Individuals at risk are those who suppress or mask internal, emotional feedback or overinterpret such feedback. Patterns of emotional distancing and disintegrating have been observed in a variety of other psychological (eg, conversion reactions, depression) and bodily (eg, gastrointestinal syndromes, chronic pain) disorders.32 A complex chain of blocked emotional experiencing, rather than a set of specific negative emotions, seems to be at the root of dysfunctions.33,34 The crucial hypothesis for health professionals and patients seems to be that an individual’s awareness of the full range of emotions and the corresponding beliefs or self-statements is essential in improving health.35 The role of the practitioner is to help the patient experience this relationship and to reinforce skill in labeling emotions, perceiving them as providing information, and bringing them under control by linking them to more salubrious health-action beliefs. For example, some patients feel angry after embarking on an ambitious lifestyle change program. This may be because they feel they are depriving themselves of life’s “pleasures” (eg, alcohol, high-calorie foods, lazy mornings). The clinician can help such patients recognize the selfdefeating perspective they have created, substitute new pleasures for perceived losses, and view health enhancement as a rewarding challenge. At the Center for Health Enhancement this awareness was facilitated by teaching conscious relaxation, guided imagery, and varied, enjoyable homework assignments. Planning for new pleasures was an important lesson also. Indulging in exotic fruits and vegetables or spending cigarette money on new hobbies are two examples. Patients at the Center also learn (and experience) a “Cuisine for Wellness, ” which is reinforced by gourmet cooking classes and the gourmet dining club, which is also available to the community. If such labeling and utilization of information from emotions is beyond the current capability of the patient (or the clinician), a referral to a psychological or psychiatric specialist may be indicated. Emotional responses, such as anger or pity, communicated to the patient from significant others also

play an important role in health-enhancement activities. Individuals tend to use those messages as cues in judging their own performance.36 Pity and sympathy, for example, may discourage the patient because they imply a lack of ability. Patronizing praise for easy tasks may also undermine self-esteem. Both families and patients need to become aware of these hazards and develop skill in providing appropriate emotional feedback. Health-Action Patterns Health-action patterns are tendencies for individuals to behave in predictable ways (ie, habits that contribute to the development of beliefs that, in turn, facilitate other health behaviors-bad and good).37 Epidemiological research documents the relationship of habits to health status.lm3Not only cigarette smoking, alcohol consumption, and sleep, nutrition, and exercise patterns, but also characteristic response styles (eg, Type A [coronaryprone] behavior patterns) are increasingly emphasized in assessing risk status and in designing intervention programs.38 For example, when working with Type A individuals, scheduling definite appointments for exercise and even stress management with clear goals are critical to success. Type A may be one of the most widely cited patterns, but many other problematic habitual life-styles warrant clinical and research attention: sick-role behavior,5,6 eg, compulsive eating and inordinate risktaking, for example. The purpose of changing one’s life-style is to develop healthy patterns for eating, exercising, relaxing, and a host of other health actions. The vigilant decisionmaking required for establishing new behaviors is ideally replaced by a habit pattern that requires less conscious involvement.” Acquiring new patterns may be facilitated by linking the desired behavior to an established habit (Premack principle).3g Patients review their current life-style for daily habits, such as reading the newspaper before breakfast. The practice of the new behavior is scheduled to precede the long-standing pattern (eg, not starting the paper until an exercise session is completed). The old habit serves as a reinforcer for the new pattern. When undesirable habits exist, self-monitoring may increase awareness in motivated patients.3s-41 With proper documentation, the monitoring can provide a continuing record of progress. New understanding about the nature of reinforcement emphasizes the importance of monitoring specific manifestations of increased mastery in life rather than recording simple counts of previously learned and easily performed behaviors, which often are not inherently rewarding.rs SUPPORT STRUCTURES Support structures (Figure 4) are the external sources of feedback, reinforcement, and assistance available to the

PATIENT EDUCATION AND COUNSELING

33

RELATIONSHIPS ENVIRONMENTS EQUIPMENT

Figure 4. Three external sources of support available to the individual.

