CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
HEALTHFUL LIVING:
LEARNING TO CONTROL UNHEALTHY HABITS
A BEHAVIOR CHANGE PROGRAM FOR THE WORKSITE
A graduate project submitted in partial satisfaction of
the requirements for the degree of Master of Arts in
Education, Educational Psychology,
Counseling and Guidance
by
Joan Habschmidt
May 1985
The project of Joan Ann Habschmidt is approved:
Shelia C. Harbet, H.S.D.
California State University, Northridge
ii
ACKNOWLEDGEMENTS
I am deeply grateful to Dr. Tony Johnson whose
genuine interest and invaluable assistance encouraged and
guided my efforts throughout the creation of this project.
I extend a special acknowledgement to Dr. Shelia
Harbet for her loyal friendship and expertise.
Appreciation is also expressed to Dr. Robert
Docter for his help and support, and to Dr. Luis
Rubalcava for his participation on the committee.
iii
TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS .
iii
vi
ABSTRACT
Chapter
1.
INTRODUCTION .
1
Statement of the Purpose .
6
Statement of the Problem .
6
Justification
8
Limitations
9
Definition of Terms
2.
3.
4.
REVIEW OF THE LITERATURE .
10
12
Health Behavior
12
Behavioral Research and
Treatment Methods
25
Corporate Health Promotion .
38
DESIGN AND IMPLEMENTATION OF
HEALTHFUL LIVING: LEARNING TO
CONTROL UNHEALTHY HABITS .
59
Implementation Overview
59
Implementation at the Worksite . .
67
HEALTHFUL LIVING: LEARNING TO
CONTROL UNHEALTHY HABITS .
73
Program Outline
73
Program Manual Introduction
75
iv
TABLE OF CONTENTS (continued)
Page
Chapter
Program Manual - Healthful Living:
Learning to Control Unhealthy
4.
Habits . . . . . .
5.
. .
SUMMARY, CONCLUSIONS, AND
RECOMMENDATIONS . . .
. . . .
.
76
118
Summary
118
Conclusions
121
Recommendations
122
BIBLIOGRAPHY
123
APPENDICES
A.
B.
SUPPLEMENTAL MATERIALS FOR
GROUP ACTIVITIES .
129
PROGRAM BIBLIOGRAPHY . .
159
v
ABSTRACT
HEALTHFUL LIVING:
LEARNING TO CONTROL UNHEALTHY HABITS
A BEHAVIOR CHANGE PROGRAM FOR THE WORKSITE
by
Joan Habschmidt
Master of Arts in Education, Educational Psychology,
Counseling and Guidance
The major health threats facing the American
public today are largely the result of unhealthy habits.
Six of the ten factors associated with America's number
one killer, cardiovascular disease, are clearly the
result of lifestyle.
In addition, health care costs have
skyrocketed in recent years, and American corporations
have
~sorbed
a large share of the financial burden.
It was the purpose of this project to design a
program to teach people how to control unhealthy habits
and how to maintain successful change.
vi
The program was
designed as a generic model for addressing various
unhealthy behaviors, and was intended for group application to occupational and clinical settings.
The program design was based on the assumption
that in order to achieve lasting lifestyle change, it is
necessary to experience the process of change as positive
and rewarding.
Towards this end, cognitive-behavioral
methods shown to influence successful maintenance were
utilized to (a) help participants identify and alter
patterns that impede change, and (b) assist participants in
developing the coping skills necessary for the maintenance
of new behaviors.
The program manual included a detailed content
outline, suggested group activities, and supplemental
materials.
Implementation guidelines were given for
both clinical and occupational settings.
It was concluded that a need exists for treatment
programs that contain maintenance components, and for
approaches that address the psychological concomitants
of unhealthy behaviors.
Finally, it was recommended that
the program be implemented in both clinical and occupational settings.
vii
Chapter 1
INTRODUCTION
Disease patterns in America h·ave changed
drastically in recent years.
At the turn of the century,
medical researchers were fighting a battle against
infectious diseases such as tuberculosis, influenza, and
pneumonia.
Fortunately, they discovered that with the
proper vaccines, these diseases could be controlled and
eliminated.
With these successes, the medical profession
began to focus its attention on the treatment of symptoms
and illness.
This treatment focus, however, has become
inadequate in the face of today's deadly diseases.
Today's killers are not caused by a single virus
or bacteria, nor can they be eliminated with a single
vaccine.
Instead, they have several risk-factors asso-
ciated with their origin.
These factors develop slowly
over time and are often the result of modern American
life-style itself.
The Center for Disease Control of
the U.S. Department of Health and Human Services (cited
in Brennan, 1982) implicated adverse lifestyle in 54% of
all deaths under the age of 65.
For example, six out of the ten factors associated with the development of America's number one
killer, cardiovascular disease, are clearly the result
1
2
of behavior patterns:
(a) cigarette smoking, (b) high
blood pressure, (c) sedentary living habits,
(d) obesity,
(e) psychological stress, and (f) abnormal levels of
cholestrol and triglycerides in the bloodstream
&Allen,
(Miller
1982).
Cigarette smoking alone has been estimated to be
responsible for 20% of all cancer, 25% of all cardiovascular disease, and 40% of all respiratory
(Boden cited in Danaher, 1982).
disea~es
The. difference in life
expectancy between smokers and non-smokers has been
estimated at 7.3 years
cited in Brennan, 1982).
(State Mutual Life Assurance Co.
So devastating are its effects
on health, that in 1979 the Surgeon General (cited in
Kristein, 1982) declared, ''Cigarette smoking is the
single most preventable environmental factor contributing
to illness, disability, and death in the United States."
Also preventable are the major factors associated
with the development of high blood pressure:
high salt intake, and psychological stress.
obesity,
Occurring in
15% to 30% of the population (Kristein, 1982), hypertension is associated with higher rates of death and
illness.
The Hypertension Detection and Follow-up
Program Cooperative Study (cited in Fielding, 1984)
revealed that, on the average, individuals with hypertension developed three times as much coronary heart
disease, six times as much congestive heart failure,
3
and seven times as many strokes as individuals with
normal blood pressure.
Finally, as much a part of our lives as alarm
clocks and deadlines, are the daily pressures caused by
unremitting psychological stress.
The list of stress-
related diseases has increased in the past 10 years to
include not only the classic psychosomatic disorders,
such as hypertension, ulcers, and asthma, but also
infectious and genetic disorders ranging from the common
cold to cancer
(Schwartz, 1982).
The threats to health are not the only ramifications of unhealthy behavior patterns.
In addition, the
cost of health care has skyrocketed in this country.
In 1960, national medical care expenditures were nearly
$27 billion, or 5.3% of the Gross National Product (GNP).
In 1970, this figure rose to $75 billion, or 7.6% of the
GNP, and in 1982 it climbed to a record $321 billion
representing 10.5% of the GNP
(Brennan cited in Levine,
1983).
The brunt of this financial burden is absorbed by
American corporations in productivity losses due to
disability and in payments of health insurance costs.
Brennan (1982) estimated that businesses pay over half
of the national health care bill.
An estimate by the
President's Council on Physical Fitness (cited in
Fielding, 1984) placed the cost of premature death alone
4
at more than 25 billion dollars and 132 million workdays
of lost production each year.
So crushing is the burden
of health expenditures that General Motors spends more on
employee health insurance than on steel, and Chrysler
estimated that for every car it _sold in 1980, $220 was
spent on employee health benefits
(Brennan, 1982).
To ameliorate this situation, growing numbers of
U.S. corporations have initiated health promotion programs aimed at educating employees on health matters and
influencing them to achieve optimum levels of physical
and mental health.
wins situation.
Such efforts can create an everyone
Employers benefit from reduced health
care costs and reduced losses in human resources;
employees benefit from the healthier and more satisfying
lives that ensue
(Brennan cited in Colby-Plunkett, 1984).
In addition, the worksite offers unique potential
as an environment for providing health promotion.
The
number of employed adults in the United States represents
70% of the population
Rocella, 1982).
(U.S. Bureau of Census cited in
The daily gathering of such a large
proportion of the population has built-in advantages:
convenience, accessibility, social support networks,
existing organizational structures, and follow-up
capability.
Studies have indicated that people tend to
be more willing to participate in health programs at work
5
than in other settings
(U.S. Dept. of Health and Human
Services cited in Novelli
& Ziska,
1982).
The task before industry is a big one, however.
To intervene before rather than after disease has struck
necessitates that the target of intervention become
individual behavior.
Unhealthy behaviors are difficult
to alter, however, because they often lack unpleasant
symptoms and, thus, go unnoticed.
In addition, while
risky or dangerous, they also offer benefits
Hall,
& Lipton,
1979).
(Henderson,
For example, cigarette smokers
may calm their nerves by smoking, and overeaters may
fulfill emotional needs through excessive eating.
Adding
to the difficulty, cultural norms, themselves, often
support health damaging behaviors.
Baric (1969), writing about European society,
contended that cultural norms exert tremendous influence
in actually promoting sick-role behavior and discouraging
the preventive behavior that would eminate from an atrisk role.
Identical conditions exist in the United
States.
The sick-role is (a) institutionalized and
familiar,
(b) time limited, (c) based on the reality of
symptoms, and (d) offers overt rights and status such as
sympathy from family and freedom from responsibility.
On the other hand, the at-risk role is neither institutionalized nor familiar; it is not time limited (the
6
person at-risk must undertake action now for a possible
future pay-off); it is based on the abstract quality of
thought; and it offers no rights, but instead, often
imposes responsibility.
To meet the challenge of helping people change
unhealthy behaviors, the American Psychological Association (APA) has established a new division of Health
Psychology.
Matarazzo (1980), one of its foremost
spokesmen, stated the task before the profession:
As the field which has the longest history
of involvement in the study of human behavior,
psychology has the scientific knowledge base,
the practical applied experience, and the
educational institutional supports to begin
immediately to make important contributions in
health psychology, as these relate to the
broad, interdisciplinary field called behavioral
health (p. 814).
Statement of the Purpose
It was the purpose of this project to design a
program to teach people how to control unhealthy
behaviors and how to maintain successful change.
The
program was designed for group application to clinical
and worksite settings.
Statement of the Problem
While many behavioral programs for treating
unhealthy habits have proven initially successful, they
often fail to help people maintain new behaviors over
7
time and across situations
(Marlatt
& Gordon,
Fielding, 1984; Haynes, 1976; Danaher, 1982).
1980;
Research
has demonstrated the magnitude of the problem.
Patient compliance with prescribed medical
regimens has been found to average about 50% (Ley cited
in Gordon, 1982); most smoking cessatlon programs are
able to achieve a 30% abstinence level (Danaher, 1982);
the majority of dieters who show weight losses at the
end of behavioral treatment programs tend to regain it
six months to a year later (Henderson, et al., 1979);
and, finally, the recidivism rate for exercise participation has been placed at 50%
(Dishman cited in Pate
Blair, 1983).
Thus, it has been recently speculated that the
factors associated with initial behavioral change are
quite different from those that maintain the behaviors
(Marlatt
Kingsley
& Gordon, 1980; DiClemente & Prochaska, 1982;
&Wilson cited in Charis, 1984; Haskell &
Blair, 1982).
This project was developed to help reduce the
problem of recidivism.
Its design was based on the
assumption that to achieve the maintenance of improved
health behaviors, it is necessary to experience the
process of change as positive and rewarding.
Towards this end, the program objectives are:
(a) to help participants explore, on the cognitive,
&
8
behavioral, and affective levels, how they block their
own efforts to change; (b) to help participants identify
conflicting motivations that support unhealthy behaviors;
and (c) to help participants acquire the self-support
skills necessary to maintain new behaviors.
Justification
A group therapy approach to fostering healthy
behavior takes advantage of the inherently therapeutic
features of the group process.
Group membership,
acceptance, and approval are of the utmost importance in
an individual's development
(Yalom, 1979).
In a group
participants have the opportunity to experience mutual
support, share a commonality of struggles, and strive
for similar goals.
Thus, groups can have tremendous
power in shaping beliefs, attitudes, and behaviors.
When a behavioral change program is conducted at
the worksite the opportunity exists to enhance group
effectiveness through the reinforcing aspects of social
support networks and health-oriented corporate cultures.
In addition, corporations benefit through reduced health
care costs,
r~duced
absenteeism, and increased worker
productivity.
However, the task of helping people change
unhealthy behaviors is a difficult one, as evidenced by
the high rates of recidivism.
Often, the obstacles that
9
prevent change are out of the individual's awareness
(Yalom, 1979; Wheelis, 1973).
Thus, a first and neces-
sary step toward change is to help people become aware
of the obstacles they place in the way of their goals.
A behavioral change program aimed at uncovering the
cognitive, behavioral, and motivational blocks to change
would be highly warranted.
Yet, insight alone does not achieve or maintain
change
(Wheelis, 1973).
Instead, research has demon-
strated that self-efficacy (Bandura, 1977), internal
locus of control (Rotter cited in Balch
& Ross,
1975),
and effective coping skills (Bandura, 1977) are crucial.
Thus, a behavioral change program that includes concepts
and techniques shown to influence maintenance would
further help people accomplish lasting health behavior
change.
Limitations
This project contains the following limitations:
(a) it was not implemented, therefore, its effectiveness
is untested; (b) it was evaluated informally by only one
content review specialist; (c) it was not designed to
assist people with alcohol or drug addictions, eating
disorders, or any other diagnosable mental disorder; and
(d) the facilitator must be a licensed psychotherapist.
10
Definition of Terms
Health Promotion:
Any combination of health
education, and related organizational, political, and
economic intervention designed to facilitate behavioral
and environmental changes conducive to health
cited in O'Donnell
& Ainsworth,
Health Behavior:
(Green
1984).
Activity undertaken by
individuals who believe themselves to be healthy for
the purpose of preventing disease or detecting disease
in an asymptomatic state
(Rosenstock
Health Psychology:
& Kirscht,
1979).
Aggregate of the specific
educational, scientific, and professional contributions
of the discipline of psychology to the promotion and
maintenance of health, the prevention and treatment of
illness, and the identification of etiologic and
diagnostic correlates of health, illness, and related
dysfunction, and to the analysis and improvement of the
health care system and health policy
At-Risk Person:
(Matarazzo, 1982).
Those who are engaged in
certain activities which increase their risk of disease
to a much higher degree than the rest of the population
(Baric, 1969).
Unhealthy Behaviors/At-Risk Behaviors:
Behaviors
that have characteristics that increase the individual's
11
risk for developing serious health. problems
(Fielding,
1984).
Habit:
A pattern of behavior that is charac-
terized by automaticity, diminished awareness, and
potential independence of reinforcement
Matarazzo,
&Weiss
(Hunt,
cited in Clark, 1983).
Process of Change:
Basic coping activities that
the individual engages in to modify a particular problem
(Prochaska
& DiClemente,
Maintenance:
1984).
Is not an absence of change, but a
continuance of change.
It is the stage in which people
work to continue the gains attained during action and to
prevent relapse to their more troubled level of functioning
(Prochaska
& DiClemente,
Behavioral Health:
1984).
An interdisciplinary field
dedicated to promoting a philosophy of health that
stresses individual responsibility in the application of
behavioral and biomedical science knowledge and techniques to the maintenance of health and the prevention
of illness and dysfunction by a variety of self-initiated
individual or shared activities
(Matarazzo, 1980).
Chapter 2
REVIEW OF THE LITERATURE
This literature review contains three sections:
(a) a review of health behaviors which summarizes the
dynamics of illness, preventive, and compliance behaviors;
(b) a discussion of recent trends in behavioral research
and treatment methods which were relevant to the design
of this project; and (c) a review of corporate health
promotion efforts including a discussion of the major
components of these programs:
weight control, stress
management, physical exercise, hypertension control, and
smoking cessation.
Health Behaviors
Illness Behaviors
Illness can be defined as any activity undertaken
by a person who feels ill, to define the state of his
health and to discover a suitable remedy
cited in Becker, 1979).
(Kasl
& Cobb
In a broader sense, illness
behavior involves the manner in which people monitor
their bodies, define and interpret symptoms, take
remedial actions, and utilize the health-care system
(Mechanic, 1982).
In addition, illness behavior has a
number of stages:
(a) initial recognition and
12
13
interpretation of symptoms, (b) assumption of sick-role,
(c) seeking assistance, (d) being a patient, and
(e) recovery
(Suchman cited in Gatchel
& Baum,
1983).
At any one of these stages, a wide array of behaviors
is possible.
Comprehensive Approach
Mechanic (1982) developed a comprehensive
approach to the explanation of illness behavior.
According to this, symptoms are distinguished by their
visibility, frequency, and amenability to varying interpretations.
Thus, symptoms that are dramatic, occur
frequently, and can only be interpreted as resulting from
illness (such as a high fever) are more likely to be
identified and responded to than vague, infrequent
symptoms that could be attributed to psychological,
social, or other reasons (such as fatigue or poor
appetite).
Mechanic suggested that a person's response to
symptoms is effected by (a) perceived seriousness of
symptoms, (b) extent to which adoption of the sick-role
would disrupt the person's life, (c) the individual's
threshold for tolerating pain and discomfort, (d) knowledge and beliefs about illness which effect what symptoms
are identified as important and serious, and (d) perceptions of treatment accessibility.
14
Psychological Distress
Implicit in Mechanic's (1982) model is the view
that psychological distress is an ever present and
significant factor in an individual's perception of
physical health.
According to Counte and Christman
(1981), psychological distress is related to increased
concern with health, increased perception of susceptibility to disease, and increased assessment of symptom
seriousness.
In contrast, Pennebaker and Brittingham (cited
in Gatchel
& Baum,
1983) suggested that people become
more aware of bodily sensations when they are bored and
less aware when they are occupied.
Whatever the exact
effect of psychological states, suffice it to say that
emotions come to bear on one's perception and response
to symptoms.
Secondary Gains
Another approach to the explanation of illness
behavior examined the secondary gains afforded by the
sick-role.
According to Mechanic (1982), illness
behavior is part of a socially defined status and may
serve as an effective means of achieving release from
social expectations, as an excuse for failure, or as a
way of obtaining privileges.
As a result, the decision
to seek medical care is often a result of the
15
contingencies surrounding the perception of symptoms
rather than the physical sensations themselves.
Cultural Norms
There are dramatic social and cultural differences in the way individuals and groups define illness and respond to symptoms
(Mechanic, 1982).
A
classic study conducted by Zborowski (cited in Mechanic,
1982), examining ethnic variations in response to pain,
revealed that Jewish and Italian patients tended to
exaggerate pain experiences, while Irish patients frequently denied them.
