We know change isn’t always easy. It can be especially difficult when it comes to our clients altering their diets, amount of physical activity, or even bad habits like cigarette smoking. What are some strategies practitioners can employ to create lasting changes in our clients?
In this episode Dr Adrian Lopresti is joined by Dr Michelle Jongenelis, Senior Research Fellow and Deputy Director of the Melbourne Centre for Behaviour Change. Michelle talks about her own research and clinical experience in creating lasting behavioural change for clients, exploring why it can be difficult for people to change, what strategies practitioners can use to assess motivation and willingness to change, and how to set collaborative and realistic goals with our clients to help ensure successful and longterm changes.
Covered in this episode
[00:35] Welcoming Dr Michelle Jongenelis
[03:11] How can we make change easier?
[07:00] Assessing motivation to change in our clients
[13:31] The importance of self-efficacy
[18:04] Process vs outcome
[20:30] Using if-then planning
[27:11] Substituting realistic alternatives
[30:22] Providing adequate rationale
[33:19] Assessing what stage of change your client is in
[35:58] Factoring in environmental barriers to change
[40:11] How long until a behavioural change becomes a habit?
[43:26] Handling lapses and getting back on track
[47:20] Don't forget about self-monitoring
[49:43] Additional resources for practitioners
[52:30] Thanking Michelle and final remarks
Adrian: Hi, and welcome to FX Medicine, where we bring you the latest in evidence based integrative, functional, and complimentary medicine. I'm Dr Adrian Lopresti, clinical psychologist, and joining us today is Dr Michelle Jongenelis.
Dr Jongenelis is senior research fellow and Deputy Director of the Melbourne Centre for Behaviour Change. She has expertise in health promotion, intervention development and evaluation, behavioural psychology, and clinical psychology. She works across multiple and diverse health related behaviours, including alcohol and tobacco control, nutrition, physical activity, and sun protection.
Michelle joins us today to talk about developing healthy habits, and how we can help facilitate behaviour change in our patients. Hi Michelle, thanks for joining us today.
Michelle: Oh, thank you so much for having me, Adrian.
Adrian: And that was great. I'm most certainly interested in talking to you today, because of some of the research actually, that you've done on young children through to older adults on areas of physical activity and your soft drink. I've seen some of the papers you've written on soft drink consumption and healthy eating, and even some of your work on e-cigarette use.
Michelle: Yeah, lots of things that people need to be doing to change their behaviour for the better. So definitely most of my research applies to those things that we all could be doing, like, as you pointed out, increasing physical activity, eating our fruits and vegetables, not drinking so much soft drink. And of course, not drinking as much and definitely not smoking or using e-cigarettes.
Adrian: Yeah, great. I know that you do some work at the Melbourne Centre for Behaviour Change. Can you tell us a little bit about that centre?
Michelle: Yeah, so we're a fairly new centre, we were meant to launch last year and then COVID hit and unfortunately, our launch party got delayed. So we basically do research, and training, and engagement consultancy, in relation to all things behaviour change. So we have a health focus at the moment.
So like I said, all those health behaviours that we need to make ourselves feel better and be healthier, not just at the population level, but we also have some researchers working for us who will do this work in specific sub-populations. So for instance, one of our researchers is currently working on breast cancer survivors or patients and how exercise can be integrated into their treatment for when they are doing their chemotherapy, etc.
Michelle: And next year, we have our director starting with us whose work focuses on behaviour change in the context of things like, climate control, climate change, organ donation, all those sort of socially responsible behaviours. So we're looking forward to expanding as a centre and having that added to our health arm.
Adrian: Oh, that's terrific. I mean, certainly today we wanted to talk about behaviour change, and how we can support our clients in changing their behaviour. So from your research and your clinical experience, how difficult is it for people to change?
Michelle: I mean, change isn't easy, we definitely can't sugarcoat that. But it can be made easier if one follows a set of guiding principles. And that's a really, I think, a really beautiful thing I find about behaviour change is there are set prerequisites, and if you follow these, then you are more likely to be successful in change. And that applies to all behaviour.
So it doesn't necessarily mean that for each specific behaviour that's presenting in front of you, you suddenly have to change your treatment protocol. Actually things like making sure the client is motivated, setting SMART goals, If-then planning, self-monitoring, all of that sort of stuff. That's the basic stuff. And that can apply to any behaviour. So it's sort of, in some ways makes the treatment process a little bit easier.
Adrian: Yeah, and that's great. I certainly today, I wanted to talk more about some of those strategies that practitioners can use to support their clients. I know that changing physical activity, improving the diet, and reducing smoking, and all that and even weight loss, and others, people can near really try to exert effort to make changes in those areas. And sometimes they can start off well, and then unfortunately, some of the changes can dwindle off some of the time. So if we, as practitioners, can use techniques with our clients to help support them through that process. That'd be great.
I remember I saw just recently a meta analysis on I think it was about 30 odd, long term weight loss studies. And more than half of the people put on all their weight within two years and I think was about 80% put all their weight on after five years. So it indicates how important for us as practitioners to be able to support them.
Michelle: Yeah, definitely. I mean, in some ways short term behaviour change is actually quite easy. If you give someone a couple of weeks for instance to lose weight for a wedding or lose weight for an event. People will do it. And they won't struggle with it.