These sources include relationships, environments, and equipment. They have the potential to be resources for health enhancement or obstacles that act to maintain old habits and, in some cases, to sabotage efforts to establish new ones. The clinician and the patient must work together to strengthen opportunities for reinforcing desired behaviors and to weaken or eliminate situations that encourage undesirable habits. patient.

Relationships The evidence for the positive effects of social support on health risk has been rapidly accumulating.42343 Lay

systems provide a critical resource to complement the health professional’s work with individual patients.43 Strengthening social supports is more feasible in many cases than reducing exposure to stressors.44 During a crisis, such as attempts to change health life-style, social relationships may be easier to modify than personality traits or coping habits.42 Relationships are defined as a source of social support. This support acts as a buffer against stress and a resource for meeting challenges.8p43,45-48Thoits42 described two ways in which support is provided. Socioemotional aid, sometimes called expressive support, refers to sympathy, understanding, acceptance, and related elements of validation of the self. Instrumental aid is more practical and includes advice, information, sharing of financial resources, and transportation. Support can be provided by friends, relatives, coworkers, or professionals and their assistants. At the Center for Health Enhancement, couples are encouraged to attend the programs and classes together, with reduced costs as an incentive. The way couples relate to each other is an important focus for understanding

the

nature and extent of support available to patients.21 In searching for sources of support during health-behavior

VOLUME G/NUMBER1

change, the individual’s entire social network should be considered as a resource.43,47*48-s1 Individual developmental and family life-cycle differences should be taken into account. For example, the family may seem to be the most obvious source of relationships to provide support. However, for adolescents the peer group may be more effective. Similarly, patients over 65 may prefer not to involve their adult children in their health plans.52 Small children are often overlooked as adults plan health-enhancement strategies. They can and should be expected to participate in their parent’s improved dietary and exercise habits in ways that are appropriate for their age. The clinician can work with the patient and individuals in caring relationships with the patient to make the most of this potential resource. In the beginning, family or friends may simply be willing to serve as spectators, passively observing and providing support primarily by their presence. 44 The health-related aspects of the relationship may be characterized predominantly by shared intimacy and availability where the patient feels free to share feelings, fears, and needs. A second phase in the support relationship is often that of the fans, who cheer successes and minimize failures. Indifferent or negative attitudes on the part of the spouse, for example, have led to a threefold increase in dropout rates from health programs over those when the spouse was supportive. 53Empathy has been shown to be an important influence in undertaking health-behavior change.‘3s54 Supportive individuals may assist with scorekeeping by monitoring progress. They may also provide other resources, such as transportation to appointments, purchase or loan of special equipment, and assumption of some of the patient’s other responsibilities to free up additional time and energy for health-enhancement activities. Another option is the role of coach. Validation of the patient’s efforts and accomplishments is the primary focus. It is a delicate role where the line between encouragement or assistance and outright nagging is very fine.21 The practitioner can teach the patient and family ways to provide feedback that is constructive and motivating while not going beyond the patient’s tolerance for involving others in the health-enhancement process. Finally, some supportive individuals may elect to become teammates. For example, the patient and family or friends may exercise together, give up smoking together, or adopt health life-style changes recommended for the patient. A hazard is that the patient’s efforts, achieved at great cost if his or her health status is impaired, may be overshadowed by the achievements of a more healthy spouse or friend. Differentiation becomes important: each person must evolve a freedom to be different and to be apart as well as joined. This is