Friedman and Suchman (cited in Counte
&
Christman, 1981) identified group norms to be so strong,
that they referred to the group's influencing powers as
a "lay referral" structure.
Suchman (cited in Counte
&
Christman, 1981) explained:
Few individuals it would appear are confident
that they need medical care by themselves . . .
they need the support and reassurance of others
in the family before they can recognize and
accept illness, relinquish their social responsibilities, and seek medical care (p. 39).
Demographic Factors
Finally, demographic research has attempted to
explain illness behavior.
These studies revealed that
health care utilization tended to be higher for females,
higher for whites than nonwhites, and was positively
correlated with age, income, and education
(Rosenstock
16
& Kirscht,
1979).
By far, the most consistent finding in
this body of research was chronically low utilization
rates among the poor.
Preventive Behavior
While a variety of theoretical models have been
formulated to account for illness behavior, far less
attention has been given to the study of preventive
behavior and consequently fewer explanatory models have
been proposed
(Rosenstock
& Kirscht,
1979).
The Health
Belief Model (HBM) is one of the few developed to
account solely for preventive behavior.
The Health Belief Model
Since its development in the early 1950's, the
HBM has received such wide theoretical and research
attention that many other models have adopted analogies
of it
(Becker, 1979).
In addition, it has been expanded
and applied to virtually every other form of health
behavior.
The HBM was derived from a well-established body
of psychological and behavioral theory, particularly
value-expectancy models which emphasize the influence of
a person's perceptions on behaviors.
According to these
models, behavior can be predicted from the value an
outcome holds for the individual and from expectations
17
that a given action will indeed produce that outcome
(Becker, 1979).
As first conceived, the HBM hypothesized that
people generally do not seek preventive health care
unless they (a) have some level of health motivation and
knowledge, (b) perceive themselves as vulnerable,
(c) view the condition as threatening, (d) are convinced
of the benefits of intervention, and (e) see few difficulties in undertaking the recommen4ed action
(Rosenstock cited in Becker, 1979).
Specifically, the HBM contains three elements:
(a) a "readiness to action" which comes about when
individuals evaluate their health based on perceptions
of vulnerability to and severity of a particular illness;
(b) an estimation of whether an advocated health
behavior will reduce susceptibility and/or severity,
weighted against many psychological, financial, and
other barriers to treatment; and (c) a "cue to action"
either from internal symptoms or external recommendations,
which must occur if the advocated health behavior is to
be triggered
(Becker, 1979).
For example, a 45-year-old obese, hypertensive,
male business executive would be considered "ready for
action" if he perceived himself in danger of developing
coronary heart disease and understood the seriousness of
this.
If he sought medical advice, he would follow it
18
depending on the effort entailed and on whether he
believed such advice would actually work.
Finally,
these actions would be set in motion only after he
personally experienced symptoms, or received some outside
stimulus (such as hearing that a close friend had a
heart attack or attending a lecture on heart disease).
Early research.
One of the early research
studies that applied the HBM was conducted by Hochbaum
(cited in Becker, 1979) who studied more than 1200 adults
in three cities, measuring their beliefs in both
susceptibility to tuberculosis and benefits of early
detection.
elements:
Perceived susceptibility contained two
(a) beliefs about whether tuberculosis was a
real possibility, and (b) strength of belief that one
may have tuberculosis without having symptoms.
Among
those exhibiting both beliefs, 82% had obtained at
least one voluntary chest x-ray during a specified period
preceding the study interview, as opposed to only 21%
of those exhibiting neither belief.
Belief in suscep-
tibility appeared to be a more powerful variable than
belief in treatment benefits.
Current research on risk-factor behaviors.
In a
1979 study of preventive behavior, Rundall and Wheeler
(cited in Janz
& Becker,
1984) conducted a survey of
781 adults measuring the dimensions of susceptibility
19
and severity to four diseases (heart disease, stroke,
high blood pressure, and lung cancer), in addition to
measuring the efficacy of and barriers to preventive
treatment.
Of these, susceptibility and barriers were
significantly correlated with obtaining preventive
medical check-ups.
Weinberger (cited in Janz
& Becker,
1984) found
ex-smokers more likely to view smoking as a serious
health problem and to feel personally susceptible to its
potential adverse effects.
On the other hand, moderate
smokers perceived smoking as a serious threat, but did
not view themselves as susceptible to smoking-related
health problems.
Heinzelman and Bagley (cited in Pate
& Blair,
1983) reported that those who voluntarily participated
in an exercise program were more likely than nonvolunteers
to acknowledge personal vulnerability to disease
(particularly heart disease), to perceive the health
benefits of exercise, and to express feelings of control
over health status.
Substantiating this finding, Shepard, Morgan,
Finncane, and Schimmelfing (cited in Pate
& Blair,
1983)
found that exercise participants believed more strongly
than nonparticipants that exercise prevents heart attacks.
20
Summary of current research.
Janz and Becker
(1984) summarized the results of 46 studies of the HBM
conducted since 1974, and put the model's utility into
the following perspective:
Overall, these investigations provide very
substantial empirical evidence supporting-HEM
dimensions as important contributors to the
explanation and prediction of individuals'
health-related behaviors. Prior to 1974, it
appeared that 'perceived susceptibility' was
the most powerful dimension of the HBM; however,
few of these studies had attempted to measure
'perceived barriers.' In the post:-1974
research, 'barriers' consistently yielded the
highest significance ratios, regardless of study
design for both preventive health behavior (PHB)
and sick-role behavior (SRB), and this overall
finding persists when all HBM studies are
summarized. In general, 'susceptibility'
appears somewhat more important in PHB than in
SRB, and the reverse is observed for 'benefits. '
However, the most notable difference among the
HBM dimensions is the relatively lower power
of 'perceived severity' with the major exception
of its importance to understanding SRB. In the
1974-1984 research, the significance ratio for
'severity' in PHB was only 36%; in SRB studies,
the figure is 85% (p. 44).
Demographic Factors
Preventive health behavior has also been studied
from a demographic point of view.
This research demon-
strated that preventive care was used mostly by younger
and middle-aged adults, females, and those with better
education and higher incomes
(Rosenstock
& Kirscht,
1979).
As in illness behavior, whites generally showed
higher use of preventive services and the poor showed
21
chronically low usage.
Even when immunizations were
free, higher-income families achieved a much better rate
of protection than did poorer families.
Moreover, poor
people were over-represented among hospital populations
(Rosenstock
& Kirscht,
1979), probably reflecting the
failure of the poor to receive treatment at earlier
stages of disease.
Compliance Behavior
Compliance can be defined as the extent to which
a patient's behavior coincides with a clinical prescription
(Sackett cited in Kirscht
& Rosenstock,
1979).
This definition includes a wide array of prescriptions
ranging from simple one-time actions such as an immunization, to repeated short-term behavior such as taking
medication, to long-term modification of habits.
In
addition, the behavioral demands of these regimens vary
in complexity as well.
Research has revealed that compliance, or, rather,
the lack of it, is a serious problem.
A survey by
Marston (cited in Stone, 1979) covering 66 carefully
designed studies found a 43% median of patients who
failed to comply with treatment instructions.
In a
review of 68 studies, Ley (cited in Gordon, 1982)
revealed that only a little over half of those studied
followed their physicians' advice.
The majority ignored
22
recommendations even when presented as crucial to their
health.
Adding to the seriousness of the problem, was
the finding that physicians tended to overestimate the
degree to which their patients were adhering (Charney
cited in Stone, 1979), and they were unable to judge who
complied and who did not
(Kasl cited in Stone, 1979).
Haynes (1976) conducted a survey of 185 original
research studies to determine why people vary in their
cooperation with treatment regimens.
In doing so, he
identified 200 determinants of compliance.
The following
discussion summarizes these determinants as categorized
by Haynes (1976).
Interaction Between Patient
and Physician
Overall, patient-doctor interaction was found to
effect compliance rates.
Stone (1979) cited two aspects
in particular that were important:
(a) the effectiveness
with which necessary information was given to patients,
and,
(b) the emotional impact of the interaction.
Kasl (cited in Counte
& Christman,
1981) identified the
crucial element in the interaction to be the expectations
that the doctor and patient held for each other, the
mutuality of such expectations, and the potential for
exploring and revising them.
For example, according to
Kersch, Gozzi, and Francis (cited in Stone, 1979)
mothers who believed that the staff in a pediatric clinic
23
viewed them as "good mothers" adhered more- in giving
their children prophylactic antibodies than mothers who
did not have such beliefs.
In addition, Haynes' survey (1976) revealed a
positive correlation between degree of treatment supervision and compliance, and between patients' stated
levels of satisfaction with physicians and compliance.
Demographic Factors
Unlike the case of illness and preventive
behaviors, non-compliance was found to cut across racial,
sexual, and economic lines
(Stone, 1979; Haynes, 1976).
Some studies have indicated, however, that compliance
increases with education and socioeconomic status
(Stone, 1979; Kirscht
at the age extremes
& Rosenstock,
1979); and decreases
(Kasl cited in Counte
& Christman,
1981).
Nature of the Illness
Haynes (1976) discovered that the nature of the
illness had no influencing effects, while Stone (1979)
claimed that serious illness with painful or distressing
symptoms elicited the highest rates of adherence, and
chronic illness, the lowest.
24
Characteristics of the
Treatment Regimen
Regimen characteristics were found to influence
compliance significantly
(Stone, 1979).
Generally, the
simpler the regimen and the shorter the treatment period,
the more the regimen was followed.
For example, non-
compliance increased when increasing doses of a medication
were prescribed
& Rosenstock,
(Stone, 1979; Blackwell cited in Kirscht
1979); when medication was prescribed for
a long period of time, it was more likely to be discontinued early
(Haynes, 1979).
Degree of Behavioral
Change
Another significant feature of the regimen that
was reported without dissention in Haynes' survey (1976),
concerned degree of behavioral change.
Typically, high
non-compliance rates were associated with programs that
sought behavioral change (McAlister cited in Kirscht
Rosenstock, 1979).
&
Haynes (1976) explained his findings:
Passive cooperation, as for therapies
administered by professional staff in clinics
or in hospitals, is most easily attained.
Active cooperation is less easily achieved
and a steep gradient has been demonstrated in
which compliance exhibited by patients who
must acquire new habits, such as taking medications, is much greater than that exhibited
by those who must alter old behaviors, such as
dietary or vocational habits, which exceeds,
in turn, that of those who must break personal
habits, such as smoking or drinking or nonmedical use of drugs (p. 31).
25
Situational Factors
Finally, situational factors were found to
influence-adherence.
In particular, Haynes (1976)
reported that family influence was considerable.
Several
studies showed that compliance was higher among patients
with supportive intact families and lower among those
from unstable families
(Stone, 1979).
Recent interest in the effects of social support
on compliance has grown
(Kirscht
& Rosenstock,
1979).
In a study of 200 individuals with hypertension, Caplan
(cited in Kirscht
& Rosenstock,
1979) found that adherence
was related to the help and approval of others.
Behavioral Research and
Treatment Methods
The following section of the literature review
summarizes information on recent trends in behavioral
treatment approaches which were relevant to the development
of this project.
These trends have included an emphasis on client
responsibility, as evidenced in the increased application
of self-managem.ent techniques and growing interest in the
concepts of self-efficacy, locus of control, and selfattribution.
In addition, recognition of the problem of
h{gh recidivism has stimulated interest in discovering
techniques for improving behavioral maintenance.
'
I
26
Self-Management Techniques
Self-management techniques supplement traditional
behavior change methods by permitting the extension of
behavior modification methods to persons who are able to
implement their own behavior change program outside a
controlled environment
(Kanfer, 1975).
The emphasis in
this approach is on individual responsibility and commitment.
Self-management techniques are particularly
applicable when behavior is influenced by conflicting
negative and positive stimuli.
Thus, according to
Kanfer (1975), "In self-management problems, the client
who seeks help is usually enjoying some aspect of the
problem of which he complains"
(p. 315).
The self-
management method attempts to help such clients establish
self-control by teaching them to rearrange the contingencies that influence the undesirable behavior.
Self-Regulation Framework
The basic premise of self-management was derived
from an understanding of the process of self-regulation
(the process in which a person directs his own behavior).
According to social learning theory, much of everyday
behavior consists of chains of reactions that are cued
to run smoothly.
When the chain is interrupted, behavior
27
will stop and an individual will engage in a selfregulation process.
This process has three distinct, sequential
stages (Kanfer, 1975):
(a) self-monitoring, which is the
careful and deliberate attending to one's own behavior,
(b) self-evaluation, which reveals the discrepancy
between what one is doing and what one ought to be doing,
and (c) self-reinforcement, which is contingent upon the
degree to which behavior diverges from some previously
set performance standard.
Thus, when an overeater enters a self-management
program, she learns to notice the chain of events that
leads up to her overeating, she interrupts this chain
with a new, desired behavior, and she evaluates the
efficacy of this new behavior, which, if positive, leads
to self-reinforcement.
The Role of Self-Attribution
in Self-Management
The effectiveness of self-management appears to
lie in the fact that, by takirig full responsibility for
change, individuals attribute the change they achieve to
their own actions
(Kanfer, 1975).
In other words, the
degree to which people attribute improvement to their
own efforts, as opposed to some external agent, has a
direct influence on the achievement and maintenance of
the new behavior.
28
For example, self-attribution was found to be
significant in a study conducted by Davidson, Tsujimoto,
and Glaros (cited in Wilson, 1980).
In this study,
insomniacs were treated with a combination of a mild
sle_ep-inducing drug and self-produced relaxation.
Following treatment, the drug was discontinued and half
the subjects were informed that they had received an
optimal dosage of the drug; the other half were told
that their dose had been too weak to.have had significant
effect.
Subjects who attributed success in improved
sleeping to their own efforts, showed superior maintenance of improvement, compared to those subjects in the
drug-attribution condition.
Locus of Control
There has been much recent speculation that the
effectiveness of behavioral programs may be due to
general encouragement for clients to assume responsibility
for treatment outcomes, rather than to any specific
components of the treatments themselves
MacDonald, 1977).
(Tobias
&
Thus, locus of control as a predictor
of behavioral change has received much attention.
It is hypothesized that internally oriented
individuals, those who are able to control important
aspects of their lives, tend to be more successful in
achieving behavior change than externally oriented
29
individuals who believe that luck Dr fate are important
determinants of their lives
Ross, 1975).
(Rotter cited in Balch
&
Evidence has supported this notion that an
individual's perception of personal control, independent
of other factors, can lead to behavior change
&Valins
cited in Tobias
& MacDonald,
(Davison
1977).
Balch and Ross (1975) studied 34 overweight
women enrolled in a nine-week behavior treatment program.
and found significant correlations between internal locus
of control and both completion and success in the program.
They concluded,
These findings suggest that locus of control . . . is relevant and should be considered
in the selection of applicants for self-control
weight reduction therapy
(p. 119).
In another weight loss study, Manno and Marston (cited
in Wallston
& Wallston,
1978) found, in their control
group, that externally oriented subjects lost less weight
than their internally oriented counterparts.
Both Bernstein and Sipich (cited in Tobias
&
MacDonald, 1977), in outcome studies of smoking and
reading skills, respectively, included "control" groups
that were instructed to rely on their own efforts and
determination to produce change.
In both studies, these
groups scored better than nontreated groups, and they
were not significantly different from the behavioral
treatment groups against which they were compared.
30
Wallston and Wallston (1978) conducted an extensive review of research into the utility of the locus of
control construct, and concluded:
The locus of control concept is relevant
to the prediction of health behaviors. An
internally oriented [health education] program should provide more choice of treatment,
more involvement of the patient in making
choices, and, in general, strong emphasis on
individual responsibility
(p. 114).
Maintenance
Despite the successes of behavior modification
in initiating changes in behavior, there remain grave
problems in maintaining behavioral change over time and
across situations
(Marlatt
& Gordon,
1980).
"Most traditional treatment programs for addictive behaviors .
. tend to ignore the relapse issue
altogether in their intervention procedures"
Gordon, 1980, p. 435).
(Marlatt &
However, recently, there have
been two major directions taken in trying to deal with
this problem.
One approach involves bigger treatment
packages called "broad spectrum" or "multi-modal" programs.
The second major approach has been the develop-
ment of self-control procedures in which the client
self-administers a change program
1980).
(Marlatt
& Gordon,
Despite these efforts, however, the problem
still looms a large one.
31
Maintenance as a Separate
Treatment Entity
One reason advanced for this continuing problem
is the view that factors which initiate change are quite
different from those that maintain it.
is viewed as a separate treatment entity
Thus, maintenance
(Marlatt
&
Gordon, 1980).
Supporting this view, DiClemente and Prochaska
(1982) studied successful, initial quitters involved in
three different smoking cessation methods - self-quitters,
aversion group members, and behavioral management group
members.
At a five month follow-up interview, no dif-
ference was found in the proportion of maintainers and
recidivists for the three groups.
DiClemente and
Prochaska (1982) concluded:
The most direct interpretation suggests
that there may be no intrinsic relationship
between the process involved in short-term
cessation and the process of long-term
maintenance
(p. 141).
This same point of view was substantiated by
Kingsley and Wilson (cited in Charis, 1984) in regards
to long-term maintenance of weight reduction.
These
researchers discovered the importance of social support
and the reinforcement of self-regulatory behaviors in
the maintenance of weight loss following the conclusion
of group therapy treatments.
32
Factors Associated with
Maintenance
In response to open-ended questions concerning
what helped or hindered the maintenance efforts in
DiClemente's and Prochaska's study (1982), successful
maintainers reported:
(a) self-statement? reinforcing
their quitting smoking, (b) physical exercise and deep
breathing as substitutes for some aspects of the smoking
habit, (c) avoiding people and situations that were cues
to smoke, (d) a firm commitment to quitting, and
(e) social support.
In a study conducted by Perri, Richards, and
Schultheis (1977) comparing 24 successful self-controllers
(defined as those who maintained a 50% reduction in
cigarette smoking for four months) to 24 relapsers, it
was found that the success group used self-reinforcement
and behavioral problem-solving techniques significantly
more than the relapsers.
This finding dovetailed with
Bernstein's (cited in Perri et al., 1977) speculation
that the development of a "coping strategy" rather than
a particular technique for quitting was the key to
successful smoking reduction.
Prochaska, Crimi, Lapanski, Martel, and Reid
(1982) found that smoking cessation relapsers relied
more on externally oriented contingency management than
'
d
33
successful self-changers who relied more on inner-directed
processes.
Thus, they concluded:
The successful changers, however, who rely
more on self-reinforcement [Perri, Richards, &
Schultheis, 1977], self-liberation, and
increased awareness of self can continue to
rely on these experiential processes even after
the social environment ceases to reinforce
their non-smoking behaviors
(p. 989).