The tricky part is actually sticking with a behaviour change until it becomes a habit. So most, like I said, most people will change their diet or increase their physical activity for a few weeks and then unfortunately, they'll stop before it becomes habitual. And that's why New Year's resolutions so often fail, because people don't maintain it, or they set really unachievable goals for themselves, realise they can't achieve it, and then sort of give up entirely.
So if people can set, like I said, set SMART goals, and then stick with their behaviour change until it does become a habit, then the success can be achieved in the long term.
Adrian: Yeah, definitely, as you were speaking I was certainly thinking about New Year's resolutions and all the resolutions that people set. And unfortunately, probably by January 2nd, many of those changes have stopped, or maybe many haven't even started because they haven't really developed a good plan to begin with.
Michelle: Correct. Yeah, planning is super important. So we can't just go into something straight away, and expect there to be change, it's like running a marathon without training for it in the months ahead. So with adequate planning, and also the motivation as well, there's so many steps before you actually start taking action to change your behaviour. And that's what people often forget, that we really need to do that pre-planning first, so that when we eventually do start taking action and changing our behaviour, we're in the best possible mindset and we've done what we need to do to make that change successful.
Adrian: I know that often when we have our clients attend our session, our practice that it's often assumed that they're motivated to change. And unfortunately, that's not always the case. I know certainly, when I work with my clients, they're certainly motivated to get better. But in terms of making those specific changes around diet or lifestyle, they may not necessarily have that motivation to change. So how do we assess whether somebody is motivated?
Michelle: Well, I mean, there are a few things of course. I guess it would be more important to, as you've pointed out, not assume that the person presenting before you because they're presenting before you necessarily wants to change.
Michelle: So you want to be sort of getting at their...or trying to assess for their change story. So what are the reasons behind why they're changing? And then determining whether those reasons, I guess, are enough in the long term. So a lot of people don't realise what it takes to change. Someone might come in and say, "Yeah, I want to increase my physical activity. But I actually don't want to get up at 6:00 in the morning and go for a run, or I don't want to come home from work and go for a run." That suggests that their motivation is lacking. They might want, as you've pointed out, they might want to get better, but they don't want to do what it takes to get better.
Michelle: So actually explaining to people, "Well, this is what might be in your future, how do you feel about these things?" And if they very quickly come back and say, "Oh, well, actually, no, that's not what I signed up for." Then you will need to do some work around their motivation and working on what change means to them.
And it could be that at that point in time, they might not want to change. But before we assume that, it is worth talking to them about again, what their change story looks like for them. Why are they wanting to get better? Why are they wanting to do what they want to do? Is it because they want to run around after their grand-kids? Is it because they have a health condition that will worsen dramatically? So things like that,
Adrian: Okay. All right. So it's not just talking about the behaviour, but also looking at okay, well, what's the purpose behind the change? What's driving you to change, and it might be a much bigger goal? Rather than just losing weight, for example, might be to be able to spend time with their grandchildren and things like that. Is that what you mean, in terms of that conversation?
Michelle: Yeah, absolutely. So you need to make behaviour change relevant, very few people suddenly get up in the morning and go, "Oh, I'm going start running at 6 a.m. without being motivated to run at 6 a.m. There has to be something behind that decision to change someone's behaviour.
So for instance, smokers will often quit because it's just too expensive to buy cigarettes and they can't afford it anymore. They're going without eating or they can't go on the holidays they want to go on. Other smokers will quit for family reasons. So they're having kids, or their partner is pregnant, or something's happening and they want to be there and live a longer life so they can run around after their kids or grand-kids.
So the same goes for things like physical activity, or junk food consumption, people know that it's unhealthy.
Michelle: So I guess that's something that I think is important to realise is that people don't necessarily need to be told that smoking is unhealthy or that junk foods unhealthy, we know that. So we need to get at something else that can motivate our clients. And usually it is around the family stuff if they have a family, or some other reason, and it's up to the practitioner to chat with the client and figure out what it is about this client that's presenting in front of you, that is going to motivate them. And that'll be different for different clients.
So the motivation is the same, all clients need to be motivated. But what's gonna motivate a client will depend on the client in front of you, if they don't have kids, then telling them that they can live longer for their kids is not going cut it. So what else do you need to sort of get an in with your client? What's personally relevant for them?
Adrian: Okay, so if you have somebody for, say, for example, coming in and one of the change is around smoking, you may not necessarily be concentrating on the smoking, but what kicking the habit will do in terms of financial freedom and things like that, and being able to pay the mortgage. And that might be something that you link their motivation towards then?
Michelle: Yeah, definitely. So like I said, most people, if not all people know that smoking is bad for them, but it is an addiction. So it does require a different sort of conversation. And for some people, the financial thing might not cut it, and you might need to try something else. So again, it's just about figuring out what the person in front of you is going to respond to.
So what is their story? What attitude do they hold towards smoking? You know, how does it fit within their life? Are they worried about not being able to cope with stress? If that's the case, if that's what's preventing them from changing, then as a practitioner, you're going to need to work on that. You're gonna need to figure out “How do I get this person to manage their stress levels that doesn't involve smoking?” So really sort of chatting to the person about their personal story. And I realise it's hard, particularly for GPs who only have maybe a 10 minute or 15 minute slot, some GPs only have a seven minute slot to chat with their clients about this. But really important to elicit that story that your client has about their behaviour, because that's the only way you're going to figure out what it's going to take for them to change.