34 a relationship phase where the clinician may help the individuals realize that too much closeness or enmeshment may be adhesive rather than cohesive.55*s The clinician in this framework has maximum impact by establishing a climate of referent power.” Rather than banking on the power of specialized expertise and authority, the clinician uses norm-setting, acceptance, promoting personal responsibility for health-related actions, and helping the patient to attribute success to personal efforts and failure to environmental variables. l l Environment The interaction between the individual and the environment is widely recognized as influencing health behavior and health status.18,57*58In the planning and evaluation of health-enhancement activities the environment is usefully defined as a contextual space50 or behavior settingsO with stimulus properties that include both stressors and chaIlenges.29 Individuals experience a wide range of situations that provide cues for action that can inhibit or reinforce life-style changes. Clinician and patient alike need to think both “large” and “small” with respect to environments. It is important for professionals and patients to recognize responsibility for changing the larger environment.61 This refers to community or national action to deal with air pollution, crowding, noise, and other phenomena that individuals acting alone usually cannot change. The small settings or situations are ones that can be changed by individuals or small groups. In some cases, the patient may choose to change environments for a defined period or permanently. The residential and weekend programs at the Center, for example, provided a setting where the environmental cues and the social support network were specifically designed to enhance health-behavior change.i4 In the more immediate environment there are several dimensions that can shape health and life-style.18~57~s2 These include organizational policies; climate for growth and change;57 routines; and physical, spatial, and architectural elements.62 Organizational policies are the formal and informal rules of thought and action in every setting.95’57Policies at the work place, in the family, or amongst friends can encourage or discourage employees in exercising, building supportive relationships, or making healthier food choices. The Center has a worksite health-consulting program that addresses such issues as the availability of quiet space, walking paths, and healthful snacks in vending machines. Patients should also be encouraged to examine their routines at work, at home, and in their social lives to identify new arrangements that cue healthy behaviors. Some examples might include taking a coffee break away from the site of the catering truck, changing the

route home so that the gym is on the way, or planning recreations that are not centered on lavish food sharing. Critically examining the climate for growth and change in the various environments of the individual’s life can be important in identifying potential resources and obstacles.57 Beliefs held by the support group about change itself and about specific changes are often unspoken by-products of the culture.63 For example, smoking and hearty lunches with two drinks may be norms for being part of the “old-boy network. ” Diversity, flexibility, and intimacy are more subtle but equally significant facets of an environment that promote change while providing interpersonal cohesiveness and caring to support the risk-taking that is necessary for health-behavior change. 64 Patients can learn to draw on these resources in facilitating environments to cope with more hostile or neutral settings. Physical, spatial, and architectural elements of the environment with potential influences include the ambient temperature, lighting, ventilation, noise levels, availability of suitable locales for health activities (eg, excessive inclines in the neighborhood may discourage beginning exercisers), and well-lighted and accessible stairways. Some of these are amenable to change if brought to the attention of the proper authorities or peer groups. In other cases, alternative environments may be the most healthy choice. In attempting to promote life-style changes, clinicians need to be aware that individuals tend to discount situational or environmental information that conflicts with strongly held beliefs. I1 Patients may need to be encouraged to break free of their assumptions that their environments are unsupportive and learn to exploit the full range of possibilities. In some cases, this means seeking out new environments. Equipment Equipment consists of supplies and other tangible resources needed to carry out the patient’s plans. If healthy eating is a focus, recipes and cookbooks describing proper cooking techniques are needed. If the terrain around the patient’s home is too hilly for bicycling, perhaps a stationary bicycle can be purchased or borrowed. The patient needs the proper clothing for exercise. Use of resources often taken for granted should be discussed. The telephone, for example, is a means of strengthening social networks, a link to a buddy who provides moral support at critical moments, and a means of consulting with experts.” The role of the clinician is to encourage the client to realistically assess needs for equipment and supplies and to encourage creativity in terms of sources and substitutions. Clinicians should be careful to distinguish between availability and accessibility in their assessment of patients’ needs and resources. Simply because an

PATIENT EDUCATION AND COUNSELJNG

35 item is on the market does not mean that it is within reach of the patient. Money, travel time, skill in using equipment, and space for storage are factors that affect accessibility.