The efficacy of self-reinforcement as a maintenance factor in controlling overeating behavior was
substantiated by Rosenthal (cited in Goleman, 1982).
In a behavioral treatment group, dieters were taught
specific techniques to reduce the possibility for
relapse (such as recognizing potential high-risk situations and developing alternatives to overeating).
After
three months, those given this training had lost an
average of 13.9 pounds compared to an average 8.7 pounds
lost by those who did not receive the training.
In regards to physical exercise, Dishman (cited
in Pate
& Blair,
1983) reported that adherence to a
fitness program was inversely related to percentage of
body fat and directly related to self-motivation.
collected by Oldridge (cited in Pate
& Blair,
Data
1983) in
a cardiac rehabilitation setting suggested that smokers,
blue-collar workers, and those who were sedentary in their
leisure time were least likely to adhere to an exercise
program .
• <l
34
Finally, social support was found to be a key
factor in exercise maintenance in a study of male
exercisers conducted by Heinzelmann and Bagley (cited in
Pate
& Blair,
1983).
Eighty percent of those men whose
wives had a positive attitude towards their participation
in regular exercise exhibited a good adherence rate,
while only 40% of those whose wives' attitudes were
neutral or negative showed good adherence.
Relapse
Relapse is defined as any discrete violation of
an imposed rule or set of rules governing the rate or
pattern of consumption behaviors
1980).
(Marlatt
& Gordon,
The term is generally applied to those violations
that occur after the behavior has been brought under
control for a certain period of time (usually the period
following the termination of formal treatment).
Marlatt
and Gordon (1980) have proposed that there are common
determinants associated with relapse which apply
regardless of the particular behavior involved.
Temporal Consistency
Research conducted by Hunt, Barnett, and Branch
(cited in Marlatt
& Gordon,
1980) demonstrated that the
temporal patterns of relapse across treatment programs
for smokers, alcoholics, and heroin addicts was strikingly similar:
about two-thirds of all relapses
35
occurred within the first 90 days £allowing treatment.
From this, Marlatt and Gordon (1980) concluded:
These data strongly suggest the possibility
of common elements underlying the mechanism of
relapse itself . . . . We would like to suggest
that there may be common behavioral and cognitive components associated with relapse,
regardless of the particular 'add-ictive sub. stance' involved (p. 413).
Factors Associated
With Relapse
Marlatt and Gordon (1980) collected further data
supporting their claim of a generic relapse model by
interviewing 137 individuals who had relapsed after
initial success in treatment programs for either smoking,
alcoholism, or heroin addiction.
They found that
relapse episodes for all the behaviors fell into just
three categories:
(a) coping with negative emotional
states (37%), (b) social pressures (24%), and (c) coping
with interpersonal conflict (15%).
In a study of smoking cessation maintainers and
relapsers conducted by Prochaska et al.
(1982), the high
relapse risk situations were largely found to be intrapersonal and involved negative emotional states such as
anger, irritation, and depression.
Recidivists in a study of smoking cessation
maintenance conducted by DiClemente and Prochaska (1982)
reported that the central factors leading to relapse
were:
(a) inconsistency in maintaining either exercise
36
or some health-related physical activity,
(b) personal
problems, (c) the experience of missing the habit, and
(d) job-related tensions.
In yet another study of smoking relapse situations, Shiffman (1982) discovered that 71.2% of all
reported relapse crises occurred in the presence of
negative affect.
However, Shiffman's data also suggested
that while situational factors were important as antecedants of relapse, the more
importa~t
determinant of the
actual relapse occurrence was related to the ex-smoker's
coping responses.
Subjects who reported using behavioral
coping responses relapsed only 28% of the time, while
those who did not use such responses relapsed more than
twice as often (58%).
Cognitive coping skills reduced
the relapse rate from 55% to 30%.
Self-Efficacy
There has been much recent interest in Bandura's
(1977) self-efficacy construct and its possible effects
on the maintenance of new behaviors.
This concept is
distinguished from the outcome expectancy concept which
is defined as a person's estimate that a given behavior
will lead to certain outcomes.
Instead, an efficacy
expectation is the conviction that one can successfully
execute the behavior required to produce the outcomes
(Bandura, 1977).
37
Thus, in terms of preventive health behavior,
a person might believe in the benefits of a particular
treatment, but if he has doubts about his capability of
performing the necessary treatment activities, then he
will most likely not even engage in them.
The expectations of personal mastery not only
effect the initiation of change, but the persistence
needed to maintain it.
According to Bandura (1977):
Efficacy expectations determine how much
effort people will expend and how long they
will presist in the face of obstacles and
aversive experiences.
The stronger the perceived self-efficacy, the more active the
efforts
(p. 194).
Smoking cessation studies have substantiated the
effects of self-efficacy on behavioral maintenance.
Prochaska et al.
(1982) reported statistically signifi-
cant differences between the self-efficacy measures of
maintainers and relapsers of non-smoking behavior.
DiClemente (1981) also studied self-efficacy as
a factor in the maintenance of long-term non-smoking
behavior.
Subjects were assessed for strength of self-
efficacy beliefs at the time of their initial quitting.
At a five-month follow-up, those who maintained abstinence, were found to have had significantly higher selfefficacy scores than those who relapsed.
Self-efficacy
was found to be independent of subjects' retrospective
38
judgments of their commitment to quitting.
In addition,
self-efficacy was found to have predictive superiority
over past· performance.
Corporate Health Promotion
Overview
Health promotion efforts at the worksite vary
considerably in focus, objectives, size, and scope
ranging anywhere from a few health education lectures,
to extensive multicomponent programs
(Fielding, 1984).
According to Ware, Health Education Programs Coordinator
for Ford Motor Company (cited in Novelli
& Ziska,
1984),
most programs fall into the following categories:
1.
One-shot activities.
Such programs fre-
quently consist of single lectures on various health
matters and single screenings for health threatening
conditions such as high blood pressure and elevated
cholesterol levels.
Often these programs have little
or no attendant counseling, follow-up, or referral.
2.
Fitness first.
These programs are centered
on employees' physical well-being and emphasize cardiovascular fitness and weight control.
They generally
have little direct association with disease prevention,
though they may very well serve as initial steps toward
addressing broader health promotion needs.
39
3.
Comprehensive approach.
These· consist of
planned, well-funded programs with long-range objectives,
broad-based participation, and both cost and behavioral
assessment.
They usually target a number of at-risk
behaviors and involve full-time staff.
Comprehensive Approaches
According to Fielding (1984), increasing numbers
of programs established in the last five to ten years
have taken this comprehensive approach which consists
of:
(a) assessing and summarizing employee health needs
into a corporate health risk profile, (b) assessing the
degree of individual risk through the use of health risk
appraisal tools, and (c) delivering risk-reduction
interventions aimed at improving the health risk profile.
The following discussion briefly illustrates the scope
and variety of these programs.
Kimberly-Clark Corporation has a 2.5 million
dollar multiphasic testing and physical fitness complex
where employees are offered health reviews, multiphasic
screenings, exercise treadmill tests, cardiac rehabilitation classes, and health education classes covering
smoking control, breast self-exam, high blood pressure
and diet management
(Fielding, 1984).
Metropolitan Life Insurance Company, a leader
in health promotion for years, offers similar health
education programs, in addition to providing low-sodium,
'
\)
40
low-fat, and low-calorie food selections in the employee
cafeteria
(Novelli
& Ziskz,
1982).
Mattei and Tosco Corporations offer cooking
demonstrations on how to prepare nutritious meals, and
behavioral change classes on weight management, smoking
cessation, stress reduction, how to establish a lasting
personal exercise program, and many more
(Fielding,
1984).
In addition, all of these companies provide
employees and their families with regular health newsletters covering program news and general health information
(Fielding, 1984).
Benefits of Health Promotion
Efforts
The benefits of these programs are highly
speculative at this point because evaluative efforts
have been limited by costs and by the relative newness of
health promotion as a product.
However, the limited
data available has offered very promising findings.
A study conducted by Wilbur (cited in Fielding,
1984) into the effectiveness of Johnson
& Johnson's
comprehensive program, "Live for Life" revealed encouraging results.
Participants showed significant improve-
ments over non-participants in aerobic conditioning,
weight loss, smoking cessation, and stress management.
In addition, the number of self-reported sick days
• 0
41
utilized was down compared to an increase for nonparticipants; and feelings of job satisfaction, ability
to handle- job strain, and job self-esteem were all
significantly improved.
At Equitable Life, 72% of the total eligible
employee population participated in the program's first
year of operation.
A survey of participants completed
at year's end indicated that 82% feltmore health conscious, 72% felt healthier, 56% felt they had a more
positive outlook on life, and 76% urged others to
participate
(Manuso cited in Manuso, 1983).
Cost-Effectiveness of Health
Promotion Efforts
The data required to prove the
cost-effectivene~s
of health promotion is lacking (Brennan, 1982; Kristein,
1982; O'Donnell
&Ainsworth,
1980).
According to
Kristein (1982):
There is no hard evidence that one company
with a health promotion program has saved money
as compared to another similar company which
does not have such a program. There is no clearcut example of a company saving money, in the
long or short run, in terms of medical care
spending or insurance costs or any other category of sp~nding (p. 27).
Preliminary findings of studies recently conducted
at Bordens, Campbell Soup, Control Data, New York Telephone, and Metropolitan Life Insurance corporations have
demonstrated that a positive cost-effectiveness relationship probably exists between worksite health promotion
42
and critical factors such as absenteeism, productivity,
disability claims, medical utilization patterns, and
overall morbidity and mortality experience
(Berry cited
in Brennan, 1982).
Weight Control Programs
Worksite weight control efforts include
(a) single lectures, (b) series of educational lectures
on weight management, (c) peer support groups, (d) monetary incentives, and (e) behavioral change approaches.
Among these, programs with behavior techniques have
shown the greatest promise in helping people manage
their weight
(Foreyt, Scott,
& Grotto,
1980; Fielding,
1982).
Benefits of Weight
Control Programs
Though behavioral approaches have proven more
successful than others, research findings indicated
considerable variability in program outcomes even when
similar methods were employed
(Wing cited in Ureda
&
Taylor, 1982), and marked individual variability in
degree of weight loss within programs
(Ureda
& Taylor,
1982; Penick et al. cited in Henderson et al., 1979).
By far the greatest problem in weight control
has been recidivism
(Fielding, 1984).
Among controlled
studies with follow-ups of a year or more, observed
43
differences between treatment and control groups
generally were found to decrease over time to the point
of losing significance
(Henderson et al., 1979).
The pioneering study of obesity treatment at the
worksite by Stunkard and Penick (cited in Fielding, 1984)
revealed this problem.
Subjects who completed a 16-week
behavioral treatment program lost an average of eight
pounds, but six months later this average had fallen to
two and a half pounds.
Stunkard and Penick (cited in Fielding, 1984)
reviewed the results of nine behavioral weight control
studies and found that 14 of 26 treatment groups demonstrated varying weight gains during a 12-month follow-up
period.
Cost-Effectivenss of Weight
Control Programs
No information has been available on costs and
cost-effectiveness of weight management programs in
occupational settings
(Fielding, 1984).
Stress Management
Stress management interventions have particular
relevance to the worksite because occupational settings
themselves play a part in producing stress.
Although
data linking occupational stress to disease has emerged
only recently, Manuso (cited in Schwartz, 1982) reported
44
that 58% of the men and 36% of the women in a sample of
95 health promotion participants believedthat job-related
factors caused or contributed to their problems.
Corporate stress-management programs, like other
risk-reduction efforts, vary in scope and objectives.
Purely educational approaches range from hour-long
lectures to two-day seminars in which communication of
specific knowledge about stress is the goal.
Compre-
hensive approaches aim at behavioral change and skill
acquisition such as assertiveness training, relaxation
techniques, and mental self-control procedures.
Benefits of Stress Management
Programs
Research into the effectiveness of stress management programs has been scarce (Manuso, 1983; McLean
cited in Schwartz, 1982).
However, the available data
pointed to positive results.
Among employees of the Converse Rubber Company,
Peters (cited in Schwartz, 1982) compared the effects
of daily relaxation breaks on measures of employees'
blood pressures and self-reports of health performance
and
well~being~
three groups:
Volunteers were randomly divided into
those in Group A were taught a relaxation
technique and instructed to take two 15-minute relaxation
breaks daily; those in Group B were instructed to relax
any way they chose during their two relaxation breaks;
45
and Group C received no instruction and no· break time.
After an eight-week experimental period, self-reports
indicated that the greatest improvement on every index
occurred in Group A; the least improvement occurred in
Group C; and Group B showed intermediate improvements.
The results of blood pressure paralleled the self-report
measures.
Manuso (1983) studied the effects of an individualized biofeedback program administered to employees
suffering from headaches and generalized anxiety.
data indicated that:
The
(a) participants were able to
decrease forehead muscle tension by 50%, (b) symptom
activity decreased from a high-moderate to a low category, (c) interference of symptoms with ability to
function on the job declined from 18% to 4%, (d) medication intake decreased from seven to two pills per week,
and (e) monthly visits to the corporate health center
decreased from two to less than one.
In another study conducted by Manuso (1983) in
which employees participated in a group-administered
audiovisual program on stress reduction, participants'
perceived stress levels decreased by 45% following treatment, and use of company health care services decreased
about 50% as well.
46
Cost-Effectiveness of Stress
Management Programs
In both programs conducted by Manuso (1983),
cost-benefit ratios demonstrated that for each dollar
invested, there was a $5.52 return in terms of decreased
health care utilization, less time away from the job to
use health care services, and increased efficiency in
performing job requirements.
This data on cost-
effectiveness stands virtually alone in the literature
suggesting the need for further assessments of "bottom
line" effects.
Physical Fitness
Recent epidemiologic studies have demonstrated
a link between active lifestyle and reduced risk of
coronary heart disease
(Haskell
& Blair,
1982).
Such
information has prompted many corporations to introduce
exercise programs at the worksite.
These programs range
from educating employees about exercise benefits and
recommending individualized fitness routines, to offering
elaborate fitness facilities with full-time staff
(Fielding, 1984).
Improvements in Productivity
Heinzelmann and Bagley (cited in Haskell
& Blair,
1982) discovered that 60% of the participants in an
employer sponsored 18-month jogging-type exercise program
'
6
.
47
reported improvements in work performance compared to
only 3% of the control group.
In another study conducted at the National
Aeronautics and Space Administration by Durbeck (cited in
Haskell
& Blair,
1982), exercise participants reported
that, since they had begun to exercise, they could work
mentally and physically harder, enjoyed their jobs more,
and found their normal routines less boring.
These data
and other data on increased productivity were based on
self-reports; as yet no study has been conducted that
objectively demonstrates increased productivity as a
result of exercise participation
Haskell
& Blair,
(Fielding, 1984;
1982).
Effects on Absenteeism
Definitive conclusions regarding an association
between absenteeism and exercise participation have been
equally lacking (Haskell
& Blair,
1982; Fielding, 1984).
According to Fielding (1982), self-selection and poor
choice of controls account for this.
Given available data, net reductions in
absenteeism compared with baseline and control groups
ranged from about one-half to two days per year
(Fielding, 1982).
An unpublished study conducted by the
Metropolitan Life Insurance Company (cited in Fielding,
1984) revealed that annual absenteeism rates per 100
participants in a voluntary exercise program decreased
"
48
from 6.3 to 4.9 days while the control group showed a net
increase from S.6 to 7.0 days.
In a study conducted by Cox (cited in Fielding,
1984), high adherers to a company exercise program
experienced a 42% decline in average monthly absenteeism
compared to a 20% decline in both t"he test company
overall and a control company.
Recidivism Rates in Exercise
Programs
As in weight control programs, adherence to
exercise habit has been found to be a significant problem.
Dropout rates from cardiac rehabilitation programs varied
from 20% to SO% after an initial four to six months
(Hanson, 1982).
Dishman (cited in Pate
& Blair,
1983)
placed the recidivism figure for all exercise programs
at SO% after six months.
In addition, studies indicated that those who
volunteered to exercise were actually less likely than
nonvolunteers to be at risk for coronary heart disease
(Yarvote cited in Pate
& Blair,
1983).
In a medically
supervised exercise program for executives of Exxon
Corporation, Yarvote (cited in Haskell
& Blair,
1982)
compared the 309 executives who volunteered for the
program to those who did not.
It was discovered that
nonparticipants were older, smoked more, had higher
49
blood fat levels, higher blood pressure, more heart
disease, and poorer treadmill performance.
Cost-Effectiveness of
Exercise Programs
Available studies have provided some support for
the hypothesis that fitness programs can effect the
"bottom line," but the evidence was weak.
Much more
research and more tightly controlled studies are needed
(Fielding, 1982).
High Blood Pressure Programs
Hypertension occurs in 15-25% of the worksite
population with an even higher rate found among older
male workers
(National Heart, Lung, Blood Institute
cited in Fielding, 1984).
Since it can be ameliorated
by proper treatment, occupational hypertension activities
have been underway for years
1982).
(Alderman, Green
& Flynn,
These efforts fall into two categories:
(a) detection at the worksite with subsequent referral
to community resources and private physicians for
continuing treatment; and (b) detection and treatment
provided at or near the worksite.
Both approaches
generally include some type of follow-up effort since
research has found this to be an imperative factor in
achieving successful control
Fielding, 1984).
(Alderman et al., 1982;
50
Benefits of High Blood Pressure
Programs
In general, worksite hypertension programs have
high success rates; 80-90% control can be expected from
diligent, well-organized, and well-run programs
(Fielding, 1984).
A voluntary
onsit~
screenin&referral,
and follow-up program conducted by Massachusettes Mutual
Life Insurance Company (cited in Fielding, 1984) led
to an increase in the percentage of those under control
from 36% to 82% within a year.
In another detection and referral effort
developed at the University of Michigan and carried out
in collaboration with labor unions and management, more
than 80% maintained satisfactory control after two years
(Alderman et al., 1982).
Alderman (1982) singled out
the staff's systematic and diligent follow-up as the
crucial factor in the program's success.
In a review of the Massachusettes Life Insurance
program by McManus (cited in Novelli
& Ziska,
reduction in absenteeism was reported.
1982), a
Prior to the
program's inception, employees with hypertension used
43 days for hospitalization per 100 workers per year,
while those with normal blood pressure used only 39 days.
In the first three years of the program's operation,
this relationship reversed.
51
Cost-Effectiveness of High
Blood Pressure Programs
The annual per person cost of treating hypertension averages $200 to $250 per year (in 1980 dollars)
for the first year with costs declining by 10 to 30% in
subsequent years
(Kristein, 1982).