Adrian: So if we think about people in the characteristics of people that do change, I mean, what does the research say around what characteristics or individual characteristics increase the likelihood of someone changing?
Michelle: It's pretty much just someone who is motivated, really. So I've firmly believe that anyone can change if they're motivated enough to change. So while there are certainly probably some areas where you might find some sex differences, or some age differences, I think a lot of the time, they're just assumptions.
So for instance, the assumption that as people get older, they're going to slow down, and they better not do physical activity because of x, y, z. I think we need to watch out for those assumptions and just sort of assume that the person in front of us with the right motivation with the right tools, can and has the capacity to change.
Adrian: Okay, okay. I know there's a lot of research around things that might be important in terms of motivation is things like self-efficacy or one's confidence in being able to change. Can you tell us a little bit about that the importance of helping support somebody self-efficacy around change?
Michelle: Yeah, so if someone doesn't believe that they have the ability to do what it takes to change, then they're not going to be motivated to change. So if you set a goal with someone, or if someone wants to increase their physical activity, if they don't believe they can go for a run, and that's different to not being able to. So if someone has a physical ailment that prevents them from running, that's different. Self-efficacy is someone's belief that they can do what it takes.
So working on self-efficacy, there are four different ways that self-efficacy can be increased. The most potent way of increasing self-efficacy is through what we call “mastery experiences.” So getting people to actually experience accomplishments. So if someone wants to increase their physical activity and believes they can't, you might not say to them, "Well, start by going for a run every day." You might say, "How about you start by going for a half hour walk three times a week," and you sort of what we call “graded tasks,” where you build them up to the point where they are then going for that run, if the run is the end goal, or they are then finding themselves in the gym.
Michelle: So, like I said, it's what we call those mastery experiences, setting graded tasks, you don't get people necessarily to quit straight away, you for instance, quit smoking straightaway, you might taper them down. So you might get them to use nicotine patches of different strengths. So the greater tasks are really important getting them to experience that mastery.
And then of course, there are other forms of increasing self-efficacy, so things like vicarious experiences, so getting them to look at what other people have done to quit smoking or to exercise. And what did they do that they found helps them? And getting that sort of support around that. Hearing other people's stories.
Yeah, verbal persuasion is another one. So encouraging your client to change being not necessarily positive, but being realistic around what they can do.
Adrian: Okay. Okay. So really then targeting self-efficacy, you could be really starting small with somebody getting them to experience some success in change with small changes, whether it be walking, or a small change in relation to a dietary change or something like that, and getting them to kind of boost their confidence in relation to that, then gradually building it up from there.
Michelle: Yeah, absolutely. Yeah.
Adrian: All right, because I know, obviously, a lots of people that have come in they may have tried to change numerous times. And obviously, they have got a history of, I suppose, from the mind, failing. So that's going to have a really negative effect on their confidence in changing I suppose, isn't it?
Michelle: It is, yes. So you find this often in smoking is, "Oh, well, I've tried to quit x times in the last few years, and nothing's work. So what makes you think it's going to work this time?" And when a client presents to me with something like that, I will always question, what goal that they had set for themselves for that behaviour change. Often people are setting really unrealistic goals, particularly around New Year's resolutions, "I'm going to exercise, I'm going to be super healthy." And then they slip up once and they think, "Oh, well, that's it, I've stuffed up, I might as well just not bother with this anymore."
So making sure that the goals that they set for themselves are the SMART goals. So that they're realistic, it's something that they can achieve. And people often focus on sort of the end result, "I am going to lose the 10 kilos, or the 20 kilos, I am going to quit smoking, I am going to run a marathon." And what they don't see is the little incremental goals that they need to achieve in the meantime. And so because of that, whenever they don't achieve that bigger goal, which happens all the time, because they haven't set a realistic one, they then experience that sense of failure. And that then makes them less likely to want to change their behaviour again in the future.
So setting those incremental, SMART goals is really important for making sure people experience a little bit of self-efficacy and have less of a chance of failing the next one, their next attempt.
Adrian: Yeah, so if somebody's coming in wanting to lose weight, that not might not necessarily be, let's say it's 10 kilos they want to lose, that's not the goal we're going to be really working towards, it's going to be more the process rather than the outcome. It's what things that you need to actually do to get to that outcome? So that might be a specific goal around dietary change or something like that, and working towards that?
Michelle: Correct. Yeah, weight loss is a tricky one, because weight loss in and of itself isn't a behaviour. So when you're wanting to change someone's behaviour, you can't change...the behaviour isn't the weight, the behaviour is, as you pointed out, all the things that go into someone's weight. So exercise and good eating, etc. So correct when you're working on the broader goal being weight loss, you actually need the smaller SMART goals that are around the individual things that that client is doing.
