For years, psychologists have questioned and tried to identify what makes people behave the way they do. Countless hours have been spent studying behavior and identifying underlying thought patterns to produce a definitive answer to this question.
Fitness professionals know full well how hard it can be to help clients change their eating behavior. Even when they are committed to losing weight and are involved in a regular fitness program, they are often unwilling or unable to change other unhealthy
behaviors that contribute to weight gain. Simply telling clients to eat more nutritious meals and avoid junk foods just doesn’t work.
Although counseling clients about specific food plans is beyond the scope of practice for fitness professionals, there are ways we can help our clients make positive changes in their eating habits. This article presents practical actions you can undertake today to help clients reach their weight loss goals tomorrow.
If you are interested in helping people change, it helps to have an understanding of basic psychology. The Stages of Change behavior model is a good place to start.
Many readers are familiar with the Stages of Change model developed by James Prochaska and Carlo DiClemente in 1983. These psychologists determined that individuals trying to change behavior often go through a specific order of changes before they are
successful (Prochaska, DiClemente & Norcross 1992). Originally developed to help people quit smoking, the Stages of Change model is now used to treat a host of behavior problems, including overeating and physical inactivity.
Simply put, clients will go through the following six stages
before successfully changing any behavior:
This model is fairly simple to understand and very popular within the fitness industry. However, for fitness professionals dealing with clients who want to lose weight but can’t stick to their programs, the challenge lies in knowing which strategies to use at the different stages of change.
The Precontemplation Stage
This is the stage at which individuals are not even considering a change in their behavior. Because they don’t think they have a problem, precontemplators are not likely to seek your help. But chances are, you have at least one or two precontemplators among your existing clientele. The fact that they are already engaged in an exercise program doesn’t guarantee that they are ready to change their eating habits, too!
To help precontemplative clients, you first need to explore their cognitive, or thought, process about their current eating patterns. It is essential to take this step before trying to change any specific behavior, in order to head off resistance to change. Start by discussing the advantages of making a dietary change, along with the disadvantages of not making a change. But be very careful at this stage not to force the issue, as this can backfire and make clients more resistant to change.
For example, talk about the poor quality of fast food or how difficult it is to eat well when dealing with a busy schedule, but refrain from giving specific advice about ways to change. Ask how much more quickly clients think they would get the weight loss results they want if they considered changing their diet. The goal here is to plant the idea and let clients think about it on their own terms and schedule.
The Contemplation Stage
At this stage, clients are thinking about making some change but may still be somewhat ambivalent. Compared to precontemplators, clients at this stage are likely to be more open to discussing the possibilities of doing something different.
One way to make progress at this stage is to ask clients to weigh the advantages and disadvantages they identified during the precontemplative stage. This process, known as a decision balance, essentially involves evaluating the choice of an advantageous
behavior over a disadvantageous behavior (Janis & Mann 1977). This process can determine the client’s motivation and identify potential barriers and limitations to change. See “A Simple Decision Balance Tool” on page 47 for details on this process.
Another important consideration during the contemplation stage is the ability to problem solve, which is essential when someone is going to make any life-changing decision. Problem solving can be accomplished by asking questions such as, “What could you do when buying groceries that would help you start to make a dietary change?” or “Who will support you at work if and when you decide to change your eating habits?”
These questions can help identify specific thoughts and behaviors that trigger inappropriate eating habits. For example, many clients are apt to overeat on holidays or social occasions, such as Super Bowl Sunday, because it is the norm. But if they realize this tendency, they can strategize ahead of time to take actions that will at least limit the number of excess calories they consume at such times.
Again, don’t attempt to help your clients formulate answers
to the questions you pose at this stage. Although refraining can be difficult, if you furnish the ideas, clients will not “own” their solutions and will instead relegate that responsibility to you! And if their weight loss attempts ultimately fail, they will hold you responsible.
ASSESSING MOTIVATION & CONFIDENCE
Once you have some idea of your clients’ motivating statements, you need to assess each client’s actual level of motivation and confidence.
Ask clients to rate their current levels of motivation to change their eating habits on a scale of 0 to 10, with 0 indicating “no motivation” and 10 indicating “very motivated” (Miller & Rollnick 1991). If a client chooses the number 6, for example, ask what would need to change to move up a notch or two. This will force the client to identify steps he or she can take to effect a change. These steps may involve learning new skills (e.g., healthy cooking methods) or may necessitate some problem solving (e.g., finding healthier fast-food alternatives).
Keep lists of clients’ answers and ideas but continue to resist giving solutions. These ideas will become the short-term goals that will start the journey of behavior change.