In terms of cost-
effectiveness, Chadwick (cited in Brennan, 1982) projected
that these programs and others concerned with blood lipid
level control are close to the break even point.
Alderman (cited in Brennan, 1982) has substantiated this
projection in his hypertension screening work with the
United Storeworkers Union in New York City.
He indicated
that program costs were about equal to savings accrued
from reduced absenteeism.
However, despite these
generous estimations, neither the methodology nor the
key variables have been worked out to make possible a
consensus on the subject
(Fielding, 1984).
Smoking Cessation
Corporate smoking cessation efforts take many
forms:
(a) some businesses merely encourage the company
physician to advise employees to quit smoking;
(b) others
utilize outside consultants such as SmokeEnders and the
American Cancer Society; (c) still others provide in-house
programs which include monetary incentives, blanket
worksite smoking prohibitions, and behavioral
52
self-control techniques such as rapid smoking and substitute non-smoking skills training.
Benefits of Smoking Cessation
Programs
Ford Motor Company utilized a broad-spectrum
behavioral approach and coupled self-control techniques
with either aversive smoking, abrupt withdrawal, or
gradual withdrawal.
At termination of the program, the
greatest reduction in smoking was found among persons
who had used the aversive smoking approach.
However,
at a six-month follow-up assessment, only 20% continued
to abstain (Danaher, 1982).
While this 20% figure was
disappointingly low, it was quite consistent with data
found in clincial settings.
Hunt and Bespalec (cited in Danaher, 1982)
examined 89 smoking cessation studies and discovered that
more than half those who had stopped smoking by the end
of a program subsequently relapsed; the greatest recidivism appearing within the first five weeks of follow-up.
These compelling results have helped establish
a 30% abstinence level as the benchmark against which
efficacy of smoking programs can be measured
1982).
(Danaher,
This figure was arrived at through research
conducted in clinical settings.
Controlled experimental
research at the worksite has been virtually nonexistent
53
according to Fielding (1982), and .meager, at best,
according to Danaher (1982).
Cost-Effectiveness of Smoking
Cessation Programs
Smoking cessation appears to be a better than
break even proposition in terms of cost.
According to
Brennan (1982), it tops the list of a cost-effective
ranking of risk-reduction programs.
What would appear
to be a low abstinence level, 20-30%, does, in fact,
represent an economically successful program (Chadwick
cited in Brennan, 1982).
Kristein (1982) estimated that
in the short-run, a company can save $345 per year per
smoker who quits.
Summary of Literature Review
Demographic research has indicated that health
care utilization is positively correlated with income
and education, and tends to be higher for females and
higher for whites than non-whites.
Illness behavior varies a great deal and is
influenced by an individual's (a) needs for the secondary
gains afforded by the sick-role, (b) state of psychological distress, (c) interpretation of symptoms,
(d) cultural background, and (e) knowledge and beliefs
about illness.
Preventive health behavior is explained by the
Health Belief Model (HBM) which has received wide
'
<)
54
research validation for over 30 years.
The model
explains preventive behavior as the result of three
basic factors:
(a) a "readiness to action" which occurs
when a person feels vulnerable to an illness, (b) efficacy evaluation of the proposed preventive treatment
weighted against the many barriers to treatment, and
(c) a "cue to action."
Research conducted between 1974
and 1984 has revealed that "barriers" to treatment was
the most significant factor influencing preventive health
behavior and sick-role behavior.
Compliance refers to the extent to which a person
follows a prescribed medical regimen.
Non-compliance has
been found to be a serious problem; research studies
placed the rate of non-compliance at about SO%.
affecting compliance are:
Factors
(a) quality of patient-
physician interaction, (b) nature of illness, (c) characteristics of the treatment regimen, (d) degree of
behavioral change needed, and (e) situational factors
such as social support.
Of particular interest among these factors is
the discovery that people have the most difficulty
adhering to treatments that require behavioral change
and habit modification.
This is highly significant
because control over today's chronic diseases is
directly contingent upon people's commitment to modifying
unhealthy habits.
55
Thus, many behavioral treatment programs have
proven initially successful in helping people attain new
health behaviors, but fail to help them maintain these
over time and across situations.
In smoking cessation
programs, a 30% abstinence level is the norm.
Weight
control follow-up studies reveal that initial weight
loss is often regained.
Relapse generally occurs within the first 90
days following treatment and appears to cut across
behavioral lines.
Usually relapses occur as a result of
(a) negative emotional states, (b) peer pressure to
engage in old behavior, and (c) interpersonal conflicts.
Maintenance of behavioral changes appears to be related
to self-reinforcement of new behavior, and to the use of
coping strategies in the face of high-risk situations.
Recognition of the recidivism prublem has led
many behavioral theorists to examine the concepts of
self-efficacy and locus of control as predictors of
behavioral maintenance.
Self-efficacy refers to people's beliefs that
they have the capability to successfully execute the
behavior required to produce a certain desired outcome.
Thus, this concept adds perceived personal mastery to
the HBM's outcome expectancy theory which holds that
individuals will engage in preventive treatment if
they believe in the utility of it.
For example, a smoker
56
may believe that aversive conditioning works to eliminate
smoking behavior, but if he views himself as incapable of
sustaining such a drastic procedure, then he will either
not engage in it, or do poorly if he attempts it.
The locus of control concept hypothesizes that
people who are internally oriented (able to control
important aspects of their lives) will be more able to
achieve change than those who are externally oriented
(who believe that luck is an important determinant of
their lives).
Both self-efficacy and locus of control concepts
have received research validation.
The growing emphasis on client responsibility
in behavioral therapy is also apparent in the increased
usage of self-management techniques which teach people
how to rearrange the contingencies that influence
undesirable behaviors.
These techniques require that
clients take responsibility for developing and implementing their own behavioral change plans.
In order to reduce skyrocketing health care
costs, many U.S. corporations have taken on the
responsibility for helping their employees change
unhealthy habits.
Corporate health promotion efforts
fall into four categories that have varying levels of
intervention:
(a) educational programs which provide
health information and consist of lectures, health
57
fairs, and treatment referrals; (b) evaluation
screening programs which test employees to identify
medical problems; (c) prescription programs that take a
major step beyond screening by informing employees how
to correct medical problems; and (d) comprehensive programs that include all of the above plus behavioral
change interventions.
Comprehensive approaches to corporate health
have grown in the past ten years.
Some of the major
leaders in this movement are Kimberly-Clark, Levi
Strauss, Mattel, Metropolitan Life Insurance, Johnson
and Johnson, Campbell Soup, Control Data, IBM, Ford, and
Xerox.
Data supporting the benefits and cost-effectiveness of these programs is highly speculative and lacking
in overall rigorous designs.
However, a study of
Johnson and Johnson's "Live for Life" program revealed
significant improvements in employees' aerobic conditioning, weight control, smoking cessation, and stress
management.
There has also been research validation of
health promotion's influence on increased productivity
and reduced absenteeism.
Behavioral change programs conducted at the
worksite are plagued by the same problem of recidivism
as programs conducted in clinical settings.
Smoking
cessation, weight control, and exercise programs have
58
particularly high recidivism rates_, while hypertension
control appears to achieve the highest rates of success.
Though the field of corporate health promotion
is new, it is steadily growing, and bound to continue to
do so in the future.
Chapter 3
DESIGN AND IMPLEMENTATION OF HEALTHFUL
LIVING: LEARNING TO CONTROL
UNHEALTHY HABITS
This chapter is divided into two sections:
(a) the implementation overview provides a brief description of the program design and offers guidelines for
implementation; (b) the discussion of implementation at
the worksite provides marketing and promotional strategies, as well as ideas for utilizing the work setting
to enhance program effectiveness.
Implementation Overview
This program was designed for application in a
clinical setting as well as an occupational setting.
The following section covers the necessary guidelines
for both applications.
Program Overview
This program was designed to teach people how
to implement a behavioral change program and how to
maintain successful change.
The program utilizes a
brief group therapy approach to assist participants
explore how they handle the change process.
59
The goal
60
of such exploration is to identify and alter patterns
that impede success.
Program Organization
This program was organized into five developmental phases that successively build upon each other
to help guide participants through the change process.
The content of each phase is not intended to be delivered
in one session or any specific number of sessions.
Instead, the delivery pace should be determined by the
setting in which the group is implemented and the
specific needs of the group.
Following is a brief description of the phases:
Phase 1:
Change.
Entry into the Group:
Deciding to
This sets the foundation for a group culture
supportive of self-exploration.
Phase 2:
Identifying the Problem and Imple-
menting a Self-Management Plan.
This helps participants
appraise the nature of their present behavior and teaches
them how to develop a personalized plan of action.
Phase 3:
Implementing the Plan:
Resolving Obstacles.
Exploring and
This assists participants in
resolving problems as they arise and alerts them to ways
they sabotage their own efforts.
61
Phase 4:
Developing Coping Strategies for
Maintaining Change.
This helps participants increase
the inner-resources that will aid them in continuing to
control their behavior once the group terminates.
Phase 5:
Your Own.
Terminating the Group:
Doing it on
This assists participants in consolidating
new skills and in separating from the group.
Program Application in
Homogeneous Groups
This program was designed as a generic model for
application to various health behaviors (excluding
alcohol or drug addiction and eating disorders).
Its
design rests on the assumption that the process of
changing various unhealthy habits has inherent similarities.
Persons who want to lose weight, stop smoking,
reduce stress and increase exercise traverse common
pathways to do so and face similar struggles in attaining
their goals.
It is recommended, however, that the program be
applied in groups that address only one problem.
People
who are attempting to control the same unhealthy behavior
share a commonality that facilitates learning and
strengthens group cohesiveness.
For example, when a dieter and a smoker relapse,
they may both engage in similar self-defeating thoughts
such as, "I'll never change."
"This proves I'm a
62
failure."
"I shouldn't have eaten that candy."
shouldn't have smoked that cigarette."
"I
However, the
situations that provoked the relapses may very well have
been different.
In fact, research has suggested that
one-half of the relapse episodes experienced by smokers
occurs in the presence of other smoke~s
1982).
(Shiffman,
Obviously, a group of smokers would gain a great
deal from practicing how to apply relapse prevention
strategies to these specific situations.
Experiential Focus
The educational aspect of this program is aimed
at increasing the information available to participants
so they can make the most effective responses to the
difficulties facing them.
To set the stage for success-
ful change participants must understand the nature of
the change process, know how to design a plan for change,
and must be informed of the rules and policies of the
group.
Beyond this, however, it is recqmmended that the
group leader work at participants' experiential levels
by imparting information when it is relevant to them.
For example, information on irrational thinking patterns
would be most effective if introduced after the leader
has observed and pointed out these patterns as they
occurred.
In this way, participants will receive feedback
that is generated from their own experiences.
It is
63
hoped that such timely insight will have enough impact
to motivate participants to apply it to their lives.
In addition, information should be presented as
simply as possible and program handouts should be
utilized as needed (either during or in between sessions)
to facilitate assimilation of new ideas and skills.
Psychotherapeutic Scope
While this program incorporates behavioral and
cognitive learning principles, it also includes selfawareness and self-exploration components.
In order to
achieve lasting change, participants must become aware
of their defenses against change and appreciate the
obstacles they place in the way of their success.
Such
self-awareness can be gained only through a process of
self-exploration.
The leader's facilitation of this
should be guided by the following definition of the
counseling process:
[It is] the process whereby clients are
afforded the opportunity to explore personal
concerns; this exploration leads to an increase
of awareness and of choice possibilities. The
process is frequently short term, focuses on
problems, and assists the person to remove the
blocks of growth. This process helps the
individual discover his or her resources for
more effective living (Corey, 1977, pp. 8-9).
64
This process is distinguis.hed from psychotherapy
which is defined as:
[It] frequently focuses on unconscious
processes and is more concerned with personality structure changes than is counseling.
Rather than merely aiming at the resolution
of particular life cris~s, psychotherapy is
geared toward an intensive self-understanding
of the dynamics that account for these life
crises (Corey, 1977, p. 9).
When such intensive understanding into the
origin and persistence of a presenting behavior is
necessary, the leader should have available resources to
make a referral for psychotherapeutic services.
Duration of Group
It is recommended that this group be held once
a week for a duration of one and a half to two hours.
It
should extend over a minimum of ten weeks in order to
build group cohesion and allow participants the time
needed to assimilate information, practice new skills
and build up a proficiency in utilizing them.
The recommended maximum length is four months.
Because this group is not intended to effect deep intrapsychic change, it is believed that this is ample time
to effect the self-awareness needed to remove obstacles
to change and to increase options for implementing new
behaviors.
65
Pre-Group Interview
A pre-group interview in which a prospective
member would meet individually with the leader is highly
recommended.
This would allow the leader the opportunity
to screen out anyone appearing to be inappropriate (a
person in crisis, suffering from depression, or having
any other obvious mental disorder).
It also would give
potential members a chance to evaluate the program and
determine whether it is right for them.
Such pre-group
preparation can function to enhance early cohesiveness
and reduce the dropout rate
(Budman, 1981).
The objectives of this interview would be to:
(a) assess the person's ability to relate to others,
(b) assess the person's motivation level and willingness
to take responsibility for behaviors, (c) prepare the
person for the group by talking over expectations, fears,
and misconceptions, (d) explore any past attempts to
change, (e) clarify the nature of the problem behavior
and, (f) recommend a complete physical examination when
symptom states exist.
Target Population
This program was designed for adults who want
to control health damaging behaviors such as overeating,
smoking, sedentary lifestyle, excessive stress and poor
diet.
In particular, people who have relapsed and those
who have made unsuccessful past attempts to alter their
66
problem behavior would benefit from the self-awareness
focus of the program.
The group size should range from six to ten.
It should have enough people to provide ample interaction
and yet be small enough to give everyone a chance to
participate frequently.
Leader Qualifications
The leader of the group should be a licensed
counselor, psychologist or social worker with the following qualifications:
(a) knowledge of behavioral and
cognitive principles and techniques, (b) previous
experience facilitating a therapy group, and (c) knowledge of the health principles and specific behavioral
and cognitive strategies related to the behavior being
addressed.
Follow-up Sessions
Monthly follow-up sessions are recommended for
three to six months after the group has terminated when
the risk of relapse is particularly high.
These sessions
would provide further stimulus for participants to adhere
to their new behaviors and also allow the leader to
assess the outcome of the program.
Group discussion
would focus on the efforts made to continue behavioral
changes, difficulties encountered and successful strides
gained.
'
6
67
Program Evaluation
Participant feedback is an integral part of the
program and should be solicited by the leader on a
regular basis.
A post program evaluation (See Appendix
A, Handout 19) was designed to ensure continued program
improvement.
Implementation at the Worksite
Special consideration of factors involved in
worksite implementation are addressed in this section.
The discussion includes:
(a) marketing the program,
(b) promoting the program to employees, and (c) utilizing
the work setting to enhance program effectiveness.
Developing a Marketing Strategy
Target Market
The first step in developing a marketing
strategy will be to identify the primary target market.
Careful identification of those companies most likely
to value the objectives of the program will ensure that
marketing efforts are utilized most productively.
To accomplish this, it is recommended that the
program be marketed to corporations that already have
actively operating health promotion efforts.
Because
of the specific psychological focus of the program, it
is not likely to be used as a start-up intervention.
'
"
68
In determining program applicability to a
particular work setting, several aspects of the existing
health promotion efforts will warrant careful consideration.
First, the corporation's health strategy must go
beyond the educational, screening, and prescription
levels, and, in addition, include active intervention on
a behavioral level.
The long-term goals of such a health
strategy might be furthered by the objectives of the
program.
The second consideration will be whether the
health promotion efforts address various health problems.
For example, if a company's health focus is mainly
physical fitness, a psychological approach to health
would probably not be viewed as a viable addition.
Finally, the health promotion philosophy must be one that
appreciates the interdependent nature of physical and
emotional health.
In addition, it will be highly beneficial to
assess the "corporate culture" to determine the attitude
towards health promotion.
Is it a valued commodity?
Is the general "mood" of employees and management one of
receptivity?
In particular the attitude of top manage-
ment will be important to ascertain because support at
top levels has great impact upon employees' acceptance
and enthusiasm for health promotion
(Thigpen, 1984).
69
Finally, evaluating employee health needs will
also be crucial in assessing the primary target market.
For example, the program would not serve the needs of
telephone linemen who suffer from back problems due to
the heavy physical nature of their work.
Rather, as
research on health behavior has demonstrated {Rosenstock
& Kirscht,
1979), those with better education and higher
incomes are more likely to engage in preventive health
actions.
Thus, a more receptive employee population
would be middle-level executives who suffer from problems
of overeating, smoking, lack of exercise, and high blood
pressure.
Selling the Program
Developing a framework for defining what the
program provides will be crucial in selling it to management.
It is recommended that it be marketed as a pro-
gram designed for the special needs of employees who
have already made past attempts and have failed to
maintain behavioral changes.
Thus the program might be
utilized by a health promotion program to troubleshoot
the problem of recidivism and augment its already
existing interventions.
By pointing to research that
has demonstrated the magnitude of the relapse problem,
a tangible program benefit will be identified.
In cases in which health promotion is provided
as an employee benefit or when a pilot study is desired,
70
the program should be targeted to a high-risk, top-level
segment of the employee population in order to increase
its potential cost-effectiveness.
Thus, the program
would be marketed as a way to promote the corporation's
investment in its human resources.
Promoting the Program
Use of Print Media
Promotional efforts should make full use of the
print media.
High quality designs and reproductions can
usually be prepared inexpensively by program staff and
made available through the use of existing communication
channels
(O'Donnell
&Ainsworth,
1984).
The promotional alternatives available are
numerous:
posters, flyers, direct mail, paycheck
stuffers, and inclusion in the health promotion and/or
employee newsletter.
Introductory Lecture
In combination with promotional materials, it
is highly recommended that the program be introduced in
lecture format at a time that is most convenient (such
as lunchtime), and in a location that is most accessible
to employees.
The lecture should give listeners
tangible, high utility information on the dynamics of
change and helpful hints for handling the process.
71
Every effort should be made to ensure that the material
is relevant to the employees and is presented as simply
and dynamically as possible.
Building a Supportive Work
Environment
"The sharing of goals by two or more people over
time constitutes a culture"
(Allen, 1984, p. 74).
Given
this definition, the groups in which the program will be
implemented will certainly become cultures.
The group's
norms, values, goals, and supported behaviors will effect
each and every member.
When the program is implemented at the worksite,
the opportunity will exist for expanding the group's
influence into the social environment of the work
setting.
Such an opportunity will greatly enhance the
group's effectiveness.