So in the first week, it might be something like, making sure I'm eating vegetables every day, or at least one vegetable every day, if they've started off eating none. And again, it'll be different depending on the client in front of you. But if there's a client who every night treats themselves to chocolate after dinner, you might work with them by saying, "Well, how about this coming week, a SMART goal that you set for yourself is you only eat that chocolate, Monday to Friday and then on the weekend, you don’t. Or you choose one day where you're not going to eat the chocolate, and then you grade that down.
So to use the example I used earlier with the walking, that's how you would approach the physical activity. So how about this week we start building in some physical activity. And depending on where you are, what your baseline is, with physical activity, we can decide what you might be capable of moving forward.
Adrian: That's great. I think how you mentioned that weight loss is not a behaviour, it's really an outcome. And really what we've got to be working towards is the specific behaviour changes that they need to make. And I know certainly when it comes to weight loss, we can't control how much weight we lose, but we can control the behaviours that we need to do. And then as a result as a side effect, I suppose your weight loss then occurs over time.
Michelle: Yeah, absolutely. Yeah. And a lot of clients don't realise that. A lot of clients are sort of so focused on the outcome and not the process, which is where it comes back to bite them later on.
Adrian: So we've got then motivation is obviously extremely important, then we've talked about self-efficacy, then you've talked about SMART goals and making sure that those goals are achievable. And you've kind of graded things start small and gradually increase over time.
So what happens if somebody comes in and they've got this goal to go vegan, and natural, and to be perfect with regards to their eating? How would you deal with a client like that?
Michelle: Well, I mean, I would want to know what the story is behind that, behind that change. So why are they coming in and wanting that? What are the reasons for that? Do they know what it involves on a day-to-day level, because that's going to get at their sort of motivation and self-efficacy. So if this is what you want to do, this is what it looks like, is this something you're prepared to do?
So really making sure that you're assessing their motivation for that, so that increased chance of not failing later on. So in terms of I guess, what we would then do with them, assuming that they're motivated, assuming that they have a SMART goal in place, would then be working on the individual SMART goals. And then in terms of how we go about achieving those goals, we can utilise what we call if-then planning or which are also known as “implementation intentions.”
So the “if” is the cue to act and then the “then” part is the acting. So if someone for instance, is wanting to, start eating a vegan diet, but they keep walking past this burger store on the way home for dinner, and they know that they have the desire to go in and buy the burger, then the if-then plan that they might come up with might be something like, if I'm walking home from work, then I won't walk past the burgers store, or if I'm walking home from work, then I will pick a different path home. So identifying that cue to act, and then making sure you act in a different way to what you usually act.
And if-then plans can can be used for different things, it can be used in times of crisis. So when you are presented with that burger store, for instance, or when you're presented with a bakery that has really lovely smelling pastries in it, and you're trying to lose weight, if-then plans can be used for that. But they can also be used to sort of develop a cue to act in a particular way.
So if you're wanting to increase your physical activity, you might say, “Well, if it's Saturday at 10 a.m., then I'm going to go for a walk.” Or “If it's Wednesday at 7 p.m., then I'm gonna go for a run.” So identifying those cues, and training your brain to then notice those cues and act the way that you would like to act in that way.
Adrian: Okay, so it's all about really coming up with developing cues, the action and problem solving, too. So let's say for example, if I have a craving, in the evening after dinner, then I will come up with a plan to kind of manage that craving, is that right?
Michelle: Yeah, definitely. So that would be what we call something that an if-then plan that needs to be developed in a time of crisis, essentially, when you're faced with, your goal potentially being thwarted by something. So often people get thwarted by feelings of, I guess, for lack of a better phrase, emotional distress. I'm feeling if you're anxious, I will usually have a glass of wine at this time but my goal is to reduce my alcohol intake. So perhaps it's if I'm feeling anxious, then I will, listen to some music, or have a hot shower, or get out of the house and go for a walk, or something. And those if-then plans will depend again, on your client and what works for them.
So for some people having that hot shower is going to be enough. For others, it's not going to be enough to help them with their anxiety, they might need to go for a walk, they might need to engage in some mindfulness, lots of different things to help them not drink that glass of wine that they would have usually had in that situation.
Adrian: Okay, so really, then, part of it is about trying to identify if the behaviour that they want to change ,what function that has. So if it's having glass of wine is a way that they unwind, and that serves a function for them, then we need to kind of develop alternatives to that behaviour. Is that right?
Michelle: Yeah. So there are two types of behaviour change or there are two behaviours that often need changing. There's doing stuff that improves our health, like, engaging in physical activity and eating fruits and vegetables. And then there are other behaviours that we do that we need to not do anymore, like, drinking, smoking, etc.
So the approach that you take to both will be similar in some ways and different in others. So if-then plans for the former so that the physical activity stuff will be identifying that cue and saying, "Well, if this happens, then I'm going to go for a walk." Whereas with the latter, it will be, as you pointed out, figuring out what function that particular problematic behaviour solves. And it does solve a function people don't do bad things or don't engage in maladaptive behaviours for no reason. It is serving a purpose for them, whether that's anxiety reduction, or stress relief, or often there is a distressing emotion that they're trying to avoid these behaviours, maladaptive behaviours are often avoidance behaviours. So it is a matter of figuring out for your particular client, what function it's serving, and then making sure that there are alternatives in place, otherwise, they're not going to be motivated to change.