Next, use a similar scale to rate clients’ current levels of confidence about making a change. Examples of questions to ask are “How confident are you that you will be able to change your eating habits?” and “Do you think you are able to learn new cooking skills?” If a client comes up with a level 4, ask why not a 3? This question can uncover the factors that the client feels most confident about. Conversely, you can ask what would take the client’s confidence up to the next level. Again, you should write down the answers for later use.
Confidence level is directly related to another psychological
theory called self-efficacy (Bandura 1986). Self-efficacy refers to the confidence one has in his or her ability to perform specific behaviors in specific situations. For example, a client may be able to control portion size when cooking at home but may find this difficult at social events; in this case, self-efficacy is specific to the situation.
Self-efficacy can also be behavior specific. For example, a client may believe that he or she can consume less fat each day but may not be as confident about reducing daily alcohol intake.
You can use four specific strategies to increase a client’s
- performance mastery
- vicarious experience
- verbal persuasion
- emotional arousal
Performance mastery is learned through personal experience. Try asking your clients to plan three meals for a particular day; this will require that they buy and prepare the food, then sit down and enjoy eating it. This exercise lets clients practice the new activity independently and gives you the chance to provide support and positive feedback.
Vicarious experience involves learning from another person’s behavior. An effective tool is to use “before and after” personal testaments and pictures of past or current clients who have successfully changed their dietary habits. You might even introduce clients to some of these individuals who have made lasting lifestyle changes and maintained significant weight loss.
Verbal persuasion relies on feedback to enhance self-efficacy. For example, when you give clients feedback in the form of praise and encouragement, their behavior will begin to improve, which in turn will increase their self-efficacy. (It’s even more
effective if you give the positive feedback as soon as a client
accomplishes a behavior so that he or she also achieves performance mastery.)
Emotional arousal occurs when clients are informed of the benefits of healthy behaviors, such as maintaining a healthy diet or weight. This fosters a belief in positive outcome expectation, a key component of any behavioral change. For example, ask clients to imagine what life will be like after they have achieved their desired weight. Prompt them to “experience” the results by visualizing something they will do once they have attained their goal. Visualization can be a very powerful motivating tool when clients get temporarily off track or feel discouraged.
The Preparation Stage
Preparation is the stage when clients are on the verge of changing and have begun to investigate the options available to them. At this point, they are making the transition from the cognitive process to the behavioral change process.
This is when fitness professionals can really help clients by providing a variety of different solutions. However, when offering these solutions, avoid making statements such as “I always recommend this approach to my clients.” Again, you will lose credibility with clients if that particular approach doesn’t work for them!
As your starting point, use the motivating statements obtained during the decision balance exercise. For example, you might say, “You said one reason you wanted to lose weight was to have more wardrobe choices. What can you do this week in terms of your eating patterns that will move you closer to this goal?”
At this point, you are essentially identifying your clients’ process, or short-term, goals. Process goals are day-to-day behaviors that will move clients toward their goals. These small achievements really do improve ability and confidence. Try to avoid any short-term goals that are too ambitious, as these can backfire and reduce self-efficacy.
Keep in mind that clients like to be involved in the decision process and will take more responsibility for any decisions if they are. Even if a client chooses an option you feel is not very productive, go with it at this point. You will have opportunities to move the client in a more productive direction later.
The Action Stage
The action stage starts when clients are ready to follow through with their process goals. For example, some clients may have taken steps toward eating better at breakfast and lunch, but they still indulge in unhealthy snacks late in the afternoon when blood sugar levels are at their lowest. In other words, the new behavior is occurring on a limited and irregular basis, with little or no structure.
This is when a food diary or log can help. By recording their eating behavior, clients become more self-aware. This, in turn,
increases the likelihood that they will adapt and commit to more regular healthy eating. It also gives you an opportunity to discuss successful changes, however small. This step merges a behavioral approach (the food diary) with a cognitive approach (the client’s thoughts about success).
While it may seem a bit like raining on their parade, now is also a useful time to broach the subject of behavior relapse (Marlatt & Gordon 1985). Explain to clients that they should expect to deviate from their process goals from time to time and that lapsing occasionally is typical.
For example, a common scenario clients face is the abstinence violation effect (AVE). This usually happens after a week of healthy eating and portion control. A client looks in the refrigerator and sees a small slice of pie. A modified version of the decision balance takes place when the client decides to eat the pie and justifies it by pointing to a solid week of abstinence. Once the client has eaten the pie, though, guilt sets in and the negative self-talk begins. (“I am a bad person because I caved in to that slice of pie, so I might as well totally abandon my weight loss goals by consuming the entire contents of my refrigerator.”)