This can be accomplished by
encouraging group members to spend time together
implementing their new behaviors in the work setting.
In this way, they will have increased opportunities for
supporting and reinforcing each others' new behaviors.
The creat·ion of a social support network will act as a
powerful motivator as well.
The emphasis of these collaborative efforts
should be on the enjoyment of the new behaviors.
ticipants should ask themselves, "What can we do
Par-
72
together to help in our mutual efforts to
~top
smoking,
lose weight, exercise regularly, etc?"
For example, a group of dieters could be
encouraged to have lunch together and to make a project
out of identifying the most nutritious and lowest calorie
food in the cafeteria.
Smokers could be encouraged to
take their breaks together in order to practice deep
breathing exercises as a substitute for smoking.
Exercisers could participate in a daily physical activity
such as jogging or stair climbing.
In addition, participants should be encouraged
to make use of the proximity to other group members by
seeking support when needed.
Utilizing the work setting
as a support system will be particularly crucial after
the group has terminated.
Setting a powerful subgroup
in motion before this will go a long way in combatting
the risks of relapse.
Chapter 4
HEALTHFUL LIVING: LEARNING TO
CONTROL UNHEALTHY HABITS
Program Outline
Phase 1:
Entry into the Group:
Deciding to Change
Objective 1: To provide participants the
opportunity to evaluate the program philosophy,
assess whether they "fit in" and decide if they
want to commit themselves to the group.
Objective 2: To set the foundation for a group
culture supportive of self-exploration and to
reframe participants' efforts and goals in
positive terms.
Phase 2:
Identifying the Problem and Developing a
Self-Management Plan
Objective 1: To help participants recognize
how beliefs, feelings, and actions influence
self-concept and how, in turn, self-concept
reinforces these.
Handouts:
Belief in Success
The Case of Bob
Objective 2: To teach participants the
principles of self-management and to assist
them in designing their own personalized
strategy for change.
Handouts:
'
6
Steps in Self-Management
Self-Monitoring Journal Sheet
Developing a Plan of Action
73
74
Program Outline (continued)
Phase 3:
Implementing the Plan:
Resolving Obstacles
Exploring and
Objective 1: To take a process focus and
assist participants in becoming aware of the
expectations and standards they self-impose.
Handouts:
Expectationi Work For or
Against You?
Change in Action
Objective 2: To identify and alter the selfdefeating aspects of participants' attempts to
control their targeted behavior.
Handouts:
Creative Visualization
Self-Talk Record
Self-Controlling Styles
Challenge Your Controlling Styles
Objective 3: To deepen self-exploration and
uncover motivations that maintain the problem.
Handouts:
Phase 4:
Should-Want Inventory
Hidden Pay-Offs
Developing Coping Strategies for Maintaining
Change
Objective 1: To help participants develop
skills that reinforce self-acceptance.
Handouts:
Learning Opportunity Worksheet
Self-Support Talk
Process Assessment
Objective 2: To assist participants in
building relapse prevention skills.
Handouts:
'
0
The Road to Relapse
Relapse Prevention Plan
75
Program Outline (continued)
Phase 5:
Terminating the Group:
Own
Doing it on Your
Objective: To consolidate learning and
prepare participants to separate from the
group.
Handouts:
Program Evaluation
Program Manual Introduction
A detailed description of
th~
aforementioned
outline is contained in the program manual appearing in
the remainder of this chapter.
This manual contains a
description of program content and suggestions for group
process and activities.
The handouts that supplement the
program are contained in Appendix A.
The sources from
which program content and activities were adapted are
listed in Appendix B.
76
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Phase 1:
Entry into the Group:
Deciding to Change
Objective 1:
To provide participants theopportunity to evaluate the program
philosophy, assess whether they "fit in" and decide if they want
to commit themselves to the group.
CONTENT.OUTLINE
I.
This program assumes that successful change depends upon how we
treat ourselves while we attempt
to change.
A. To achieve change, we must he
committed to the process.
Therefore, we must learn to
take some satisfaction from it.
B. The end result of our efforts
will not guarantee healthier,
estee~oosting lifestyles.
C. Instead, the skills that
enhance self-concept and
promote change must be applied
and practiced throughout the
process.
GROUP PROCESS AND ACTIVITIES
To help alleviate members'
anxieties, the leader will provide
introductory structure by
discussing program principles and
focus.
Leader will present the program
in as convincing a manner as
possible.
--.]
---1
Phase 1:
Entry into the Group:
Objective 1:
To provide participants the opportunity to evaluate the program
philosophy, assess whether they "fit in" and decide if they want
to commit themselves to the group.
Deciding to Change
CONTENT OUTLINE
II.
III.
GROUP PROCESS AND ACTIVITIES
This program focuses on exploring
how we handle the change process.
A. The main objective is to
identify and alter selfdefeating attitudes, behaviors
and thinking patterns.
B. It is also aimed at building
skills for effectively handling
the change process and maintaining control over behavior.
Leader will emphasize that participants must take personal responsibility for change and that they
will get out of group only what
they are willing to put into it.
However, the leader will stress
that, while participation is
important, it is voluntary (no one
will be forced to self-disclose).
By so doing, the leader will ensure
a sense of safety in the group.
There are some basic ground rules
we must all adhere to in order to
create a productive group.
A. Confidentiality is an absolute
necessity so that each of us
feels safe to share personal
experiences and problems.
Leader will discuss all relevant
rules and administrative matters,
encouraging members to voice
reactions.
--.J
00
Phase 1:
Entry into the Group:
Objective 1:
To provide participants the opportunity to evaluate the program
philosophy, assess whether they "fit in" and decide if they want
to commit themselves to the group.
Deciding to Change
CONTENT OUTLINE
B. Regular attendance is important
because it strengthens a commitment not only to ourselves but
to the group as a whole. When
each of us is committed, we
feel that "we're in this
together" and feel safe to
explore ourselves.
C. From time to time, homework will
be assigned. This is intended
to help you get the most out of
the program and is not intended
to become a pressurea-obligation.
Failure to do an assignment
should not constitute a reason
to miss group.
GROUP PROCESS AND ACTIVITIES
Leader will indicate the importance.
of homework but, at the same time,
stress that it is voluntary.
---1
({)
Phase 1:
Entry into the Group:
Objective 2:
To set the foundation for a group culture supportive of self-exploration
and to reframe participants' efforts and goals into positive terms.
I.
II.
III.
Deciding to Change
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
Leader will introduce self and then
ask each member, "Briefly tell us
about yourself.
A. What problem behavior would you
like to change?
B. What was your life like before
you developed the problem?
C. What is your life like now
that you have this problem?
Leader and participants will become
acquainted with each other.
Leader will promote cohesiveness
by pointing out commonalities of
members' experiences.
Leader will ask participants to
share hopes and expectations of
the group.
Leader will reframe participants'
goals in positive terms.
Leader will acknowledge participants for taking a positive step
towards health and will encourage
them to recognize the positive
quality of their decisions as
well.
Leader will model an encouraging,
respecting attitude towards members
and instill hope through his or her
own optimism.
00
0
Phase 1:
Entry into the Group:
Objective 2:
To set the foundation for a group culture supportive of self-exploration
and to reframe participants' efforts and goals into positive terms.
IV.
Deciding to Change
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
Leader will end first session by
asking, "How do you feel about the
group so far?"
Leader will invite participants
to voice concerns and to take
responsibility for how the group
functions.
00
1-'
Phase 2:
Identifying the Problem and Developing a Self-Management Plan
Objective 1:
To help participants recognize how beliefs, feelings and actions
influence self-concept and how, in turn, self-concept reinforces
these factors.
CONTENT OUTLINE
I.
Beliefs, actions and feelings
reflect self-concept.
A. A strong belief in success is a
factor that influences attainment of goals.
1. Strong success beliefs inspire
actions that lead to success.
In turn, achievements reinforce self-efficacy beliefs.
2. The strength of success
beliefs (that is our confidence level) is not static,
but fluctuates as do our
moods.
B. Achievements and success beliefs
influence positive feelings.
GROUP PROCESS AND ACTIVITIES
Participants will share how successful they feel they will be in controlling their problem behavior.
They will indicate this on the
"Belief in Success" scale (See
Appendix A, Handout 1). They will
be encouraged to use this rating
scale to monitor their confidence
level throughout the program.
Participants will share any past
attempts they've made to change.
Leader will help them explore what
went wrong and how these failures
may be effecting their confidence
levels.
00
N
Phase 2:
Identifying the Problem and Developing a Self-Management Plan
Objective 1:
To help participants recognize how beliefs, feelings and actions
influence self-concept and how, in turn, self-concept reinforces
these factors.
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
C. Feelings, beliefs and behaviors
operate in a cycle in which each
reinforces the other.
Leader will introduce the circular
and reinforcing aspects of feelings,
thoughts and actions by discussing
"The Case of Bob" (See Appendix A,
Handout 2).
1. If we carry on health damaging
behaviors, our input into the
cycle is negative and this
contributes to a low selfconcept.
2. Behaviors that support
healthful living reinforce a
positive self-concept.
D. Thus, when we attempt to change,
we are changing more than a mere
habit, we are trying to influence
our self-concept.
Participants will discuss how their
problem behaviors make them feel
about themselves. Whenever possible,
leader will point out the commonalities of members' feelings in order
to promote rapport and trust.
00
C..N
Phase 2:
Identifying the Problem and Developing a Self-Management Plan
Objective 2:
To teach participants the principles of self-management and to assist
them in designing their own personalized strategy for change.
CONTENT OUTLINE
I.
To achieve successful change, we
must take full responsibility for
designing and managing our own
strategy. Self-management is a
method which allows us to
establish personalized steps
that lead to our goals.
A. Step 1: Define the Problem
1. Describe the problem behavior
as specifically and concretely as possible.
2. To do this, pay close
attention to your behavior
and notice the events that
precede and follow it.
3. Getting a clear picture of
what happens before and after
the behavior enables us to
identify what needs to be
changed.
GROUP PROCESS AND ACTIVITIES
Participants will utilize "Steps in
Self-Management" (See Appendix A,
Handout 3) to follow along as the
leader teaches them the method.
Participants will utilize the "SelfMonitoring Journal Sheet" (See
Appendix A, Handout 4) to record
their behavior for at least three
days. By so doing, they will
establish a baseline for the
behavioral occurrence and increase
their understanding of it as well.
Leader will illustrate this point by
giving an example such as a dieter
who defined her problem as overeating. The leader will explain,
"After the dieter monitored her
behavior, she learned that she
snacked on sweets in the evening
00
.j:::>
Phase 2:
Identifying the Problem and Developing a Self-Management Plan
Objective 2:
To teach participants the principles of self-management and to assist
them in designing their own personalized strategy for change.
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
while watching TV and feeling bored.
This relieved her boredom but left
her feeling guilty. From this
information, she made a decision
to alter the compulsive snacking. 11
B. Step 2: Translate the behavior
into an A-? B~C (antecedants
behavior
consequences) model.
Leader will describe an example
model such as the snacking problem.
If a blackboard is available, s/he
will write out the model:
A
watching TV,
feeling
bored
)"
B
snacking on
sweets
) C
relieves
boredom
but
induces
guilt
If self-monitoring has been completed
already, participants will write
out their own models and share these
with the group.
00
tn
Phase 2:
Identifying the Problem and Developing a Self-Management Plan
Objective 2:
To teach participants the principles of self-management and to assist
them in designing their own personalized strategy for change.
CONTENT OUTLINE
C. Step 3: Manipulate the model to
generate alternative solutions
by changing the antecedants of
the behavior.
1. List as many alternatives as
you can think.
2. These are the steps (called
subgoals) that can lead you
to your long-range goal.
3. Subgoals always pertain to
the process behaviors that
contribute to the problem.
GROUP PROCESS AND ACTIVITIES
Using an example A~B-7C model such
as the snacking behavior, the leader
will give examples of alternatives
such as the ones available to the
dieter:
1. Snack on foods low in calories.
2. Do not keep favorite snack foods
in the house.
3. When snacking, eat at a slower
pace.
4. Make a rule that eating take
place only in the kitchen.
5. Instead of watching TV, go for
a walk.
If participants have self-monitored
their behaviors, they will help each
other brainstorm ways to change the
cues associated with their process
behaviors.
00
0\
Phase 2:
Identifying the Problem and Developing a Self-Management Plan
Objective 2:
To teach participants the principles of self-management and to assist
them in designing their own personalized strategy for change.
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
Participants will utilize
"Developing a Plan of Action" (See
Appendix A, Handout 5) to list their
own alternatives.
D. Step 4: Commit yourself to a
subgoal.
1. Choose which subgoal will help
you the most, yet be the
easiest to implement.
Participants will record their
commitment on the handout,
"Developing a Plan of Action"
(See Appendix A, Handout 5)
Participants will verbalize their
commitment to the group.
2. Make sure your subgoals are
specific, stated in positive
terms and attainable (set only
slightly higher than your
present level of operation).
Leader will be alert to members
setting overly ambitious goals and
will guide them to replace these
with readily attainable ones.
00
---J
""
Phase 2:
Identifying the Problem and Developing a Self-Management Plan
Objective 2:
To teach participants the principles of self-management and to assist
them in designing their own personalized strategy for change.
CONTENT OUTLINE
E. Step 5: Reward yourself when you
attain your subgoal.
1. By rewarding yourself, you are
changing the consequences of
behavior (part "C" of your
model) . You are reinforcing
your desired behavior.
2. Rewards should be truly
enjoyable, able to be applied
immediately, and whenever
possible, include other people
who are supportive of your
goals.
GROUP PROCESS AND ACTIVITIES
The leader will give examples of
appropriate rewards such as those
chosen by the dieter: (1) go out
to dinner with a friend, (2) buy
a new dress, (3) take a long bubble
bath, and (4) see a movie.
Participants will set up a reward
system by utilizing "Developing a
Plan of Action" (See Appendix A,
Handout 5).
Leader will ask members to decide
how the group as a whole could
reward them. S/he will suggest
such rewards as a group hug, a
rewards ceremony, congratulatory
statements, etc.
00
00
Phase 2:
Identifying the Problem and Developing a Self-Management Plan
Objective 2:
To teach participants the principles of self-management and to assist
them in designing their own personalized strategy for change.
CONTENT OUTLINE
F. Step 6: Evaluate the alternative.
1. Ask yourself, "Am I benefiting
from this strategy and are the
costs (hassels) of implementing
it what I expected? Would
other solutions solve my
problem more effectively with
less effort?"
2. If the answer to the latter
question is yes, then either
go back to Step 3, reassess
your alternatives and commit
to a new one, or return to
Step 1 and redefine the
problem.
3. If your alternative is working,
then simply continue it or
try it on an even bigger scale.
G. Step 7: Continue to re-evaluate
the problem and re-state new subgoals as your understanding of the
problem increases and as your
needs change.
GROUP PROCESS AND ACTIVITIES
Leader will emphasize that
constructive evaluation requires a
non-critical attitude and that one
of the functions of the group is to
support each other in developing
this.
00
~
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 1:
To take a process focus and assist participants in becoming aware of
the expectations and standards they self-impose.
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
I.
Self-expectations are beliefs we hold
about the way we should be.
A. When we engage in self-change we
try to act in ways that we believe
will make us successful.
B. We judge ourselves and assess our
progress based on these beliefs.
Leader will give examples to
clarify this such as a smoker who
believes that total abstinence from
the start is absolutely necessary,
a dieter who forbids himself to eat
over a certain amount of calories
per day, and a jogger who can't miss
exercise no matter how sore her
muscles are.
C. Expectations can work for us or
against us in our attempts to
control our behavior.
Participants will rate how
perfectionistic and rigid their
standards are by utilizing "Do Your
Expectations Work for or Against
You? (See Appendix A, Handout 6).
They will compare and discuss the
results with each other.
II.
Functional self-expectations assist
us and act as helpful guides as we
move along the path of change.
\.0
0
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 1:
To take a process focus and assist participants in becoming aware of the
expectations and standards they self-impose.
CONTENT OUTLINE
They are based upon:
A. An accurate understanding of the
change process.
1. The change process is not an
exclusively uphill climb.
There are plateaus and setbacks.
2. Resistance to change is a
natural part of the process
and as such should be honored
and understood rather than
condemned.
B. Flexibility.
1. Standards should be flexible
enough to take into account
individual needs.
2. They should be strong enough
to maintain a commitment.
C. A realistic appraisal of present
behavior. Expectations should not
be so high as to be unattainable
or so low as to be unmotivating.
GROUP PROCESS AND ACTIVITIES
Participants will receive and
discuss "Change in Action" (See
Appendix A, Handout 7).
Participants will discuss the
various "shoulds" they use in trying
to motivate themselves. The leader
will encourage them to challenge
any that diminish self-esteem and
impede attainment of goals.
Leader will enlist members' support
in helping each other lower standards
that might be heading them in the
direction of self-defeat.
lD
f-'
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 2:
To identify and alter the self-defeating aspects of participants'
attempts to control their targeted behaviors.
CONTENT OUTLINE
I.
Control is an important issue to be
dealt with in the process of change.
A. When we decide to change, we admit
that something about us is not
okay and that a particular
behavior or aspect of ourselves
is out of control.
B. One of the goals of the change
process is to regain control
over the targeted behavior.
C. Along the pathway of change,
the control issue is ever
present.
1. We continually engage in ways
to maintain control over our
undesirable behaviors and thus
live up to our goals and
expectations.
2. Our styles of imposing control
can be helpful or actually
function to impede progress.
GROUP PROCESS AND ACTIVITIES
Leader will give examples of
situations that are out of our
control (traffic jams, bad weather,
someone else's reactions to us, etc.)
and ask participants to discuss
how they tolerate such instances.
Participants will explore how
strongly they feel a need to be
"in control."
To reinforce positive steps in
taking control, the leader will
invite members to share all the ways
they have advanced their goals.
They will discuss adjustments they've
made in expectations, awarenesses
they've gained and positive actions
taken.
\0
N
Phase 3:
Implementing the Plan:
Objective 2:
To identify and alter the self-defeating aspects of participants'
attempts to control their targeted behaviors.
CONTENT OUTLINE
Exploring and Resolving Obstacles
GROUP PROCESS AND ACTIVITIES
To increase confidence and a sense
of control, the leader will introduce the technique of visualization
and lead the group in a mastery
imagery (in which they imagine
themselves having achieved goals).
Leader will distribute "Creative
Visualization" (See Appendix A,
Handout 8) so that participants can
practice mastery imagery at home.
To reinforce the benefits of such
imagery, members will be encouraged
to rate their confidence levels on
the "Belief in Success" scale
(See Appendix A, Handout 1) after
they practice the technique.