CHANGE PROCESSES Many health behaviors are not easily accessible to anyone but the client without long periods of institutionalization or residential treatment.41 While this has been tried with some success at the Center,r4 it is expensive and time-consuming. Casting the client in the role of the change agent is important in any case, as it is clear that the behaviors required for maintaining changes are often different from those required to attain new skills.65 The task of the clinician is to focus on the patient’s capacities and strengths for daily living and meeting life’s crises. 5g The clinician’s role is more than problem-solving: it includes consulting, teaching, monitoring, and supporting the client through a variety of change processes. in the current literaModels of change ture7~11~*g~45~57~66~s6 have in common several ideas: that change is rarely the result of single experiences, that client beliefs or cognitions and information play a key role, that mastery through practice and evaluation for refinement are essential components, and that environmental factors may serve as restraining forces or sources of support. Therefore, the following processes (Figure 5) are proposed for teaching clients a problemsolving approach based on personal responsibility for health as the ultimate goal. The key is careful timing so that the patient feels minimally overwhelmed and maximally challenged by success. This experience of mastering a challenge is intrinsically reinforcing.

READINESS APPRAISAL GOAL DECISIONS RESOURCE CONSULTATION STRATEGYDECISIONS COMMITMENT CHECK STRESS INDCULATION EXPERIMENTATION SELF EWLUATION

Figure 5. Eight internal change in the individual.

VOLUME G/NUMBER1

processes

that can facilitate

Readiness Appraisal The initial stage, labeled variously unfreezing,BB awareness,67jBBor cognitive appraisa15’ is basically an appraisal of readiness for change. The role of the clinician is to provide necessary information for decision-making and motivation.lg At the Center, this information process begins with the comprehensive health evaluation, which includes a full physical examination, laboratory work-up, and health-risk appraisal questionnaire. Clients need to realize that they can actively cope with existing problems, recognize problematic situations and habit patterns as they occur, inhibit the temptation to act impulsively,1g and identify an emotional leverage point for change (eg, a sense of hope as well as the need to change).6g*70 Goal Decisions The next step is to define the problem and identify goals that are feasible and acceptable to the client. Goalsetting is also an important source of self-motivation7i because personal standards permit the evaluation of ongoing progress. It is important that goals be specific, set at a level appropriate to the client’s abilities, and have a realistic time frame.72 Returning to work may be a long-term goal for the cardiac rehabilitation patient. However, short-term goals need to be established that will develop feelings of self-efficacy through mastering challenges that generate greater interest in the activity (eg, to exercise for a certain period without angina or shortness of breath, to discuss return to work with the employer). Resource Consultation It is at this stage that patients gain additional information about possible strategies and learn new skills. The goal is an informed client who can make meaningful decisions.4*73 The clinician assesses what the patient does know and contrasts it to what needs to be learned to succeed.22*23s74The clinician may need to seek out or provide opportunities to improve the quality of a client’s decision-making. Janis and Mann73 advocate teaching specific decision-making skills (eg, balance-sheet techniques) via role play or psychodrama. Strategy Decisions Plans for action must be selected by the individual patients and tailored to their needs.8,22,23 Individualized plans, such as scheduling exercise activities within the patient’s current life-style, promote compliance.75 Strategies should also take into account available supports, styles of living, and current health status. Some examples of strategy choices are selection of autogenics versus guided imagery for stress management, group versus individual exercise, meal scheduling, and foodpurchasing tactics. Pleasurable experiences need to be

36 structured into living routines to compensate for the sense of loss and deprivation created by changes such as dieting or smoking control. These pleasures need not be contingent on performance at goal level. Patients learn to build self-motivation by setting subgoals that increase their sense of mastery and create internal incentives to achieve. I9 Commitment Check Commitment to a goal is essential both as a cognitiveemotional statement of an intention to undertake action76 and as a behavioral allocation of effort and time.41 Commitment is not complete as long as alternative beliefs or behaviors are reinforced by the client internally (eg, via self-statements such as, “If I quit smoking, I’ll gain 20 pounds”). In assessing commitment, the clinician must be observant of nonverbal communications that indicate an ambivalence or outright resistance, including both nonverbal signals (eg, saying “yes” but shaking the head “no”) or statements that are socially desirable but out of character for the client (eg, “I’m going to take up jogging,” from a patient with years of sedentary living). In addition, Bandura’srg work suggests that if patients are reluctant to commit to specific strategies when they have apparently embraced the goals, the goals may seem too distant and more attainable subgoals may be called for. Alternatively, as Kanfer4r suggests, the patient may feel that it is the clinician who is controlling the situation and cooperation may turn to opposition. In either case, it is valuable to determine the extent to which patients perceive themselves as able to carry out the proposed actions (behavioral control) and to manage environmental threats that may arise (cognitive control). This kind of checking should go on continually. Stress Inoculation In this phase, patients anticipate barriers, obstacles, and other problems that may interfere with the success of strategies they have proposed. Janis” described this technique as allowing patients to anticipate losses, to begin working through their emotional responses, and to plan ways to circumvent or eliminate potential problems. Patients are taught that setbacks often occur with chronic problem situations both due to a lack of creative alternative solutions and as a result of inability to cope with letdowns. Meichenbaum and Genest” propose that stress inoculation must include task-relevant statements and rehearsals and coping self-statements when preparing for a stressor, confronting and handling the stressor, coping with the feeling of being overwhelmed, and reinforcing successful outcomes. Experimentation This is the phase of implementation or performance. The patient and clinician review the actions the patient