There's a great saying that I always think of with my clients, it's "Never tear down a wall before first understanding why that wall was built." So if you go about tearing down someone's wall, and not having anything there to replace them with, then they're going to be very distressed, potentially, if they are using that wall to manage their emotional distress, for example. So definitely making sure and assessing what function a particular behaviour is serving. And then making sure there are alternatives or substitutions before you go ahead and tear that down.
Adrian: And that means really coming up with realistic alternatives for them, isn't it? Because I mean, if somebody's smoking is a way to cope with stress, then engaging in four to five deep breaths may not necessarily cut it for them. So we really need to think about, “Okay, what effective individual alternatives can this person use to help manage this risk rather than them returning to smoking?”
Michelle: Yeah, correct. And so that's why there are things like legitimate low-fat alternatives to particular products. So if you're saying to someone, if someone's wanting to lose weight, and one of their goals is to consume less high fat foods, than there are low fat alternatives out there that they could consume instead. So we're not saying, "Hey, you're not allowed to eat that chocolate bar anymore. You’re not allowed to eat that particular yoghurt anymore." When you do, go and pick your yoghurt from the store, perhaps pick a healthier type of yoghurt. So we're not removing that thing that they like entirely, but we are coming up with a different alternative or a substitute.
That's not to say that the alternative, or the substitute that we come up with is better, or is going to fulfil that need of theirs as good as the smoking did, for example. But it will sort of help a little bit. And then they can attempt to manage whatever doesn't help by engaging in other behaviours, or recognising that actually, change is hard, and I've just got to be mindful of this and work through it and ride this distress, like a wave, like I'm surfing a wave.
Adrian: Yeah, yeah, I know that if for me, for example, I had a...and I do like chocolate, I must admit in the evening, if I was having problems with eating chocolate in the evening, substituting it with a carrot is probably not going to be that effective for me. So...
Michelle: No, definitely not.
Adrian: Yes. So it's really starting with something, an alternative that might be even just having a smaller amount initially. Is that right?
Michelle: Yeah, that's what I was just about to say so can you have half the chocolate bar instead? Or when you go out to the shops, and you you stock up on your chocolate, I guess instead of buying the bigger chocolate bars, can you buy the fun sized packs instead? And so then you just have like a fun size Mars bar, for example, instead of the king sized Mars bar. It also works with ice cream. So rather than sort of having the big four litre tubs that you then scoop out into a bowl and it's really hard to measure that, perhaps by the single serve ice-creams instead. So a single serve paddle pop, for example. And then there's a very clear, there's an end to this, I'd have had my paddle pop rather than I've just put six scoops of ice cream and now I'm going to add ice magic and sprinkles and all of that sort of stuff. So yeah, certainly before we necessarily get rid of the behaviour or get rid of a product, like chocolate for example, stepping down. So it's actually not that much of a, I guess a fright to the system, we suddenly don't have that chocolate in the evenings because we've been reducing our intake over a couple of weeks already.
Adrian: And I think that's where we really need to work with our clients and not only hear what they're saying verbally, but also looking at their non-verbals to see whether they are actually engaging with some of the recommendations we're giving them.
So I know for me personally, I've been experiencing an injury with my knee and I've gone to the physio and the physio recommended a whole range of exercises, which verbally I said, "Yep, I'll go ahead and do them." But in my head, I was thinking, “Well, are they really going to work? Are they actually going to help heal my knee?” Because I didn't seem intensive enough. And I suppose maybe we just needed to have a bit more conversation about why those exercises are there and what the process is, over time. How the intensity of those exercises may change over time. And that might have then increased my confidence in some of the recommendations so that physio gave me.
Michelle: Yeah, so very important as practitioners to always provide a very good rationale to your clients for why you're wanting them to do a particular exercise or change their behaviour in a particular way. So clients will almost always come wanting change immediately. So as a clinical psych, in private practice, I see that all the time clients just come and they want to implement widespread changes. And so talking to clients about why that's not going to work, how that is a recipe for disaster, how if you take the time to do that planning, and to grade yourself up to a particular goal, you'll have greater success than if you just launch into it.
So again, that marathon analogy that I used earlier, if you decide you suddenly want to marathon without training, you're probably going to get a cramp within a couple of kilometres of being in there, and you won't be able to finish the marathon. So framing it like that, framing it as getting that practice up, building up your skills, building up your self-efficacy, so actually change is more likely to happen.
Michelle: And some clients might not respond very well to that. But I think if you take the time to actually provide that rationale, most clients should see where you're coming from, and be a little bit more on board with the treatment plan.
But obviously, another point to remember is that this should be collaborative, it should be a collaborative effort with behaviour change. So rather than the practitioner saying, “Well, you need to start exercising, and I think you need to do this, this, this, and this,” and talking with your client and going, “What do you think you can manage this week?” You know, if I was to say, "Can you go for a walk four times this week for half an hour? How does that sound to you? You don't have to like it. Just let me know what you think." And then if the client says, "Oh, actually, no, I don't think I can manage that." "Not a problem at all? How about three? Or how about two, or how about just one day?" So it really is a collaborative effort, which is also going to make it more likely that the client engages in that behaviour, because it's coming from a bottom up approach, not a top down practitioner imposing something on the client.
