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.
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.
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