Portal de Periódicos da CAPES

Making Health a Habit

2020; Lippincott Williams & Wilkins; Volume: 24; Issue: 4 Linguagem: Inglês

10.1249/fit.0000000000000579

1536-593X

Liz Hathaway, Mckenzie Gregg,

Mental Health Research Topics

Ivan Pavlov, yes that snappy dressed, Russian physiologist, is the original albeit unknowing creator of “Who let the dogs out?” or more precisely “What lets the dogs’ saliva out?” Credited with conducting seminal studies on classical conditioning, Pavlov showed the stimulus-response connection whereby dogs learned to salivate upon hearing a bell. Good to know for trivia, yes! Relevant to you and your clients? We say yes. Hop on your exercise bike, the stationary kind please, and let’s see if we can convince you that indeed this topic is relevant to you and your clients. WHAT IS HABIT? As early as 1891, William James explained that habits play fundamental roles in generating behavior (1). Gardner (2) presented multiple definitions of habit used in research literature and offered the following definition: “a process by which a stimulus automatically generates an impulse towards action, based on learned stimulus-response associations” (p. 280). According to Wood and Neal (3), habit is a phenomenon whereby behavior is prompted automatically by situational cues, as a result of learned cue-behavior associations. Lally et al. (4) explained that habits form through repetition of behavior in a specific context. Makes sense. A habit is a behavior that is performed routinely in similar situations. Let us continue.HEALTH-RELATED BEHAVIOR AS HABITS An issue quickly arises as health behaviors vary in level of complexity. With behavior, there is both initiation and performance of it. For the purposes of this article, we will focus on habitually initiated activities, meaning health-related behaviors that are prompted when a specific cue is encountered. Behaviors range in their levels of habitual performance as some will require more mental energy to perform versus others. For instance, navigating through a new strength training workout requires attention to the performance of the different activities, whereas engaging in a health behavior such as the elliptical, an activity your client has completed many times, would not require that same mental attention. There is a lot more that could be said about this topic, and we suggest checking out Gardner’s study (2) if interested. We will pedal on though, with our focus on helping clients create prompts to trigger habitually initiated health-related behaviors. HOW CAN YOU HELP YOUR CLIENTS BUILD HEALTHY HABITS? Let’s get to business. An evidence-based strategy to help clients create healthy habits is the formation of “if-then plans” (5). If-then plans allow your clients to think about opportunities or obstacles they often encounter and what planned behavior they would like to take in response to the stimuli. The simple setup to create an if-then plan is as follows: “If _______ occurs, I will ________.” What about an example? MG: “If I see a sidewalk grate, I will walk around it.” LH: “If I see a sidewalk grate and am with MG, I will try to subtly steer MG to walk on it.” Well, not always subtly. Shoulder lowering and physical contact typically occur. Another method to use in helping your clients create healthy habits is the “cue-response” method. Charles Duhigg, in his book The Power of Habit, broke habit into three components: cues (combinations of stimuli), responses (chains of thoughts and/or actions), and rewards (increases/decreases in pleasant/unpleasant sensations, emotions, or thoughts) (6). Whether you use the “if-then plans” or the “cue-response” method, they both are similar in that they link a stimulus with an associated behavior. We use the “cue-behavior” method. Let us think about how you can help your clients choose appropriate cues and behaviors for healthy habit formation. CHOOSING THE BEHAVIOR We all have habits — some good, some not so good. The comment about “dropping someone like a bad habit” makes no sense. Habits are incredibly hard to break, which is why we want them to work to our and our clients’ advantages. The first thing you want to do with your client is ask what types of healthy habits he/she would like to create. As you allow your client to think through some potential behaviors, it’s always good to have some examples to offer if asked. We offer a quick table below grouped into two categories. When thinking about health-related behaviors, there are those that are performed multiple times per day and those that are typically performed only once a day. This will be important to keep in mind when deciding upon an appropriate cue. Beware, your clients may be overly ambitious, Chuck Norris style, and want to save the world in a day, but with habit formation, we want to advise to start small and focus on one or two behaviors at a time. Once those become more automatic and ingrained in our routine, then additional behaviors can be added.CHOOSING THE CUE One of the keys