Adrian: And that's where I often will think about the stage of change model. So just for people who aren't aware, the stages of changing are your pre-contemplation, contemplation, action, and then maintenance. And often think about, when I'm seeing a client, they might be coming in, so let's say you're going for a run, for example, and I'm not a big runner. So if somebody recommended running to me, I would be in the pre-contemplation stage for running. But if it was something like going to the gym, which I enjoy more, I might I would be in the action change, for going to the gym.
So if we think about it all and we go, "Okay, where am I at with regards to exercise?" That might be a bit too broad, it might be actually breaking it down to going, "Well, what about this specific behaviour? Where are you at, in relation to the different stages of change for this specific behaviour?” Whether it be an exercise, whether it be a dietary change, I'm not a big seafood eater. So again, I would be pre-contemplation if somebody recommended a lot of seafood. But when it comes to other foods, then I might be in the action stage. Any comments on that?
Michelle: Yeah, and a lot of clients might come with this assumption that and this fear, I guess that, "Oh, I want to lose weight, or I've been told I need to lose weight for it, to get a particular surgery on my knee, or whatever it is. This means that I'm going to have to start exercising every day. And it means I'm going to have to completely change my diet.” And so there is a little bit of a fear there. And so put in a reluctance to then engage in behaviour change.
So making sure that you nip those assumptions in the bud very early on. And I'll often say that to my clients, I'll say, "Look, I just want to start talking to you about this stuff. I don't expect you to go away from this session today and suddenly change your life and be doing all these things right? We're just having a conversation. I want to know what you think you can manage this week. What's one thing that you could potentially do that is a change no matter how small, what does that look like for you?"
So as you've pointed out, you don't eat seafood. Obviously fish is an important part of someone's diet. I personally hate fish and I don't eat it. So if I had someone saying to me, “You really need to increase your fish intake,” I would say, "No, thank you. I don't want to do that." And that's perfectly fine. It's about changing and how else can we change your diet for the better? What if I was to say this instead? And getting that that collaboration, right, so that the client does stick with it. And yeah, addressing those fears that behaviour change means getting up at 6 a.m. And going for a run every day, because that's not what behaviour change is about. And that's not what's going to be sustainable in the long term.
Adrian: So we've got, as a practitioner we need to make sure that we have a really good assessment to identify where the client and their motivation is at, obviously, having good rapport with our clients. And then there's developing realistic goals, which are collaborative, which the client is involved in, and ensuring you get feedback throughout the process from them. Are there any other factors that we can address with our clients when it comes to behaviour change?
Michelle: Yes, that's the main ones, there are a few other things that practitioners will need to do with their clients. So a big one is the environment. So if a client is coming to you wanting to change, what's the environment that they living and working in, and is that conducive to change?
So are there potentially some enablers in their environment for poor behaviours, so for instance, smokers will often have a group of friends who also smoke. And so if you have a client coming to you wanting to quit smoking, then their friendship group is potentially going to act as a barrier to that. So you want to also be working with your clients on what's likely to get in the way of this behaviour change that's not generated by you.
So let's assume you can get up every morning at 6 a.m. and go for a walk or go for a run. What other things might get in the way of that that are more external to you? So the smoking one is a big one, especially if there's only two smokers left in the group, your client is one of them, which means the other smoker in the group will be on their own outside having a fag. You're going to have to sort of work with your client on this other smoker, friend of yours is really going to want you not to quit smoking, because they don't want to be alone outside. So what sort of skills do you need to be able to say, "Hey, actually, no, I'm not going to go out and have a cigarette with you."
So also working with your client on identifying potential barriers in the future, and coming up with if-then plans to help with those barriers. Another one would be something like a client who wants to reduce their alcohol intake, but every Friday after work they go for a drink at the pub with their work colleagues. Do they need to perhaps not do that for a few weeks? Or do they need to suggest a different venue, do they suggest an activity rather than the pub, for example.
So working with your client on those behaviours, after sort of you've set the goal, that's another important thing that I would encourage practitioners to check in on.
Adrian: So that really involves obviously talking a bit about the pros and cons of change and some of the consequences that could occur as a result of change. And that could potentially mean changing your social group, if you're hanging around with smokers, or if you're hanging around with people who drink a lot. And we really need to have those conversations in our sessions with clients because to be successful in change, it could result in traumatic lifestyle, or environmental changes, doesn't it?
Michelle: Yeah, I think as practitioners, we tend to focus a lot on the pros of behaviour change, because we know how important they are. We know how healthy it's going to be for the client to change their behaviours in a different way. But again, going back to what I said earlier, around, don't tear down a wall before you understand why it's being built. If we don't do the assessment around what are the consequences of this, because there will be consequences for the client of changing their behaviour. Maybe not necessarily with things like physical activity, but certainly with things like smoking and eating junk food, for instance, there might be some consequences to that.
So there might be a loss of self or self-soothing mechanism, if they're using junk food to cope with a particular distressing response. Or there might be a loss of a friendship circle, or, difficulties in a friendship circle. And so making sure that we don't just focus on the pros of behaviour change, but we also understand what the consequences of that is for that particular client, and then planning for what's going to happen when those consequences eventuate and how our client is going to manage that so that they don't sort of give up and revert back to their pre-change ways.