You can assist here by suggesting that your clients develop a
relapse prevention strategy as a preemptive measure. Ask what they would do if faced with the pie scenario. This way, they will be prepared with specific coping skills for common situations when lapses are most likely to occur.
The Maintenance Stage
Many behavioral experts believe that the maintenance stage typically occurs after clients have engaged in their new behavior for at least 6 months. At this point, clients may be following and maintaining a healthy diet while still adhering to a regular exercise program. However, they are still vulnerable to a relapse and have to work hard to maintain their new behavior.
Your role now is to make clients aware of ways they can incorporate additional positive changes into their diet so they can continue to progress. Find ways to introduce them to new types of healthy food and their sources. Pass along low-fat recipes and cooking techniques. Encourage clients to experiment with meal planning at home. Show them that it is possible to make healthy choices in restaurants; have them bring in menus from their
favorite restaurants and plan meals in
advance. After they have eaten at the restaurants and stuck to their planned menu selections, offer positive words of encouragement and success.
Also, remind clients in the maintenance stage about all they have accomplished to date. This builds confidence for future success. You can use the confidence scale discussed earlier to rate clients’ perceptions regarding their ability to sustain the new behavior.
The Termination Stage
The final stage marks the termination of the old behavior. At this point, the new behavior has become second nature and some clients may even find it difficult to recall their previous behavior. However, keep in mind that only a small percentage of people ever get to the point where relapse is not a possibility, which is why weight maintenance can be an ongoing battle for most clients.
You may want to ask clients who have been successful to share strategies with other clients at different stages. This can be done either in writing (e.g., a postcard or e-mail message) or face to face. But do take care not to breach any confidentiality agreements that you have with clients.
At this stage and beyond, your role is to help clients modify old goals and establish new ones, while continually offering support. Helping clients achieve this level
of change can be very rewarding for all
involved. Take a moment to congratulate yourself for the role you played in your clients’ success! And don’t forget to remind clients of where they started and how far they have come.
Use this simple tool to help a client identify what motivates him or her to lose weight and also what gets in the way. The goal here is to highlight in a structured way the advantages and disadvantages of behavior change with regard to dietary practices.
Ask the client to create two columns on a piece of paper. In the first column, the client should list the advantages of changing the current dietary behavior; the second column is for any perceived disadvantages of changing. Chances are, many of your clients will be a little surprised at their own answers in each column. Do not add anything to the lists yourself or influence the answers in any way.
“I will start to lose weight.”
“I won’t be able to enjoy the foods I like.”
“I can shop for a new wardrobe.”
“I can’t afford to buy new clothes yet.”
Once the client has completed this process, compare both columns. The first column (Advantages) will offer a compelling look at what really motivates the client; the responses in this column are called the motivating statements. Devote some time here; dwell on the importance of these words or statements and, if needed, ask the client to elaborate. This will underscore the concept of change and the benefits it will bring.
The second column (Disadvantages) will show you the barriers the client faces in effecting any behavior change. You will need to consider and deal with these barriers to change when discussing healthier eating behaviors.
It is not unusual for one column to be much longer than the other. Weight loss success is not guaranteed just because a client lists 10 advantages and one disadvantage. All it takes is one disadvantage to thwart the behavior change!
Precontemplation Stage. Find opportunities to casually raise the issue of healthy eating and weight loss. Discuss the topic but avoid getting into specific strategies.
Contemplation Stage. Create a decision balance sheet to identify the client’s motivating statements and potential barriers to change. Assess the client’s level of motivation and confidence. Start to build self-efficacy and teach the client how to problem solve.
Preparation Stage. Help the client plan which changes to undertake. Set process (short-term) goals based on motivating statements made on the decision balance sheet.
Action Stage. Provide positive reinforcement for any successes, however small. Get the client to identify future improvements. Suggest starting a food log or diary.
Maintenance Stage. Continue to reinforce success and positive behavior. Explain the dangers of relapse and identify strategies for common situations that are likely to occur.
Termination Stage. Assist the client in modifying old goals and creating new ones, as needed. Remember that few clients will ever get to the point where relapse is not a possibility!
At the IDEA World Fitness Convention® in San Diego this July, Paul Bedford, MS, will present two sessions on client psychology, “Tools to Increase Exercise Adherence” and “The Psychology of a New Member.” Call (800) 999-4332, ext. 7, or (858) 535-8979, ext. 7, for details.
Janis, I.L., & Mann, L. 1977. Decision-Making: A Psychological Analysis of Conflict, Choice and Commitment. New York: Free Press.
Marlatt, G.A., & Gordon, J.R. (Eds.) 1985. Relapse Prevention. New York: The Guildford Press.
Miller, W.R., & Rollnick, S. 1991. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: The Guildford Press.
Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. 1992. In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-11.
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