1.0
tN
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 2:
To identify and alter the self-defeating aspects of participants'
attempts to control their targeted behaviors.
CONTENT OUTLINE
II.
The way we enforce self-control is
evident in the way we talk to ourselves; the inner-dialogues we carry
on throughout the day. This is
called self-talk.
A. Self-talk is made up of beliefs,
attitudes and thoughts.
1. Self-talk consists of words
that run through our minds in
response to an activating
event.
2. Self-talk is usually automatic
and often represents longstanding, well-learned
attitudes.
3. It influences how we feel, act
and see ourselves (selfconcepts).
B. Self-talk operates in the following
way:
1. When something happens at point
A (such as lapsing from a diet),
we talk to ourselves at point_ B
GROUP PROCESS AND ACTIVITIES
Participants will utilize the "SelfTalk Record" (See Appendix A,
Handout 9) to discover their selftalk and to gain insight into how
it affects their emotions.
Leaders will be alert to instances
in which participants engage in
obstructive self-talk. Leader will
point these out and invite members
to do the same.
Leader will give an example of an
activating event (writing the
A~B~C model on a blackboard, if
\0
.j:::.
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 2:
To identify and alter the self-defeating aspects of participants'
attempts to control their targeted behaviors.
CONTENT OUTLINE
(eg. "I shouldn't have eaten
so much. I'm a pig!"). This,
in turn, influences our emotional
response (eg. "I feel terrible!").
2. A does not cause C. Instead,
B influences C.
3. Unrealistic and irrational selftalk helps create unpleasant
emotions.
C. The self-talk we use to control our
unwanted behaviors often stems from
attitudes we learned as children
through experiences with authority
figures (parents, teachers, etc.).
1. As such, controlling self-talk
is often authoritative.
2. Often, it is critical and
irrational, thus hindering our
progress.
GROUP PROCESS AND ACTIVITIES
available) and ask participants to
share what their self-talk and
subsequent feelings would be.
Participants will volunteer to share
personal examples of negative selftalk. They will discuss insights
gained from recording their thoughts
on the "Self-Talk Record" (See
Appendix A, Handout 9).
Members'will discuss the authoritative aspects of their self-talk.
To facilitate this, the leader will
ask participants to describe how
parental authority was enforced as
they were growing up and to note
any similarities between this and
how they treat themselves now.
\0
tn
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 2:
To identify and alter the self-defeating aspects of participants'
attempts to control their targeted behaviors.
.,'
I
CONTENT OUTLINE
III.
Controlling self-talk falls into
three distinctive styles which many
of us share. Each style has
irrational thinking patterns that
are characteristic of it.
A. If we operate with a perfectionistic style, we set rigid
standards that are usually out
of our reach, but to which we
demand strict adherence.
Distorted thinking patterns are:
1. Ali-or-nothing thinking:
Everything is viewed and judged
in black and white terms.
2. Overgeneralization: One event
leads to dogmatic (mostly
negative) conclusions about
everything.
3. Magnification and Minimization:
Mistakes are magnified and
successes are downplayed.
GROUP PROCESS AND ACTIVITIES
Participants will utilize "SelfControlling Styles" (See Appendix A,
Handout 10) to further discover how
they may be sabotaging their own
efforts.
Leader will give examples of
distorted thinking patterns and
participants will discuss personal
examples and share how their controlling styles effect their
emotions.
Leader will encourage and model
mutual support and understanding
of participants' disclosures.
~
0\
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 2:
To identify and alter the self-defeating aspects of participants'
attempts to control their targeted behaviors.
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
B. If we operate with a critical
style, we find fault wherever
we can and berate ourselves for
mistakes. Distorted thinking
patterns include:
1. Labeling: We base our selfesteem and define ourselves
according to our errors.
2. Disqualifying the positive:
We filter anything positive
and dwell on the negative.
C. If we operate with a
rationalizing style we try to
protect our self-esteem by
making excuses for our failures.
There is one distinctive thinking
pattern:
1. Yes-but thinking: We duck
our responsibilities and goals
with self-talk that utilizes a
disclaimer (and is usually
preceded by the word "but").
1.0
"'"-~
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 2:
To identify and alter the self-defeating aspects of participants'
attempts to control their targeted behaviors.
CONTENT OUTLINE
IV.
GROUP PROCESS AND ACTIVITIES
To change our controlling styles and
our irrational ways of thinking, we
must alter how we deal with ourselves.
Throughout this and the next phase,
leader will conduct mastery
visualization as the needs of the
group dictate.
A. The first step is to challenge the
"inner-controllers" by refuting
irrational self-talk and substituting rational, productive
responses.
B. To identify irrationality ask
yourself the following questions:
1. "Are the beliefs reflected in
my self-talk based on objective
reality?"
2. "What is the evidence for my
conclusions?"
3. "Do these thoughts help me
reach my goals?"
4. "Do these thoughts help me
feel the way I want or help
me to feel miserable?"
Leader will give examples of
irrational statements and ask
participants to identify the
cognitive distortions.
Participants will practice refuting
irrationality by brainstorming
convincing rebuttals to the examples.
!.0
00
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 2:
To identify and alter the self-defeating aspects of participants'
attempts to control their targeted behaviors.
CONTENT OUTLINE
C. When you find yourself
experiencing negative emotions,
particularly feelings of failure
and hopelessness, take these
steps:
1. Identify the self-defeating
thought.
2. Find the irrationality in
it.
3. Write a rational response
in defense of yourself.
4. Take note of your new
feeling and increased
confidence as a result of
the adjustment.
GROUP PROCESS AND ACTIVITIES
Participants will utilize "Challenge
Your Controlling Style" (See
Appendix A, Handout 11) to monitor
and refute dysfunctional thoughts
as they occur outside the group.
Participants will help each other
find the irrationality of their
self-talk and develop convincing
self-defenses.
Participants will be encouraged
to take note of how their confidence
is affected by indicating this on
the "Belief in Success" scale
(See Appendix A, Handout 1).
1.0
1.0
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 3:
To deepen self-exploration and uncover motivations that maintain
the problem.
CONTENT OUTLINE
I.
When difficulties in controlling
behaviors persist and when low
motivation is a particular problem,
we may have to take a look at
ourselves at a level deeper than
how we think and act along the
path of change.
GROUP PROCESS AND ACTIVITIES
Leader will actively lead the group
beyond exploring at the situational
and cognitive levels and will focus
at the intrapsychic and interpersonal levels. The leader will
attempt to uncover problems at these
levels that create the impasse to
change.
The leader will not intervene at
these levels, but simply bring these
problems to participants' awarenesses and help them explore
solutions to the impasse.
A. It may prove important to
explore why we decided to embark
on the path of change in the
first place.
1. The source of our decision
to change effects how well
we succeed.
Participants will utilize "The
Should-Want Inventory" (See
Appendix A, Handout 12) to assist
them in actively exploring their
motivations for change.
f--1
0
0
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 3:
To deepen self-exploration and uncover motivations that maintain
the problem.
CONTENT OUTLINE
2. It effects our motivation
levels and strength of our
willpower.
3. The source of our decision
is usually not clear cut.
It generally represents a
combination of reasons.
B. We are internally motivated when
our goal for behavioral change
has personal significance that
eminates from a true desire to
be different (eg. a dieter who
tries to lose weight so she can
feel proud of her body).
1. Making a commitment to something we truly want, generally
feels like a choice that is
under our control.
2. Such a choice increases
motivation and strengthens
willpower.
GROUP PROCESS AND ACTIVITIES
Participants will share the personal
meaning of their goals.
Leader will take advantage of the
cohesive environment that has been
developed at this point, and
encourage self-disclosure and mutual
risk-taking.
Participants will discuss the
internal and external reasons for
decidini to change.
Participants will explore how it
feels to be internally motivated
by "wants" vs. how it feels to be
externally motivated by "shoulds."
......
0
......
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 3:
To deepen self-exploration and uncover motivations that maintain
the problem.
CONTENT OUTLINE
II.
GROUP PROCESS AND ACTIVITIES
C. When the decision to embark on
the path of change is made
because we feel pressure from
external sources (family,
friends, bosses, doctors,
etc.), then we are externally
motivated (eg. a dieter who
tries to lose weight so that
her husband will stop criticizing her).
1. Motivation tends to be low.
2. In fact, we may actually
rebel against what feels
like an imposed demand by
sabotaging our own efforts.
Leader will be alert to participants
who appear to be motivated almost
exclusively externally. Leader will
direct participants' awareness to
this and assist them in exploring
options in light of this insight.
All our behavior, whether good or
bad, has meaning in our lives. Thus,
when we have difficulty controlling a particular habit, we may have
to explore if it has a significant
meaning that motivates us to hold
onto it.
Participants will explore the
personal significance of their
unhealthy behaviors. The leader
will encourage meaningful selfdisclosure, mutual risk-taking
and high levels of empathy.
f-1
0
N
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 3:
To deepen self-exploration and uncover motivations that maintain
the problem.
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
The leader will focus on uncovering
the psychological concomitants of
the behavior.
A. Often, our unhealthy habits
have "pay-offs" (benefits)
that make them desirable to
some extent.
1. We may be consciously aware
of these pay-offs as in the
case of a smoker who calms
his nerves by smoking.
2. Or, we may not be consciously aware of them as
in the case of an overeater
who eats out of loneliness
but maintains the extra
weight as a way of avoiding
relationships.
Participants will utilize "The
Hidden Pay-Offs" (See Appendix A,
Handout 13) to assist them in
indentifying the significance of
their behavior and gaining insight
into how this might be creating an
impasse to change.
.......
0
VI
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles·
Objective 3:
To deepen self-exploration and uncover motivations that maintain
the problem.
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
B. Generally, the greater the
meaning our behavior holds
(i.e. the more important the
pay-offs), the h~rder it is
to change it.
1. We are strongly motivated
to hold onto such behavior.
2. Thus, this motivation
conflicts with the motivation to change and may
indeed account for the
failure to change.
C. When we gain greater understanding into our conflicting
motivations, we come to view
our problem behavior in a
different way.
Leader will direct
awareness to their
negative behaviors
to explore ways to
participants'
role in sustaining
thus enabling them
alter this role.
D. By defining our problems
differently, we may also need
to define our goals differently.
Leader will stress the importance of
taking responsibility for choosing
new courses of action based on the
deeper understanding of the problem.
Participants will help each other
increase their awareness of different
alternatives.
1-'
0
~
•
Phase 3:
Implementing the Plan:
Exploring and Resolving Obstacles
Objective 3:
To deepen self-exploration and uncover motivations that maintain
the problem.
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
1. We may find that our behavior
serves such an important
function that we decide not
to change after all.
---
Participants will utilize "The
Hidden Pay-Offs" (See Appendix A,
Handout 13) to weigh the pros and
cons of changing their behavior.
2. We may decide to deal directly
with the pay-offs that have
maintained the behavior. For
example, the dieter mentioned
above, may decide to deal with
her fear of becoming involved
in relationships instead of
or in addition to losing weight.
The leader will strive to keep the
group focused on its task of
identifying impasses to change and
will not attempt to solve the
dynamics of the problem. Instead,
when the nature of the impasse
requires psychological intervention,
the leader will make an appropriate
referral for psychotherapy.
3. We may discover that we can
substitute other, more constructive ways of getting the
pay-offs that our behavior has
been providing. For example,
the smoker mentioned above, can
use a relaxation technique
rather than smoking to calm his
nerves.
Participants will utilize "The
Hidden Pay-Offs" (See Appendix A,
Handout 13) to explore constructive
substitutes for their needs.
I-'
0
tr1
Phase 4:
Developing Coping Strategies for Maintaining Change
Objective 1:
To help participants develop the skills that reinforce an attitude
of self-acceptance.
CONTENT OUTLINE
I.
Developing an attitude of selfacceptance enhances our abilities
to reach and maintain our desired
change.
A. A self-accepting attitude is a
non-judgmental way of seeing
ourselves. It consists of
self-respect, constructive
assessment, and nurturing selfsupport.
B. A self-accepting attitude
enhances positive self-concept
which, in turn, influences success beliefs and actions.
C. As such, it plays an important
role in facilitating change.
Thus, it is both a goal of
change and a crucial factor
in achieving the goal.
1. Our "end result" goal will
not guarantee that we will
feel happier and healthier.
GROUP PROCESS AND ACTIVITIES
Leader will model an attitude of
acceptance towards participants and
will encourage them to do the same.
By giving each other support and
acceptance, participants will be
more inclined to treat themselves
with this same attitude.
During this phase, leader will begin
preparing participants for the
ending of the group b.y reminding
them of the upcoming termination
date.
......
0
0'1
Phase 4:
Developing Coping Strategies for Maintaining Change
Objective 1:
To help participants develop the skills that reinforce an attitude
of self-acceptance.
CONTENT OUTLINE
2. However, a self-accepting
attitude is independent of
the end result and does
improve how we feel.
D. Developing a self-accepting
attitude takes practice in
learning the skills that
reinforce it.
II.
Self-support skills are positive
coping strategies that enable
us to handle the process of change
more effectively. They help us
develop an "I can handle it"
attitude.
A. Constructive self-assessment is
a non-judgmental way of
evaluating our progress and
solving problems.
1. By utilizing this approach,
we are able to recognize difficulties in an objective way,
without the critical judgment
GROUP PROCESS AND ACTIVITIES
The group setting will provide
participants the opportunity to
practice how to solicit support in
their own environments.
Leader will stress the usefulness
of these skills in continuing their
efforts after the group has
terminated.
Participants will utilize the
"Learning Opportunity Worksheet"
(See Appendix A, Handout 14), to
assist them in taking a constructive
problem-solving approach to
handling set-backs and relapses.
I-'
0
-....)
Phase 4:
Developing Coping Strategies for Maintaining Change
Objective 1:
To help participants develop the skills that reinforce an attitude
of self-acceptance.
CONTENT OUTLINE
that often produces guilt
feelings.
2. We are able to identify
factors that contribute to
problems; ascertaining what
went wrong.
3. This information enables us
to plan a strategy for
handling the problem should
it arise in the future.
B. Self-support talk is made up of
statements that reinforce
positive qualities and affirm
what we wish. These are called
affirmations.
1. Affirmations can replace
stale, worn-out, negative
self-talk.
2. Affirmations increase belief
in success as well as confidence in handling set-backs.
GROUP PROCESS AND ACTIVITIES
Participants will discuss difficulties they are having in
implementing their change plans
and will help each other explore
resolutions.
Participants will utilize "SelfSupport Talk" (See Appendix A,
Handout 15) to assist them in
creating a repertoire of affirmations.
Participants will share personal
affirmations and brainstorm ideas.
1-'
0
00
Phase 4:
Developing Coping Strategies for Maintaining Change
Objective 1:
To help participants develop the skills that reinforce an attitude
of self-acceptance.
CONTENT OUTLINE
C. Self-support imagery is a
technique whereby we visualize
ourselves handling our emotional
needs when we feel upset.
1. To do this, we attain a state
of deep relaxation.
2. We visualize ourselves in our
present state of upset.
3. We then see a wise, nurturing
person coming towards us from
a distance. This person sits
next to us, comforts us and
listens to our problem.
4. We listen carefully for advice
and positive affirmations.
5. It is necessary to hold this
picture until our confidence
returns.
GROUP PROCESS AND ACTIVITIES
Participants will utilize the
instructions for deep breathing
and muscular relaxation contained
in "Creative Visualization" (See
Appendix A, Handout 8).
Participants will utilize the
affirmations they created from
using "Self-Support Talk" (See
Appendix A, Handout 15).
Throughout this phase, participants
will utilize the "Process Assessment"
(See Appendix A, Handout 16) to
monitor progress and report this
back to the group.
I-'
0
\.0
Phase 4:
Developing Coping Strategies for Maintaining Change
Objective 2:
To assist participants in building relapse prevention skills.
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
I.
Participants will utilize "The Road
to Relapse" (See Appendix A, Handout
17) to follow along as the leader
discusses the dynamics of relapse.
When we attain our goals, the selfcontrol we've been striving towards
finally becomes a reality. However,
just as we encountered difficulties
in reaching this point, we are
bound to confront problems in maintaining it. The risk of relapse is
ever present.
A. Situations that threaten our
sense of control pose high risks
of relapse.
1. These situations are different
for each of us. As such, we
must identify what situations
(thoughts, feelings and events)
are likely to pose such threats.
2. Some common high-risk situations
are:
(a) negative emotional states
such as anger, anxiety,
loneliness, guilt, etc.
(b) interpersonal conflicts
such as jealousies,
arguments, etc.
Participants will discuss situations
they believe will pose great threat.
To help identify precipitating
events, participants can review the
"Self Monitoring Journal Sheet" (See
Appendix A, Handout 4), and to help
identify troublesome thinking patterns, they can review "Self-Talk
Record" (See Appendix A, Handout 9)
and "Self-Controlling Styles" (See
Appendix A, Handout 10).
1-'
1-'
0
Phase 4:
Developing Coping Strategies for Maintaining Change
Objective 2:
To assist participants in building relapse prevention skills.
CONTENT OUTLINE
(c) social pressures to
engage in old behavior.
B. Whether or not a relapse occurs
depends upon our capacity to use
adequate coping skills in the face
of a threat.
1. Effectively coping and avoiding
a relapse increases our confidence, reinforces our new
behavior and decreases the
probability of future relaps~s.
2. On the other hand, when we lack
coping ability, we tend to feel
further threatened and, at
precisely these times, the payoffs of our old behavior often
tempt us more.
3. If we do slip, our confidence
sinks further and we may even
engage in old, self-defeating
ways of dealing with ourselves.
4. All of this adds up to an
increased probability of future
relapses.
GROUP PROCESS AND ACTIVITIES
Leader will describe likely highrisk situations. Participants will
discuss these and generate various
ways of responding.
I-'
I-'
I-'
Phase 4:
Developing Coping Strategies for Maintaining Change
Objective 2:
To assist participants in building relapse prevention skills.
CONTENT OUTLINE
II.
Practicing relapse prevention
strategies before we are faced
with an actual threat will help
us in coping when it does occur.
GROUP PROCESS AND ACTIVITIES
The leader will direct participants'
awareness to the reality that the
group will soon be terminating and
that the loss of group support will
add to the threatening aspects of
relapse.
·
Leader will suggest continued use of
the "Process Assessment" (See
Appendix A, Handout 16) after the
group has terminated and will ask
participants to begin thinking of
ways they can minimize the effects
of the loss.
A. Once we have identified potential relapse situations, we can
develop and practice strategies
for effectively dealing with
them.
Participants will utilize the
"Relapse Prevention Plan" (See
Appendix A, Handout 18) to list
high-risk situations and to plan
coping strategies.