has decided to undertake, for how long, in what circumstances, and what role the clinician is to play. Often, contingency contracts can offer a means of assuring active participation. 7*,79In other cases, motivation and self-regulation are enhanced by providing the patient with the concept that behavior change is not permanent or irrevocable but rather a temporary learning experience and experiment. This connotes both a scientific approach and a great degree of freedom to withdraw or modify the actions if the results are not optimal. The message is to continually find new fields to conquer. Control is also clearly with the patient; there is no fear of the clinician’s “enforcing” the contract. Self-Evaluation Self-evaluation is an ongoing process that provides data for future readiness appraisals and strategy decisions. Self-monitoring processes have been associated with maintenance of changes. 9,80 Clients learn how to monitor progress and to elicit and appreciate reinforcement from themselves and available support structures. Self-monitoring may take the form of journals, charts, graphs, checklists, and the like. The key is to provide well-timed data that lead to enhanced self-efficacy.l**lg APPLICATION OF THE FRAMEWORK Clinicians who are willing to share responsibility with their patients for the course of their health care can use framework diagrams to help patients make sense of this health-enhancement approach. The interested clinician needs to review his/her usual history-taking form and style and to revise them to ensure that both clinician and patient have adequate information about health status, styles of living, and support structures to enable the patient to begin the change processes. For some clinicians, the nature of their diagnoses22*23may need to be expanded to determine not only health status but also readiness, resources, and obstacles to change. The nature of the interaction between the patient and the practitioner changes. 4~5For some practitioners, the office or clinic visit has been primarily to tell patients what their problems are and what they should do about them. In contrast, use of this framework alters the focus from a telling/ordering or education session to a behavior-change approach. (Works on short-term helping relationships,61 techniques of behavioral medicine,82 and health promotions3 will be useful to those who would like to increase their skills in this respect.) In addition, the standards by which clinicians evaluate the quality and success of their practice may need adjustment.14 In addition to the traditional criteria of morbidity and mortality’ and satisfaction with care,84 clinicians using this framework need to assess their clients’ success in managing and adjusting their own health-enhancement program.

PATIENTEDUCATIONANDCOUNSELING.

37 These ideas about health enhancement shaped decisions about the Center’s previous residential program and the new mix of community outreach programs. l4 They are being utilized to formulate new directions for the Center and as a basis for publications designed to familiarize patients with the Center approach.

ACKNOWLEDGMENT

REFERENCES

24. Metalsky GI, Abramson LY. Attributional styles: Toward a framework for conceptualization and assessment. In: Kendall PC, Hollon SD, eds. Assessment srraregies for cognitive behavioral inrerventions. New York: Academic Press, Inc, 1981:13-5&X. 25. Landau RJ, Goldfried MR. The assessment of schemata: A unifying framework for cognitive, behavioral, and traditional assessment. In: Kendall PC, Hollon SD, eds. Assessmenr srraregies for cognitive behavioral inrervenrions. New York: Academic Press, Inc, 1981:363-399. 26 Becker MH, Haefner DP, Kasl SV, et al. Selected psychosocial models and correlates of individual health-related behaviors. Med Care 1977; 15:27-46. 27. Beck KH, Frankel A. A conceptualization of threat communications and protective health behavior. Sot Psychoi Q 1981; 44:204-217. 28. Butler L, Meichenbaum D. The assessment of interpersonal problem-solving skills. In: Kendall PC, Hollon SD, eds. Assess-