Adrian: Yeah, and that's absolutely crucial. You know, we need to be aware that it's not just all positive, there are a whole bunch of potential negatives and difficulties that a client is going to encounter when changing. So now the million dollar question, if I change my behaviour, how long does it take before it now becomes a habit?
Michelle: Yeah, that's a tricky question. So there are obviously loads of rules of thumb out there things like 10,000 hours. And it's just like that - they're rules of thumb. Some behaviours like quitting smoking, that's a nicotine addiction, that's going to be a hard habit to change than taking up exercise, for instance. So there's no hard and fast rule, it really just depends on making sure that your client is engaging in those steps.
What I can tell you is that it's going to take a lot longer, if you don't do the pre-planning as a practitioner, if you don't assess the motivation, if you don't assess the self-efficacy, if you just launch straight into action, without taking those planning steps, you will come into trouble later on, and it's just going to blow out the amount of time that it takes to change someone's behaviour. So whatever it takes for a client to turn it into a habit to make that response automatic is just however long it takes. So, sorry I don't have a lovely neat rule of thumb there for you. But a lot of clients will come in assuming that it's going to be 10,000 hours or four weeks of doing this every day, and that's certainly not the case. So that's sort of another assumption that you're going to want to nip in the bud with your clients presenting before you.
Adrian: And that's where things like obviously relapse prevention comes into play because we know that even if somebody is engaging in a behaviour for a year or two years, something happens in their life, there’s a highly stressful period they start smoking again and then they think, "Okay, well I failed." And they give up and I know that's a lot of work a lot of research on the relapse prevention side of things so.
Michelle: Yeah, and I'll often talk to clients about lapse versus relapse. So if you're working towards your goal and you find yourself having that chocolate bar at night time, really working on that black and white thinking of, "I might as well just give up now." So what you've had is a lapse but you haven't had a relapse yet. A relapse would be going back to all your old behaviours and not attempting to change at all.
So a lot of clients are very concrete and black and white about this stuff and “Now I've had a cigarette and that's it, back to square one,” which is not the case. So I'd also encourage practitioners to have that lapse versus relapse chat with their client. Tell their client that they could expect to lapse at some point in the future and then that's perfectly okay. It's then up to the client to implement things to prevent it from ending up in relapse. And so working with your client on, "Well if you have a lapse, what are you going to do? What are you going to think? What are you got to do? What sort of coping statements can you say to yourself so that you don't end up back where you were when you first came here?" So I sort of like to call it it relapse prevention in by focusing on lapse, working on what happens during a lapse.
Adrian: Yeah, and it's just normalising that it's inevitable that they're going to lapse at some stage particularly around eating and exercise and so forth. And that's also where we can also have conversations about future potential high risk times, are there situations in the future that may increase the risk of you reverting back to old habits? How do you kind of then work through that and what are some coping statements you could use, and some problem solving steps that you could kind of engage in to help sustain change and get back on track?
Michelle: Yeah, absolutely. So for the smoker example even if let's say you've been avoiding your friends for a couple of months, your smoking friends, but Christmas is coming up and you're catching up with your family and there's a couple of smokers in your family. How are you going to manage that when you've been sort of avoiding being around smokers and do you need to graduate how often you catch up with smokers in the meantime.
In terms of eating high risk time is always Christmas, but that's again very normal to sort of overindulge at Christmas time and working on, "Okay, well Christmas is over now. It's now the new year or it's now the 28th and I'm going to go back to attempting to eat like I was before before Christmas happened." So as you've pointed out, identifying potentially high-risk situations and coming up with a plan that's very specific to your client around how they're going to manage that.
Adrian: Yeah, and being aware of what the definition people are using. If they're saying that they want to be a healthy eater, what does that actually involve? And if during Christmas time you're indulging but most rest of the year you're eating really clean I mean, that's still healthy eating and that's something that people need to just be aware of. It's not a hard and fast black and white rules of either you're unhealthy, or you're healthy, or you're exercising, or you're not exercising, and even smoking. If you engage and you smoke a couple of cigarettes you still may define yourself as a nonsmoker who occasionally has a couple cigarettes. And that might then help them be realistic. And I suppose more reasonable with themselves more, rather than then having these black and bright rules around “I cannot do that. And if I do that, then I've given up and failed.” So I think that's really important, too.
Michelle: Yeah, and this sort of goes back to what we mentioned about earlier, in terms of the reasons why behaviour change often fails, it's because something hasn't become a habit, but also because people are very black and white in their thinking. They come with very unrealistic rigid rules and SMART goals and then as soon as that goal is broken, or isn't achieved, then they revert back to the opposite. So definitely wanting to talk to clients about being flexible and everything being on a continuum.
Having said that, of course, there are some behaviours that things like smoking, where we want to be a little bit more rigid about that stuff. So we've done some research where people classify themselves as a non smoker, or they classify themselves as a social smoker, “I only smoke when I'm out with others. But actually, I'm out with others every week.” That now makes you a smoker, that doesn't make you a social smoker, you are at harm. So also working on people's definitions of things.