I-'
I-'
N
Phase 4:
Developing Coping Strategies for Maintaining Change
Objective 2:
To assist participants in building relapse prevention skills
CONTENT OUTLINE
1. To make these strategies
effective, we must define the
situation concretely and
specifically.
2. Knowing the thoughts, feelings
and chain of events that
contribute to the threat,
enables us to use these
factors as warning signals
to implement a coping skill.
B. Self-support skills furnish us
with invaluable tools for dealing
with an occurrence of relapse.
1. Constructive self-assessment
can be employed to analyze what
went wrong and help plan for
the "next" time.
2. Self-support talk will help in
avoiding negative self-talk and
self-support imagery will assist
in salving feelings of failure.
GROUP PROCESS AND ACTIVITIES
Participants will role-play responses
to the situations they have identified as particularly risky. They
will give each other constructive
feedback on these role-plays and
make suggestions for improvements.
Leader will model appropriate coping
responses as well as offer specific
coaching and instruction.
Participants will be encouraged to
utilize the "Learning Opportunity
Worksheet" (See Appendix A, Handout
14) whenever a relapse occurs.
I-'
I-'
VI
Phase 4:
Developing Coping Strategies for Maintaining Change
Objective 2:
To assist participants in building relapse prevention skills.
CONTENT OUTLINE
C. Preparing a coping strategy will
not help if, in the situation, our
anxiety rises so high as to make
it virtually impossible to
implement.
1. Learning how to stay relaxed in
these situations will enable us
to apply our coping strategies
most effectively.
2. To do this, use the creative
visualization technique to
create a clear picture of the
high-risk situation. While concentrating on this, apply muscular relaxation to attain a
state of relaxation.
3. Practicing a relaxation response
while imagining the threat will
help decrease anxiety in the
actual situation.
GROUP PROCESS AND ACTIVITIES
Participants will utilize the
"Relapse Prevention Plan" (See
Appendix A, Handout 18) to create a
hierarchy of high-risk situations.
Leader will guide participants
through a stress innoculation imagery
in order to acquaint them with the
procedure.
t-1
t-1
~
Phase 5:
Terminating the Group
Objective:
To consolidate learning and prepare participants for separation
from the group.
CONTENT OUTLINE
I.
The ending of the group signals
feelings of loss and fear.
A. After we have invested ourselves
in the group process, and have
come to value it as a source of
support, we quite naturally feel
sad about giving this up.
B. In addition, it is quite natural
to have fears about facing dayto-day realities without the help
and encouragement of the group.
1. If our anxieties over the loss
rise, we may end up feeling
completely ill-prepared for
handling difficulties on our
own.
2. At these moments, self-support
skills will help allay these
anxieties by affirming our
capabilities.
GROUP PROCESS AND ACTIVITIES
Participants will share what the
group has meant to them, what
aspects in particular have been
significant and what about the
experience they will miss the most.
Leader will assist participants
clarify their fears and explore how
they can best cope with these·.
To bolster confidence in the innerresources that will sustain change,
participants will review new
knowledge, skills and self-awarenesses they have gained.
Participants will give feedback
about their observations of how
others have progressed.
1--'
1--'
Ul
Phase 5:
Terminating the Group
Objective:
To consolidate learning and prepare participants for separation
from the group.
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
Leader will actively assist participants put into meaningful perspective the gains they have made.
C. Despite the group's ending, it
is crucial to continue participating in the process of change.
We can do this by initiating
some action(s) that strengthen(s)
the commitment to our goals.
Some options are:
1. Ongoing contact with other
participants.
2. Contacting the group leader
if a crisis should arise.
3. Attendance at follow-up
sessions.
Participants will describe in detail
how they plan on continuing their
efforts.
Leader will give the specific date
of the first follow-up session and
explain its importance as a way of
strengthening the commitment to
continued change.
1-'
f-1
0\
Phase 5:
Terminating the Group
Objective:
To consolidate learning and prepare participants for separation
from the group.
CONTENT OUTLINE
GROUP PROCESS AND ACTIVITIES
The leader will explain that one of
the aims of the follow-up sessions
is to help participants with the
difficulties of maintaining change.
Thus, s/he will stress that anybody
having problems should not allow
embarrassment over this to keep them
from attending.
D. Continuing to participate in
the process of change in a
positive, self-accepting way
is the true measure of the
success of our efforts.
Participants will fill out the
"Program Evaluation" (See Appendix
A, Handout 19).
Participants and the leader will
make their good-byes and express
any last thoughts or feelings that
finalize a sense of closure.
f-1
f-1
"'-l
Chapter 5
SUMMARY, CONCLUSIONS,
AND RECOMMENDATIONS
Summary
Disease patterns in America have changed
drastically in recent years.
At the turn of the century,
the major health threats were infectious diseases.
In
contrast, today's deadly killers are chronic diseases
that are often the result of modern American life-style
itself.
Unhealthy habits account for six out of the ten
factors associated with America's number one killer,
cardiovascular disease
(Miller
&Allen,
1982).
In addition, health care costs have skyrocketed
in this country increasing from $27 billion in 1960, to
over $321 billion in 1982
1983).
(Brennan cited in Levine,
It has been estimated that half of this cost is
absorbed by American corporations in health insurance
payments and productivity losses due to disability
(Brennan, 1982).
It was the purpose of this project to design a
program to teach people how to control unhealthy habits
and how to maintain successful change.
The program was
designed as a generic model for addressing various
118
119
unhealthy behaviors and was intended for small group
application to occupational and clinical settings.
The program design was based on the assumption
that in order to achieve lasting life-style change, it is
necessary to experience the process of change as positive
and rewarding.
The program objectives were:
(a) to help
participants explore, on the cognitive, behavioral, and
affective levels, how they block their own efforts to
change; (b) to help participants identify conflicting
motivations that support unhealthy behaviors; and (c) to
help participants acquire the self-support skills
necessary to maintain new behaviors.
The program focused on the continued maintenance
of behavioral change because the literature review
revealed that most treatment programs have high rates of
recidivism
& Gordon,
Pate & Blair,
(Marlatt
Dishman cited in
1980; Danaher, 1982;
1983; Henderson etal.,
1979), and that people have the greatest difficulty
adhering to treatment regimens that require habit modification
(Haynes, 1976).
To combat the serious problem of
recidivism, the program utilized cognitive-behavioral
methods and concepts shown to influence successful
maintenance.
The literature review contained three sections:
(a) a review of health behaviors which summarized the
dynamics of illness, preventive, and compliance behaviors;
120
(b) information on behavioral research and treatment
methods that was relevant to the design of the program;
and (c) an overview of health promotion efforts occurring
today in American corporations.
Implementation guidelines were discussed that
covered application of the program to both clinical and
occupational settings.
Particular attention was given to
factors associated with worksite implementation:
how to
market and promote the program, and how to utilize the
work environment to enhance the program's effectiveness.
The program manual included a detailed content
outline, suggested group activities and supplemental
materials.
The program was organized into five develop-
mental phases intended to build successively upon each
other to help guide participants through the change
process.
The objectives of these phases were: (a) phase
one:
to set the foundation for a group culture supportive
of self-exploration; (b) phase two:
to help participants
utilize self-management principles to develop personalized
plans for change; (c) phase three:
to assist participants
resolve problems with implementing their plans and to
alert them to ways they sabotage their own efforts;
(d) phase four:
to help participants develop the coping
skills necessary for the continued maintenance of their
new behaviors; and (e) phase five:
.
il
to assist participants
121
in consolidating new skills in separating from the group.
Conclusions
Through the extensive review of the literature
and the author's experience as a health promotion
counselor, the following conclusions have been reached:
1.
The high rates of recidivism associated with
most behavioral treatment programs suggest that treatment
strategies must go beyond addressing the situational and
behavioral contingencies effecting unhealthy behaviors
and must recognize their psychological concomitants.
Thus, psychology professionals must utilize their
counseling skills to assist people remove the obstacles
to change that occur on the intrapsychic and interpersonal
levels.
2.
There is a dire need to make explicit the
underlying cognitive and affective processes that
accompany people's efforts to change unhealthy habits,
and to deal with these process issues in combination with
the situations in which they occur.
3.
Most behavioral approaches to the treatment
of unhealthy behaviors do not recognize maintenance as
a separate entity, and as a result, fail to prepare people
for the inevitable difficulties of maintaining newly
achieved behavior.
'
0
122
4.
Most corporate health promotion efforts occur
quite separately from the counseling programs offered
employees (employee assistance programs).
It is highly
recommended that more of a collaborative approach be
taken between these departments in order to provide a
health promotion approach that integrates the psychological and physical components of healthful living.
Recommendations
The following recommendations are made:
(a) the
program be implemented in both clinical and occupational
settings; (b) the program be implemented in both a homogeneous group that addresses one health issue, and a
heterogeneous group dealing with various health damaging
behaviors; and (c) participant follow-up data be obtained
for at least six months with particular attention devoted
to predictive indices of maintenance.
'
"
123
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Prochaska, James 0., Crimi, Pamela, Lapanski, Duane,
Martel, Linda & Reid, Peter (1982) Self-change
processes, self-efficacy and self-concept in relapse
and maintenance of cessation of smoking. 51
983-990
Prochaska, James 0., & DiClemente, Carlo C.
(1984)
The transtheoretical approach: Crossing traditional
boundaries of therapy. Homewood, Illinois:
Dow Jones-Irwin.
Rocella, Edward J.
(1982). Selected roles of the
Federal Government and health promotion/disease
prevention focus on the worksetting. Health
Education Quarterly. ~(Special Suppl.). 83-91
Schwartz, Gary E.
(1982). Stress management in occupational settings.
In Rebecca S. Parkinson, & Assoc.
(Eds.). Managing health promotion in the workplace:
Guidelines for im lementation and evaluation.
pp. 232-251 . Palo Alto, Ca.: May 1el Pub. Co.
'
0
128
Shiffman, Saul (1982).
Relapse following smoking
cessation: A situational analysis. Journal of
Consulting and Clinical Psychology ~ 71-86
Stone, George C.
(1979). Patient compliance and the
role of the expert. Journal of Social Issues 35
34-59
Thigpen, Peter.
(1984)
Keynote Address. Wellness in
the workplace conference. National Training Lab
Institute. Los Angeles, Ca.
Tobias, Lester L. & MacDonald, Marian L.
(1977)
Internal
locus of control and weight loss: An insufficient
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Psychology ! 647-653
Ureda, John R. & Taylor, Robert B.
(1982) Weight control.
In Robert B. Taylor (Ed.). Health promotion
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(pp. 197-214).
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Wallston, Barbara S. & Wallston, Kenneth A.
(1978)
Locus of control and health: A review of the
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Harper & Row
How people change.
New York:
Wilson, Terence (1980) Cognitive factors in lifestyle
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Park 0. Davidson & Sheena M. Davidson (Eds.).
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Book, Inc.
APPENDIX A
SUPPLEMENTAL MATERIALS FOR
GROUP ACTIVITIES
129
130
TABLE OF CONTENTS
Handout
Page
.
1.
BELIEF IN SUCCESS
2.
THE CASE OF BOB
3.
STEPS IN SELF-MANAGEMENT
4.
SELF-MONITORING JOURNAL SHEET
5.
DEVELOPING A PLAN OF ACTION
6.
DO YOUR EXPECTATIONS WORK FOR
OR AGAINST YOU? .
131
.•
. .
. . .
7.
CHANGE IN ACTION
8.
CREATIVE VISUALIZATION
9.
SELF-TALK RECORD
. . .
. . .
. . . . . .
132
133
134
. .
135
. . .
. . .
137
138
139
. . .
141
10.
SELF-CONTROLLING STYLES
142
11.
CHALLENGE YOUR CONTROLLING STYLE
147
12.
THE SHOULD-WANT INVENTORY
148
13.
THE HIDDEN PAY-OFFS
14.
LEARNING OPPORTUNITY WORKSHEET
15.
SELF-SUPPORT TALK .
. . . .
16.
PROCESS ASSESSMENT
. . .
17.
THE ROAD TO RELAPSE
155
18.
RELAPSE PREVENTION PLAN
156
19.
PROGRAM EVALUATION
. . . .
. . .
150
152
.
. . .
153
154
157
Handout 1
BELIEF IN SUCCESS
2
1
I believe I will
not achieve my
goals.
I strongly believe
I will not achieve
my goals.-
5
I am leaning
towa.rd believing
I wi 11 succeed.
4
3
I am leaning away
from believing I
will achieve my
goals.
6
I believe I will
achieve my goals.
I could go
either way.
7
I strongly believe
I will achieve my
goals.
........
(A
........
132
Handout 2
THE CASE OF BOB
Our beliefs, behaviors, and feelings all
reinforce each other and influence our self-concepts.
The case example illustrates this.
Bob is 20 pounds overweight and, for the past
three months, has been trying to adhere to a new jogging
program. Generally, he follows his exercise routine for
a few weeks and then stops. On the first morning that he
abandons his routine, he tells himself that he will make
up for it next time. However, when the "next time"
arrives, he thinks about how much harder this jog will be
since he missed the previous one and quickly returns to
sleep to avoid guilt feelings.
When he wakes up, negative thoughts flood his
mind: "I'm just a fatso who will never be in shape."
"I should have j egged."
"I'm always goofing up!" He
feels guilty and defeated. For the rest of the day he
absorbs himself in his work and escapes these negative
thoughts. However, the next morning he makes no attempt
at all to jog.
For Bob, the decision to skip one day of exercise
reinforced his decision to skip another which, in turn,
effected how he felt, how he saw himself and how much he
believed in his ability to succeed.
The figure below illustrates how these factors
reinforce each other and contribute to Bob's poor selfconcept.
*
*
*
FEELINGS
lousy
guilty
BEHAVIOR/HABITS
skips jog the first day
skips jog the next day
abandons routine
BELIEFS/ATTITUDES
"I'm a fatso who will
never be in shape."
"I'm always goofing up."
133
Handout 3
STEPS IN
SELF-~·tANAGEMENT
1. Define the Problem
Describe specifically what
happens before and after
you engage in the habit.
Self-monitor your behavior
for at least three days so
you get a clear picture.
7. Keep Re-evaluating
the problem and re-stating
your subgoals. Flexibility
in cycling back and forth
between steps is important.
2. Translate the Problem
into an A-+ B~ C
(antecedants
-)
behavior----+ consequences
model).
)
(
3. Manipulate the Mo~el
to generate alternat1ve
solutions by changing
the antecedants.
6. Evaluate the alternative
Ask yourself if you are
benefiting from it or
whether another solution
might solve your problem
more effectively. If so,
reassess alternatives or
redefine problem.
)
4. Make a conuni tmen t
to try out one of the
alternatives. Choose one
that will be easy to try,
yet will help you the most.
5. Reward yourself
when you attain one of
your subgoals. In this
way you will reinforce
your desirable behavior.
j
134
Handout 4
SELF-MONITORING JOURNAL SHEET
Behavior
Precipitating
Event
Follow-up
Event
(include thoughts and feelings
for both)
• 6
2
Overall self-worth rating 1
felt low
3
2
Overall belief in success 1
will not
succeecr-
3
4
5
6
7
felt great!
4
5
6
7
will succeed!
135
Handout 5
DEVELOPING A PLAN OF ACTION
Step 1:
State your long-range goal in positive terms.
"I want to
----------------------------------------------
Step 2:
Establish subgoals by generating a list of alternatives to
your present behavior .. These are steps that can lead to
your goal.
1.
---------------------------------------------------------------------------------------------------------
2.
3. ___________________________________________________
4.
Step 3:
Step 4:
-----------------------------------------------------
Evaluate these subgoals with the checklist below.
Each of your subgoals is:
YES
positive ....... increasing behavior in
duration or frequency.
D
attainable ..... set only slightly higher
than your present level
D
of operation.
controllable ... doesn't depend on others.
D
operational .... specific enough so that
anyone can recognize when
D
it has been met
NO
D
D
D
D
Select a subgoal that will be relatively easy to implement.
Make a commitment to achieving it.
"I will accomplish
-------------------------------------______________________________
~-----------------by
(Date)
'
6
136
DEVELOPING A PLAN OF ACTION (continued)
Step 5:
Set up a system for rewarding yourself once you've
achieved this goal.
"If I accomplish this sub goal, I will reward myself
in the following ways:
1.
---------------------------------------------------------------------------------------------------------------------------------------------------------4.
---------------------------------------------------5.
---------------------------------------------------6.
-------------------------------------------------2.
3.
II
Step 6:
Evaluate these rewards with the check-list below.
The rewards you've chosen:
are truly enjoyable
involve people who are
supportive of your goals
can be applied immediately
vary from large to small
Yes
No
D
D
D
D
D
D
D
D
"I, the undersigned, make these agreements in sincere faith that
I will carry them out to the best of my abilities."
Date
S1gnature
Handout 6
DO YOUR EXPECTATIONS WORK FOR OR AGAINST YOU?
To find out how high and rigid your standards are, indicate how strongly you agree or
disagree with the following statements by circling the appropriate number
-2
disagree
strongly
1.
2.
3.
4.
5.
6.
7.
8.
-1
disagree
slightly
0
feel
neutral
+1
agree
somewhat
If I don't set the highest standards for myself, I'm
likely to be second rate.
People will probably think less of me if I make a mistake.
If I cannot do something really well there is little
point in doing it at all.
I should be upset if I make a mistake.
If I try hard enough, I should excel at anything
I attempt.
I shouldn't have to repeat the same mistake many times.
If I scold myself for failing to live up to my expectations,
it will help me do a better job in the future.
Failing at something important means I'm less of a person.
Scoring:
+2
agree very
much
-2
-1
0
+1
+2
-2
-1
0
+1
+2
-2
-1
0
-2
-1
0
+1
+1
+2
+2
-2
-1
0
-2
-1
0
+1
+1
+2
+2
-2
-1
0
-2
-1
0
+1
+1
+2
+2
Add up your scores, noting that plus and minus numbers cancel each other.
+16 reveals a very strong tendency to set rigidly high expectations.
-16 signifies a strongly non-perfectionistic tendency.
Preliminary studies suggest that about half the population is likely
to score from +2 to +14 (Burns, 1980).
f--1
VI
--.:1
138
Handout 7
CHANGE IN ACTION
Many of us compare the process of reaching a goal to the challenge
of climing a mmmtain. We usually assume that this climb is
exclusively uphill. However, a close look at the actual terrain
of a mountain reveals that it has many paths that go upwards and
many paths that run horizontally. In between these are those
straight and narrow paths that lead directly to the top.