1. Breslow L. Risk factor intervention for health maintenance. Science 1978; 200:908-912. 2. Levy RI, Feinleib M. Coronary artery disease: Risk factors and their management. In: Braunwald E, ed. Heart disease. Philadelphia: WB Saunders Co, 1980:1246-1278. 3. Ibrahim M. In support of jogging. Am J Public He&h 1983; 73:136-137. 4. DiMatteo MR, DiNicola DD. Achieving patient compliance. New York: Pergamon Press, Inc, 1982. 5. Stone G. Patient compliance and the role of the expert. J Sot Issues 1979; 35:34-59. 6. Dunbar J. Adhering to medical advice: A review. Int J Menr Healrh 1980; 9:70-87.

7. Kirscht J, Rosenstock I. Patients’ problems in following recommendations of health experts. In: Stone G, Cohen F, Adler N, et al, eds. Healrh psychology: A handbook. San Francisco: JosseyBass, Inc, 1979:189-215. 8. Becker MH, Maiman LA. Strategies for enhancing patient compliance. J Commun Health 1980; 6: 113- 135. 9. Gormally J, Rardin D. Weight loss and maintenance and changes in diet and exercise for behavioral counseling and nutrition education. J Couns Psychol 1981; 28:295-304. 10. Sackett DL, Haynes RB, eds. Compliance wirh therapeutic regimens. Baltimore: Johns Hopkins University Press, 1976. 11. Janis IL. The role of social support in adherence. Am Psycho1 1983; 38:143-160. 12 Heinzelmann F, Bagley R. Response to physical activity programs and their effects on health behavior. Public Healrh Rep 1970; 85:905-911.

13 Oakes TW, Ward JR, Gray RM, et al. Family expectations and arthritis patient compliance to a hand resting splint regimen. J Chronic Dis 1970; 22~757-764.

14. Fielding JE, Malotte CK, Neutra RR, et al. The description and initial evaluation of an intensive live-in program in risk reduction. Prev Med (in press). 15. Dubos R. Man, medicine, and environment. New York: Praeger Publishers, 1968. 16. Callahan D. Health and society: Some ethical imperatives. Daedalus

1977; 106:23-34.

17. Wozinsky I, Zussman M. Toward comprehensive health status measures. Socioi Q 1980; 2 1607-62 1. 18. Kendall PC, Norton-Ford J. Clinical psychology: Scientific and professional dimensions. New York: John Wiley and Sons, Inc, 1982. 19. Bandura A. Self-efficacy mechanism in human agency. American Psychologisr 1982; 37:122-147.

20. Antonovsky A. Healrh, srress, and coping. San Francisco: Jossey-Bass, Inc, 1979. 21. Jaffe D, Jordan-Marsh M. Styles of couple response to a lifestyle intervention program. Fam Sys Med 1983; 1(3):37-46. 22. Bartlett E. Behavioral diagnosis: A practical approach to patient education. Patient Couns Health Educ 1982; 4:29-35. 23. Gordon M. Nursing diagnosis: Process and application. New York: McGraw-Hill Book Co, 1982.

VOLUME G/NUMBER1

The insightful and challenging comments of Lawrence Cobb, Kevin Malotte, and Lynne Morishita and the CHE staff are gratefully acknowledged.

ment strategies for

cognitive

behavioral

inrerventions.

New

York: Academic Press, Inc, 1981: 197-225. 29. Lazarus R, Cohen JB. Environmental stress. In: I Altman, JF Wohlwill, eds. Human behavior and environment. Vol 1. New York: Plenum Publishing Corp, 1977:89-127. 30. Dattore PJ, Shontz FC, Coyne L. Premorbid personality differentiation of cancer and noncancer groups. J Consult Chin Psycho1 1980; 48:388-394.