Another one would be sort of, "Oh, I don't drink every day, I only drink on weekends when I'm out with my mates. But when I drink when I'm out with our mates, I'm drinking 7, 8, 9, 10 standard drinks every weekend." So watching out also for your clients, their definitions of certain things like social smoking, like drinking, because actually, they might be engaging in behaviour that they don't realise is putting them in harm's way. But they're just sort of assuming that, "Oh, it's fine, because I don't do it every day." So being sure as a practitioner to assess for that, too.
Adrian: Yeah. So it could be the definition could be the be too rigid, or on the other side, it might be something that they just minimising and not really acknowledging the severity of the problem for themselves.
Michelle: Absolutely, yeah, yeah.
Adrian: So is there anything else? We could keep going in for hours, I suppose talking about this but is there anything else that you think be useful for practitioners to know that we haven't covered so far?
Michelle: I mean, the only the part of the behaviour change model that we haven't touched on is the self-monitoring part. So once you send your client off, you've done your planning, you've set your SMART goals, you've set some if-then plans. If a client goes off and takes action, they need to be monitoring that action. They need to be monitoring every day, what they're doing.
So if they had a specific plan for a particular day, did they accomplish that plan? Or did they not? If they didn't, that's perfectly fine, what happened, what got in the way of that plan, not sort of happening for you? If it did great, and then so then when they come back to you a week later, or two weeks later, you can have a look at the monitoring and you can say, "Well, maybe we can make your goal a little bit more difficult. Like you seem to do it every day, or you met your target for the last couple of weeks, how about we make this goal a little bit trickier for you?" But conversely, “Actually, you didn't meet your target, maybe we've overextended the goal and we need to sort of pare it back and come up with a more achievable goal for you.” You're not going to be able to have those discussions if the client isn't monitoring.
And in this day and age, there's lots of great apps for monitoring behaviour change. And also there's just the old school paper and pen. You work out with your client, what you need to assess and you send them away with a piece of paper and you say, "Hey, every time you do this, tick this box, give yourself a gold star every time you don't do it, leave the box blank, and then we'll come back and we'll check that out." So monitoring is super important, because it facilitates goal review. And that goal review might end up in a more difficult goal, or it might end up in a slightly easier goal. And then you start the process again, of taking action. So that's the other sort of part of the model that I would recommend practitioners engage in. It’s often a forgotten one. It's they send out, off you go, take action, and the monitoring can often be left behind. But that's pretty critical too.
Adrian: Great, great. Yeah, I think certainly monitoring is absolutely important component to change. Now are there any...just finally are there any resources, books, or courses, that can help practitioners learn more about behaviour change and support their client's behaviour change efforts?
Michelle: I mean, there are definitely lots of resources and books out there. Some books will often focus on a particular behaviour. So things like weight loss or eating, and the course that we have on offer at the Melbourne Centre for Behaviour Change, which is called Behaviour Change for Clinical Practice. So we've developed that course, for Allied health professionals and we've done some research with Allied health professionals to make sure that the course does suit their needs.
So in that course, we deep dive into each of the different things that we've talked about in in today's podcast. So how do we increase motivation? How do we increase self-efficacy? How do we set goals? How do we make habits? How do we help clients break habits, all from an Allied health practitioners perspective. So in the last course, we had lots of physios in there and GPs. If anyone is interested in knowing a little bit more, then I would say the course that we have on offer is very, very practical. There are videos that I'm in showing people how to have a session with a client. So I'd highly recommend that for some fairly easy viewing rather than having to go off and read 10 books because they have different sort of habits that they look into.
Adrian: Yeah, I've had a look at that course and it looks great. So I certainly recommend it for anybody who's interested in helping their clients. Just finally, any apps that you would recommend for monitoring behaviour change. Is there anything specifically that you've used?
Michelle: Yeah, so there's an app called Habitica, H-A-B-I-T-I-C-A. So that's a behaviour change specific app that people can use. It's uses the principles of gamification. So we know that gamification increases users engagement with an app. So Habitica is one that people can try.
If you are more in the mental health space, then the other app I would recommend would be MoodMission. That's a really excellent one to that I found. It has a bit of evidence behind it, too. So Habitica and MoodMission.
There are loads of other ones out there, but these are the two that I found free, which helps. They’re free so you can recommend them to your client in session and get them to download it straight away. And yeah, fairly fun to use and increase engagements.
Adrian: Well, thanks, Michelle, thank you so much for spending the time with us today. And thank you for the great work you're doing in this area. It sounds like you're certainly providing much needed information for us as practitioners and highly recommend the course for people in the future that want to do it.
Michelle: Yeah, no worries at all. It's been great chatting. Thanks, Adrian.
Adrian: Thanks, everyone for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website. I'm Dr Adrian Lopresti for FX Medicine. Thanks for joining us.
Resources Discussed in This Episode
About Dr Michelle Jongenelis
Dr Michelle Jongenelis is Senior Research Fellow and Deputy Director of the Melbourne Centre for Behaviour Change. She has expertise in health promotion, intervention development and evaluation, behavioural psychology, and clinical psychology. She works across multiple and diverse health-related behaviours including alcohol and tobacco control (including use of e-cigarettes), nutrition, physical activity, and sun protection. Michelle works as a researcher and consultant for a broad range of organisations covering the not-for-profit and government sectors.