In addition, a real mountaintop always has another side. From the
top, all the paths on this side appear as if they lead only downward.
But, in reality, there are ascending and flat paths as well.
The process of changing behavior is much like climbing a REAL
mountaintop.
Change is a difficult
and trying process. As much
as we want it, we often resist
it as well. As a result,
plateaus, set-backs, and
relapses are part of the
process. It is best to
anticipate them.
NOTE:
Plateau: We often
feel stuck ... like
nothing is happening.
It's okay to coast
for a while.
Relapse: This is
probably much like
a set-back that has
been handled before.
It is not a disaster,
but a clue to new
strategies.
IMPORTANT! When any of these occur:
1. Resist negative self-talk.
2. Use self-support skills.
3. Take a problem-solving approach
and plan strategies for next time.
139
Handout 8
CREATIVE VISUALIZATION
In visualization, we use the power of positive suggestion
to help us reach our goals. By concentrating on a mental
picture of our desired change, we can program ourselves
for achieving that change.
The first step in doing this is to relax.
If you have
your own method of relaxing, then utilize this.
If not,
then follow these instructions for deep breathing and
muscular relaxation.
*
Place one hand just below the rib cage. Take a
deep breath, and as you inhale, notice the
movement of your hand. Does it move in and out?
If you breathed deeply your hand moved outward
as you inhaled. Be aware of how deeply you
breathe.
*
Inhale, and hold your breath for ten seconds,
feeling the tension in your throat and chest.
Exhale through your mouth with a slight "sigh
of relief"; feel the release of tension.
*
After you have exhaled every last bit of air
from your lungs and throat, pause for a few
seconds before taking your next breath. This
is the quietest time of the breathing process.
If you can feel the stillness and calm at that
moment, then you are learning how to relax.
*
Now turn your attention to the muscles of your
body and allow them to relax fully; noticing
that they become heavy and limp as tension
drains. With each and every exhale, breathe
away more and more tension.
*
Clear your mind by imagining that any distracting
thoughts or worries appear as bubbles, about to
flow up and out of your mind.
Now you are ready to visualize. Picture yourself exactly
as you wish to be. Focus on this image and see as many
details as you can. See yourself celebrating feelings of
perfect health. For example, if you want to lose weight,
picture yourself enjoying healthful, nonfattening foods.
See yourself as a thin, attractive person enjoying
looking at yourself in the mirror.
140
CREATIVE VISUALIZATION (continued)
Remember ........ .
.
"
*
Mentally phrase your goal in positive,
encouraging terms. Make strong, active
statements that it exists now. For example,
if you wish to eat nutritiously, do not
think, "I will not eat junk food."
Instead, think, "I feel full and satisfied
eating natural, healthful foods."
*
Give your image positive energy, temporarily
suspending any doubts you may have.
*
Practice this often, particularly when your
belief in success is low .
Handout 9
SELF-TALK RECORD
Date
Activating Event
Self-Talk
Feeling
1-'
.,.:::.
1-'
142
Handout 10
SELF-CONTROLLING STYLES
We each have a particular way of treating ourselves
as we move along the path of change. This comes out in
the inner-dialogues we carry on throughout the day (our
self-talk). We continually try to control our undesirable
behavior in ways we believe will lead us to success.
Sometimes, however, our controlling styles actually contribute to our failure.
We will explore some of the
most common of these self-defeating styles and uncover
the irrational thinking patterns that are characteristic
of them.
The Perfectionistic Style
People who have perfectionistic styles set rigid
standards, place big demands on themselves and expect
strict adherence to these.
Perfectionists firmly
believe that without high standards, they would never
change.
They want to feel in control and it is often this
need that motivates them to allow the "innerperfectionist" full reign.
Unfortunately, they set
standards so high that they are virtually unreachable,
thus almost assuring defeat.
Ironically, the very
maneuvers they make to gain control ultimately undermine
their confidence.
Ali-or-Nothing Thinking
Perfectionists often see their attempts to
alter habits in black and white terms; intermediate
shades of gray don't seem to exist.
For example, when Barbara decided to lose
weight, she told herself that she must be either
"on" or "off" her diet.
She required strict
adherence to her self-imposed definition of being
"on" the diet. When she lapsed from her routine
by eating a tablespoon of ice cream, she scolded
herself by saying, "I shouldn't have done that!
I'll never be able to lose weight!" These ideas
upset her so much that she went on to eat an
entire quart of ice cream.
'
il
143
SELF-CONTROLLING STYLES (continued)
The Perfectionistic Style
Ali-or-Nothing Thinking
List some of your ali-or-nothing thinking:
1.
2•
--------------------------------------------------------
--------------------------------------------------------
3. __________________________________________________
4.
5.
---------------------------------------------------------------------------------------------------------------
Overgeneralization
When perfectionists overgeneralize, they
arbitrarily conclude that a mistake they made
once will happen over and over again.
For example, when Ned smoked a cigarette after
a two-week abstinence, he ruminated about it for
days telling himse If, "I'm always goofing up. I
never have any willpower." One set-back led him
to the dogmatic conclusion that he would always
fail at his attempts to stop smoking.
List some of the ways you overgeneralize:
1.
2•
--------------------------------------------------------
-------------------------------------------------------------------------------------------------------------4.
------------------------------------------------------5.
3.
--------------------------------------------------------
Magnification and Minimization
Perfectionists engage in magnification when
they look at shortcomings and exaggerate their
importance.
144
SELF-CONTROLLING STYLES (continued)
The Perfectionistic Style
Magnification and Minimization
For example, when Nancy missed exercise class,
she told herself, "My God, I missed aerobics. How
awful! Everyone will notice and think I'm a
quitter."
On the other hand, when perfectionists think
about their successes, they tend to do the opposite
-- they downplay their significance.
For example, when Nancy mastered the aerobics
class, she thought, "Big deal ... So I can keep up
with the beginning class ... that's nothing. Wait
until I try the advanced class!"
List some of the ways you engage in this type
of self-talk:
1.
2.
3.
----------~-------------------------------------------4.
5. ______________________________________________________
-------------------------------------------------------
The Critical Style
People who have critical styles find fault wherever
they can. They are very judgmental (mostly in a negative
way) of themselves and blame set-backs on their
inadequacies.
Critics berate themselves for shortcomings and, in
this way, continually diminish their self-esteem. They
assess themselves as losers who are destined to foul up.
They constantly scold themselves for this and tell
themselves that they "should" be doing better.
145
SELF-CONTROLLING STYLES (continued)
The Critical Style
Labeling
Critics chip away at their self-esteem by
basing how they feel about themselves solely on
their mistakes. They take one set-back and define
themselves according to it.
For example, when Jean allowed her anxiety
to rise so high that she flunked an important exam,
she admonished herself, "I'm stupid! This just
proves it! I'm a jerk for not taking the time to
do the relaxation techniques I learned."
What labels do you tag on yourself?
1. __________________________________________________
2. __________________________________________________
3. _____________________________________________________
4. __________________________________________________
5. __________________________________________________
Disqualifying the Positive
Critics disqualify the positive by operating as
if they were wearing a pair of eyeglasses with
special lenses that filtered anything positive. As
a result, they pick out only the negative aspects
of their behavior and dwell on it exclusively.
For example, when Ted fell short of his weekly
weight loss goal by a pound, he berated himself
endlessly and completely ignored the other two
pounds that he had lost.
When you wear these "special" eyeglasses what do
you see?
1. _____________________________________________________
2. __________________________________________________
3. _____________________________________________________
4. __________________________________________________
5. _____________________________________________________
146
SELF-CONTROLLING STYLES
(continued)
The Rationalizing Style
People who have rationalizing styles make excuses
for not sticking to their goals. They con themselves
with plausible but untrue reasons for these failures.
Sometimes, this style comes about
the admonishments of the perfectionist
Rationalizers attempt to protect their
making excuses and avoiding the truth.
and aloof (uncommitted) to their goals
selves into thinking that their habits
they feel and think.
as a reaction to
and the critic.
self-esteems by
They remain cool
and fool themdon't affect how
Yes-But Thinking
Rationalizers discount and minimize their
problems by tacking a "disclaimer" onto their
self-statements. Usually whatever follows the
word, "but" in these statements is an attempt
to dodge responsibility.
For example, when Jerry, a hypertensive
businessman, lapsed from his diet with 20 pounds
still to lose, he told himself, "I could lose a
few more pounds, but I feel fine and, besides,
how do they know I'll have a heart attack just
because I have high blood pressure."
List some of your yes-but thinking:
1. __________________________________________________
2. __________________________________________________
3. __________________________________________________
4. __________________________________________________
5. __________________________________________________
Handout 11
CHALLENGE YOUR CONTROLLING STYLE
Self-Defeating Thought
Cognitive Distortion
Rational Response
f--1
~
-....)
148
Handout 12
THE SHOULD-WANT INVENTORY
What motivated your decision to embark on the
path to change?
If your answer to this question lies mostly in a
belief that you "should" change because o£ an imposed
pressure (possibly from friends and relatives), then
your decision probably feels like a demand that has
been forced upon you.
On the other hand, if you answer that you truly
"want" a new change, then your decision probably feels
more like a choice that is under your control.
Explore your motivation for change by listing all
the reasons you should change and all the reasons why
you want to change.
(It's likely you'll have a combination of both).
"I should
because:
..,(.....,d.-e_s_c_r_l....,,
.....i_v_e_t=-e-r_m_s-.:-)
b.--e-y_o_u_r_g~o-~~a"""l~l-n_p_o_s___,...i..,...t
1.
-------------------------------------------------------3.
4. --------------------------___________________________________
2.
5.
--------------------------
Overall motivating Power: 1
2
3
4
5
6
7
------------------highly
highly
unmotivating
motivating
.
tl
149
THE SHOULD-WANT INVENTORY (continued)
"I want
------------------------------------------because: 1.
--------------------------------------2.
3.
-----------------------------------------------------------------------------
4.~~----------------------~-------5.
---------------------------------------
Overall motivating Power: 1
2
3
4
5
6
7
----------~--~--~--~---highly
highly
unmotivating
motivating
150
Handout 13
THE HIDDEN PAY-OFFS
To explore the significance of your behavior,
answer the following questions as honestly and candidly
as possible.
In general, how would your life be different without your
present behavior? Describe how much better it would be
(what you would gain) and how much worse it would be
(what you would lose).
List the "gains" you described above in the column
headed "Pros" ... these are your reasons for changing.
List all the "pay-offs" you would lose in1Jle column
headed "Cons"
these are your reasons for not
changing.
PROS
CONS
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
Do the reasons not to change outweigh
the reasons for changing? If so, do
you still want to change?
yes
no
151
THE HIDDEN PAY-OFFS (continued)
Would it be most helpful to deal directly
with the needs and issues uncovered in the
pay offs?
yes
no
If so, what is your new goal?
List the available alternatives and strategies for
working on this goal.
1.
--------------------------------------------
2. ___________________________________________
3.
--------------------------------------------
4.
----------------------------------------~~
5. ___________________________________________
Would it be most helpful to find other,
more constructive ways to get the payoffs your behavior has been providing?
yes
no
If so, list the pay-off in the left-hand column and the
appropriate substitution next to it.
(Remember, the
substitution must be one that truly satisfies your
needs. It won't help to force yourself into a solution).
Pay-Offs
1. _________________________
2•
3. __________________________
--------------------------
4. _________________________
5. _________________________
6.
--------------------------
Acceptable
Substitutes
1. ________________________
2. ______________________
3. ________________________
4. ________________________
5. ______________________
6. ______________________
152
Handout 14
LEARNING OPPORTUNITY WORKSHEET
I slipped from my goals in the following situation:
Factors that contributed to the problem:
------
-------------------
This experience has given me the opportunity to learn:
Next time I am in this situation, I will:
-----------------
In light of this set-back, I feel
accepting of
myself.
(very, somewhat, a little, not at all)
I can help myself feel more accepting and be supportive
of myself by:
153
Handout 15
SELF-SUPPORT TALK
Affirmations are strong, positive statements that
"make firm" that which we wish.
By using them, we can
replace stale, worn-out, negative self-talk with positive,
encouraging ideas.
Guidelines for creating affirmations:
*
*
*
*
Always phrase affirmations in the present tense.
Affirm in positive terms.
State what you do
want, not what you don't want.
Make them short and simple.
Do not try to change what already exists
(particularly negative feelings you're having).
Take the attitude of accepting what already is,
and at the same time, believing that every
moment offers a new opportunity to create what
you want.
Creating affirmations that are right for you:
Review the rebuttals you made to your negative
self-talk. Choose the ones that are of greatest
significance and change them into affirmations
following the guidelines above.
For example, alter
the rebuttal, "I don't have to be perfect to reach
my goals," to "I have all I need to attain my goals."
Affirmations
Rebuttals
1.
1.
2•
2•
3.
3.
4.
4.
5.
5.
6.
6.
154
Handout 16
PROCESS ASSESSMENT
So far, I feel
very pleased
_pleased
okay
-displeased
very displeased
I am feeling
very confident
-confident
--somewhat confident
-not at all confident
with my efforts to
control my habits.
that I will stick
to my goals today.
The self-support skills that will help me increase my confidence are:
Situations that are still a problem: ______________________________
I can avoid or alter these by:
-----------------------------------
Benefits I've already noticed from controlling my behavior:
--------
Handout 17
THE ROAD TO RELAPSE
r
INCREASED
CONFIDENCE
~
RESIST OLD
BEHAVIOR
"
COPING
RESPONSE
(
REINFORCED
SENSE OF
CONTROL
DECREASED
PROBABILITY OF
FmURE RELAPSE
HIGH RISK
SITUATION
~
NO
COPING
RESPONSE
\
DECREASED
CONFIDENCE
'--
Olff OF
SLIP TO
OLD BE-IAVIOR
+
INCREASED
DESIRE FOR
OLD BE-IAVIOR
J
J
I CONTROL
\._
INCREASED
PROBABILITY OF
FmURE RELAPSE
Remember ...... .
l1igh risk situations vary for all of us. Identify yours
and be prepared.
When stress increases and confidence slumps, it is common to desire
the comfort and familiarity of old behavior.
Old behaviors may trigger old, self-defeating ways of dealing with
ourselves. Try to resist this.
1-'
CJ1
CJ1
156
RELAPSE PREVENTION PLAN
Handout 18
Be prepared for the possibility of relapse by
identifying all the situations you believe will pose a
threat to the continued maintenance of your new behavior.
Be specific, describing the chain of events that builds
to the threat.
Arrange these situations in a hierarchy from the
least threatening down to the most threatening. To do
this, rate how anxiety producing each situation is by
assigning it a number from one to a hundred. This number
is called "subjective units of distress" (a suds rating).
Zero represents total relaxation and 100 represents the
most threatening situation on your list.
Your hierarchy now can be used for learning how to
relax while experiencing the relapse threat. Start with
the first situation (lowest suds rating) and build a clear
picture of it by using the creative visualization technique. Concentrate on the image and when you notice the
beginning of any tension in your body, use this as a
signal to start muscular relaxation and deep breathing.
Practice this technique with each situation until
you no longer feel any tension as you hold the image.
Another way to use this list, is to plan a strategy
for coping with the threatening situation. Record each
strategy next to the description of the situation.
Thinking it through beforehand will help you use it in
the actual situation.
HIERARCHY OF HIGH-RISK SITUATIONS
COPING STRATEGIES
1.
1.
----------------------
2.
2.
----------------------
3.
3.
----------------------
4.
4.
----------------------
157
Handout 19
PROGRAM EVALUATION
Name
Date----------------
--(~o-p~t~ian--a~1~)-----------------------
Overall, hew helpful has this program been in assisting you reach
your goals?
1
2
3
4
5
7
6
not at all
helpful
very
helpful
How satisfied are you with the progress you've made during the
program?
1
2
3
4
5
7
6
not at all
satisfied
very
satisfied
Haw strong is your belief that you will maintain the progress you
have made?
1
very weak
2
3
4
5
7
6
very
strong
What was the most valuable aspect(s) of the program? ________
Haw could the program be improved? _____________________________
158
PROGRAM EVALUATION (continued)
How effective was the leader in facilitating the group and helping
you reach your goals?
1
not at all
effective
2
3
4
5
6
7
very
effective
Explain=--------------------------------~---------------
Rate the following techniques according to how helpful they were:
1
2
3
4
5
very
helpful
not at all
helpful
Belief in success .................
Designing self-management plan ....
Setting realistic goals ...........
Anticipating set-backs/relapses ...
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Grotrp support . ....................
1
2
3
4
5
Mastery/self-support visualization
Refuting irrational self-talk .....
Altering your controlling style ...
Supportive leader .................
Exploring motivations for change ..
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Increasing self-understanding .....
Exploring pay-offs ................
Self-support talk ............•....
Process assessment ................
Relapse prevention skills .........
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
APPENDIX B
PROGRAM BIBLIOGRAPHY
159
160
PROGRAM BIBLIOGRAPHY
Burns, David D.
(1980)
therapy. New York:
Feeling good: The new mood
New American Library
Burns, David D.
(1980, November) The perfectionist's
script for self-defeat. Psychology Today pp. 36-52
Corey, Gerald & Corey, Marianne (1982) Groups: Process
and practice. Monterey, Calif: Brooks/Cole Pub. Co.
Davis, Martha, Eshelman, Elizabeth, & McKay, Matthew.
(1982) The relaxation & stress reduction workbook.
Oakland, Calif: New Harbinger Publications.
DeRisi, William J. &Butz, George.
(1975) Writing
behavioral contracts: A case simulation ractice
model. Champaign, Illinois: Researc Press.
Farquhar, John W.
(1978) The American way of life need
not be hazardous to your health. New York:
W.W. Norton & Company
Gawain, Shakti.
(1978)
Creative visualization.
Berkeley, Calif: Whatever Pub.
Mahoney, Michael J. &Thoreson, Carl E.
Self-control: Power to the person.
Calif: Brooks Pub. Co.
( 19 7 4)
Monterey,
Mason, John L.
(1980) Guide to stress reduction.
Culver City, Calif: Peace Press, Inc.
O'Hara, Michael, W. & Rehm, Lynn P.
(1983) Self-control
group therapy of depression. In Arthur Freeman
(Ed.). Co nitive
with cou les and
(pp. 67-94 .
Plenum Press.
Steinmetz, J. (1980) Managing stress before it manages
you. Palo Alto, Calif: Bull Pub.
Williams, Robert L. & Long, James D.
self-managed lifestyle (2nd Ed).
Houghton Mifflin Co.
(1979) Toward a
Boston:
Yates, BrianT.
(1984) Self-management: The science
and art of helping yourself. Belmont, Calif:
Wadsworth Publishing Co.