31. Haynes SG, Feinleib M, Kannel WB. The relationship of psychosocial factors to coronary heart disease in the Framingham study: III. Eight year incidence of coronary heart disease. Am J Epidemioi 1980; 111:37-58. 32. Bradley L, Prokop C. Research in medical psychology. In: Butcher J, Kendall P, eds. Handbook of research merhods in clinical psychology. New York: John Wiley and Sons, Inc, 1982:591-649. 33. Brown S. Dissociation of pleasure in psychopathology. J Nerv Ment Dis 1981; 169:3-17. 34. Royce JR, McDermott J. A multidimensional system dynamics model of affect. Motivation Emotion 1977; 1~193-224. 35. Norton-Ford JD, Kendall PC. Psychological enhancement of medical diagnosis and treatment. Rev Lurinamericana Psicolog (in press). 36. Weiner B, Graham S, Stem P, Lawson M. Using affective cues to infer causal thoughts. Dev Psycho1 1982; 18:278. 37. Lau RR. Origins of health locus of control beliefs. J Pers Sot Psycho1 1982; 42:322-334.

38. Jenkins CD, Zyanski SJ. Behavioral risk factors and coronary heart disease. Psychother Psychosom 1980; 34: 149- 177. 39 Watson DL, Tharp RG. Self-directed behavior change: Selfmodification for personal adjustment. 3rd ed. Monterey, California: Brooks/Cole Publishing Co, 1981. 40 Ladoucer R. Habit reversal treatment: Learning an incompatible response or increasing the subject’s awareness? Behav Res Ther 1979; 17:313-316.

41 Kanfer FH. Self-management methods. In: Kanfer FH, Goldstein AP, eds. Helping people change. New York: Pergamon Press, Inc, 1980.

38 42. Thoits PA. Conceptual, methodological, and theoretical problems in studying social support. J Health Sot Behav 1982; 23:145-158. 43. Israel BA. Social networks and health status: Linking theory, research, and practice. Patient Couns Health Educ 1982; 4:6579.

44. Cassel J. Psychosocial processes and “stress”: Theoretical formulation. Int J Health Sci 1974; 4:471-482. 45. Green LW, Kreuter MW, Deeds SG, Partridge KB. Health education and planning: A*diagnostic approach. Palo Alto, California: Mayfield Publishing Co, 1980. 46. The surgeon general’s report on health promotion and disease prevention. In: Health promotion. 1. Washington, DC: U.S. Department of Health, Education, and Welfare, 1979:117-138. 47. Mueller DP. Social networks. Sot Sci Med 1980; 14A:147-161. 48. House JS. Work stress and social support. Reading, Massachusetts: Addison-Wesley Publishing Co, Inc, 1981. 49. Cobb S. Social support as a moderator of life stress. Psychosom Med 1976; 38:300-314. 50. Meissner WW. Family process and psychosomatic disease. Int J Psychiatr Med 1974; 5:41 l-430. 51. Samson SB, Carrol CF. Maton K, et al. Human services and resources networks: Rationale, possibilities, and public policy.

52. 53.

54.

55. 56. 57.

58.

59.

San Francisco: Jossey-Bass, Inc. 1977. Mancini JA. Family relationships and morale among people 65 years of age and older. Am J Orthopsychiatry 1979; 49:292-300. Andrew GM, Oldridge NB, Parker JG, et al. Reasons for dropout from exercise programs in post-coronary patients. Med Sci Sports Exert 1981; 13:164-168. Robertson EK, Suinn RM. The determination of rate of progress of stroke patients through empathy measures of patient and family. J Psychosom Res 1968; 12:189-191. Minuchin S. Families and family therapy. Cambridge, Massachusetts: Harvard University Press, 1974. Smilkstein G. The family APGAR: A proposal for a family function test. J Fam Prac 1978; 6:1231-1239. Moos RH. Social-ecological perspectives on health. In: Stone GC, Cohen F, Adler N, et al,-eds. Health psychology: A handbook. San Francisco: Jossev-Bass. Inc. 1979:523-547. Kendall PC, Watson D. Psychological preparation for stressful medical procedures. In: Prokopol C, Bradley L, eds. Medical psychology. New York: Academic Press, 1981:197-221. Ellis R. Conceptual issues in nursing. Nurs Outlook 1982;