to habit formation is selecting an appropriate stimulus or cue. You want to work with clients to help them select a cue that will allow them to perform the behavior every time they encounter it. When the client encounters the cue, he/she needs to do the behavior for the cue-behavior link to occur and strengthen, eventually making it a habit. Depending on the difficulty of the behavior, choosing how many times your client will encounter the cue is key. For once a day behaviors, you will want to help guide your client to choose a cue that is encountered only once per day. Often this can be accomplished by linking the behavior to a time of day or meal cue. For instance, “I will go to the gym after I’ve eaten my breakfast.” Or “I will complete a stretching routine when I get home from work.” For activities that your client wants to perform throughout the day, a cue that is encountered multiple times per day is needed. For instance, your client could set an alarm on his/her phone that when it went off throughout the day, he/she would take a quick stair break to break up sedentary behavior. Common mistake? Choosing a cue that you encounter often to perform a more difficult behavior. For instance, your client decided to do a burpee every time he/she sees a tree on his/her walk. And where is this walk taking place? The country (shout out to our roots!... tree pun intended). What is likely to happen? At tree number 11, your client is exhausted and gives up. Help your client choose appropriate cues for behaviors.HOW LONG DO HABITS TAKE TO FORM? Full disclosure, LH is hopping on her soap box while MG is lifting up an amen hand during this section. If you were to search the “all-knowing” Google for the answer, often times the number “21” pops up. This misinformation leads to many becoming frustrated. Individuals are often focused on the 21 days expecting long-term results, but alas there is often no habit formation at the end of 3 weeks. Thank goodness for Dr. Phillippa Lally, a health psychology researcher. Lally et al. (4) showed that, on average, it takes 66 days to form a new habit, and individual values ranged from 18 to 254 days. Well that is certainly different than 21 days! She and colleagues also reported more complex behaviors will take longer to become habits. Moreover, we think you will agree that engaging in regular exercise is a bit more complex than flossing those pearly whites. One of the biggest points to remember in habit formation is that if your client continues to persevere and not give up during the process, at the proper time the benefits will come. Habits develop and increase in strength by successful repetition of behavior (7). This cue-behavior relationship will become stronger and more automatic as your client consistently repeats the process. Back to the million-dollar question, how long will it take for your client to form that specific habit? Typical academic answer: it depends. However, continue to strengthen the cue-behavior link, and it will get easier and take less mental effort. HOW TO MEASURE HABIT FORMATION? The simplest method is to track how many times your client performs the behavior when the cue is encountered. This can be done on an old school paper calendar or in one of the many phone apps. We know the power of self-monitoring and how individuals do not want to “break the chain” when they are able to visibly see a streak of their progress. There are also phone apps where you can share with your friends and bring in social support and accountability. Oh technology, such exciting opportunities. The Self-Report Habit Index (SRHI) is one of the most widely used self-report measures used by researchers to monitor habit strength (8). The SRHI is a 12-question survey where participants respond to each question using a 7-point agree or disagree scale. A subset of SRHI questions (the “automaticity subscale”) was used by Lally et al. (3) in her often-cited study. As the behavior becomes more automatic, the SRHI scores will increase. This is a practical tool to help you and your clients monitor habit formation progress. WRAP-UP As we try to help clients become powerful, both physically and mentally, one of these ways is in helping clients to develop self-discipline by engaging in daily healthy habits. One of the strengths of habit formation is that behavior is likely to continue when motivation dissipates (2). We know life happens and our clients’ motivation often shifts through the course of a year, so let’s work with clients now to set them up for success tomorrow. Let us circle back to Pavlov, our hat-wearing, cane-rocking, full of swag friend, who noted the stimulus-response connection. Hence, can we use this relationship to help individuals live healthier lives? Yes. Is habit formation always easy? No. Does habit formation take time and day-by-day choice and effort? Yes, at the beginning, but it gets easier! Is leading a disciplined and productive life worth it? Absolutely! So let’s make health our and our clients’ habit.