30:406-410. 60. Barker R. Ecological psychology: Concepts and methods for studying the environment of human behavior. Stanford, Califor-

nia: Stanford University Press, 1968. 61, Dreher M. The conflict of conservatism in public health nursing education. Nurs Outlook 1982; 30:504-509. 62. Geddes R, Gutman R. The assessment of the built environment for safety: Research and practice. In: Hinkel L, Loring W, eds. The effect of the man-made environment on health and behavior.

Atlanta, Georgia: Centers for Disease Control, U.S. Department of Health, Education, and Welfare, 1977:143-195.

63. Wallace AFC. Culture and personality. 2nd ed. New York: Random House, Inc, 1970. 64. Shaw M. Group dynamics. Chicago: Aldine Publishing Co, 1971. 65. D’Zurilla TJ, Goldfried MR. Problem solving and behavior modification. J Abnorm Psycho1 1971; 78:197-266. 66. Lewin K. Dynamic theory of personality. New York: McGrawHill Book Co, 1935. 67. Hall G, George A, Rutherford W. Measuring stages of concern about the innovation: A manual for the use of the SoC questionnaire. Austin, Texas: Research and Development Center for

Teacher Education, University of Texas, 1977. 68. Rogers E. Diffusion of innovations. New York: Free Press, 1962. 69. Goldfried MR. Goldfried AP. Coanitive change methods. In: Kanfer FH, Goldstein AP, eds. Helping people change. 2nd ed. New York: Pergamon Press, Inc, 1980:97-130. 70. Frank J. Persuasion and healing. Baltimore: Johns Hopkins University Press, 1961. 71. Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev 1977; 84:191-215. 72. Bandura A, Schunk DH. Cultivating competence, self-efficacy, and intrinsic interest through proximal self-motivation. J Pers Sot Psvchol 1981: 41:586-598.

73. Janis I, Mann L: Decision-making: An analysis of conflict, choice and commitment. New York: Free Press, 1977. 74. Glanz K, Kirscht JP, Rosenstock IM. Initial attitudes as predictors of intervention effects: The individual management plan. Patient Couns Health Educ 1981; 3:30-42.

75. Mulder JA. Patient compliance to individualized home exercise programs. J Fam Prac 1981; 12:991-996. 76. Bagozzi RP. Attitude, intention, and behavior: A test of some key hypotheses. J Pers Sot Psycho1 1981; 41607-627. 77. Meichenbaum D, Genest M. Cognitive behavior modification: An integration of cognitive and behavioral methods. In: Kanfer FH, Goldstein AP, eds. Helping people change. 2nd ed. New York: Pergamon Press, Inc, 1980:390-422. 78. Swain MA, Steckel SB. Influencing adherence among hypertensives. Res Nurs Health 1981; 4:213-222. 79. Kanfer F, Karoly P. Self-control: A behavioristic excursion into the lion’s den. Behav Ther 1972; 3:398-416. 80. Baron P, Watters RG. Effects of goal setting and of goal levels on weight loss induced by self-monitoring of calorie intake. Can J Behav Sci 1981; 13:161-170. 81. Janis IL, ed. Counseling and personal decisions: Theory and research in short term helping relationships. New Haven, Connecticut: Yale University Press, 1982. 82. Garfield SL, ed. Special issue: Behavioral medicine. J Consult C/in Psychol 1982; 50: 795-1055.

83. Pender, NJ. Health promotion in nursing practice. Norwalk, Connecticut: Appleton-Century-Crofts, 1982. 84. Penchansky R, Thomas JW. The concept of access: Definition and relationship to consumer satisfaction. Med Care 1981; 19:127-140.

PATIENT EDUCATION

AND COUNSELING