Self-regulation in health-related behaviour
Why is it difficult to change our everyday behaviours based on goals and
(medical) recommendations and how to promote change
Mgr. Tatiana Malatincová, PhD.
aZLZP051p/c Medical Psychology and Psychosomatic in Dentistry – lecture/practice
CAUSES OF
INSUFFICIENT
PREVENTIVE
BEHAVIOUR
1. Oral hygiene
2. Checkups / advanced care
appointments
Why people do not follow recommendations
regarding oral hygiene
• Used to doing it differently; guided to do it differently in childhood
• Resignation – accepting norms represented by parents and/or other members of the
reference group (“It is normal to have bad teeth from a certain age.”)
• Unconvinced about effectiveness: “Does this really work?”; no awareness of progress in
knowledge and technologies
• Lack of awareness of how the prevention works to reduce risks; misconceptions and
unreliable sources of information; understanding the principles of joint causality and
probability...
• “Product overload” – confused about tools and procedures; choice paralysis
• Unfavourable associations and stereotypes – “Just another scheme to strip people of
more money”; association with beauty products rather than health; associations with the
“upper-class” lifestyle (“People like me don’t do this”); boomerang effect
• Lack of information on how to use tools correctly
• Difficult to make it an integral part of one’s daily routine
• Discomfort and other negative experiences while learning to use the tools
Why people skip regular dental checkups
• Doesn’t come to mind – never a priority until there is a pressing problem
• Time and other logistic reasons
• Availability of “good” and affordable specialists
• Concerns about financial costs
• Belief that they do not need a dentist (yet)
• Unpleasant experiences – one’s own or shared by friends and relatives, leading to distrust
(“It will just make things worse!”)
• Childhood habits – “One only sees a dentist when it starts to hurt”
• Fear of procedures; anxiety about “what’s going to happen”
• Shame, guilt and fear of being reprimanded and looked down on for poor hygiene or putting
off the appointment
• Discomfort at the dentist’s office (conditioned fear responses, phobias)
Challenges of promoting preventive behaviour
Why is it harder to motivate people towards
prevention as opposed to intervention...?
No information on progress – the measure of effectiveness of preventive behaviour is the
ABSENCE of consequences! How do I know that the bad thing did not happen thanks to
prevention? Or that my poor health is the result of poor prevention?
How to make recommendations regarding
preventive behaviour more effective?
Why is it good to
build healthy habits
from early
childhood?
And how to do it
best?
Guiding children towards healthy
behaviours from early on (“Clean
your teeth like a big girl”):
• Behaviour becomes “normal”
and habitual (“automatic”)
• Feeling uncomfortable when the
behaviour is omitted
• Knowing how without doubting
one’s skill and ability
• More likely to believe that it
works (cognitive biases work in
my favour)
In the eyes of a little child, her parents represent how the
entire world operates.
Desire to do it
(change one’s behaviour)
Believing I can do it
Knowing
how to do
it
WANT TO DO ≠ CAN DO According to Schwarzer’s HAPA model (Health
Action Process Approach), being motivated
(e.g., as a result of persuasion) is NOT
ENOUGH; one needs to be able to translate the
goal representation into action! Long-term
goal achievement is a proactive rather
than reactive process.
Desire to do it
(change one’s behaviour)
Believing I can do it
Knowing
how to do
it
WANT TO DO ≠ CAN DO According to Schwarzer’s HAPA model (Health
Action Process Approach), being motivated
(e.g., as a result of persuasion) is NOT
ENOUGH; one needs to be able to translate the
goal representation into action! Long-term
goal achievement is a proactive rather
than reactive process.
When I get stuck, I
can fall one level down
and start doubting
myself...
“I have no idea how to
do it... I don’t think I’ll
be able to do it...”
The Transtheoretical Model of Change
https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/behavioralchangetheories6.html
Transtheoretical model of change
Which is better: focusing on
the downsides of the present
state or focusing on the
benefits of the positive
change?
Is stronger motivation always
more beneficial (more
“activating”)?
Coming up with an effective plan
1. Evaluating possibilities – how much can I do? When and how exactly can I do?
Which activities can I replace? How can I fit different activities together?
2. Mental contrasting – What do I want to achieve, and which steps need to be done to
do it? SMART approach (“step by step” goal achievement).
Does it help to induce emotions in patients?
Elements of promoting change
̶ Consciousness Raising - Increasing awareness about the healthy behavior.
̶ Dramatic Relief - Emotional arousal about the health behavior, whether positive or negative arousal.
̶ Self-Reevaluation - Self reappraisal to realize the healthy behavior is part of who they want to be.
̶ Environmental Reevaluation - Social reappraisal to realize how their unhealthy behavior affects
others.
̶ Social Liberation - Environmental opportunities that exist to show society is supportive of the healthy
behavior.
̶ Self-Liberation - Commitment to change behavior based on the belief that achievement of the healthy
behavior is possible.
̶ Helping Relationships - Finding supportive relationships that encourage the desired change.
̶ Counter-Conditioning - Substituting healthy behaviors and thoughts for unhealthy behaviors and
thoughts.
̶ Reinforcement Management - Rewarding the positive behavior and reducing the rewards that come
from negative behavior.
̶ Stimulus Control - Re-engineering the environment to have reminders and cues that support and
encourage the healthy behavior and remove those that encourage the unhealthy behavior.
Why people do not adhere to lifestyle recommendations
• Perceived (and possibly legitimate) physical, economic, organizational etc. obstacles
• Different kinds of old habits, usually acquired in childhood
• Giving up, accepting the old ways (“it is normal to have these kinds of health issues at this
age”)
• Doubts about effectiveness: “Does it really work?”; unaware of new advancements
• Lack of information about the effects of prevention; false beliefs and unreliable sources of
information; lack of understanding of probability and multicausality
• Being overwhelmed by the variety of unfamiliar, sometimes commercially competing
products, services, and related information
• Association with upper-class lifestyle or with particular groups – does not self-identify with
it; seen as unusual
• Lack of skill and knowledge regarding how to use implement the recommendations
properly
• Can’t fit into daily schedule – other priorities
• Discomfort (pain, clumsiness, bad initial choices...)
• Unhealthy behaviours as an avoidant coping strategy – lack of more effective strategies
Desire to do it
(change one’s behaviour)
Believing I can do it
Knowing
how to do
it
WANT TO DO ≠ CAN DO According to Schwarzer’s HAPA model (Health
Action Process Approach), being motivated
(e.g., as a result of persuasion) is NOT
ENOUGH; one needs to be able to translate the
goal representation into action! Long-term
goal achievement is a proactive rather
than reactive process.
When I get stuck, I
can fall one level down
and start doubting
myself...
“I have no idea how to
do it... I don’t think I’ll
be able to do it...”
“Since I’m unable to
do it, why should I
torture myself? I’ll
just leave it be...”
Possible goal devaluation
through various consequences
of cognitive dissonance
When ego (self-esteem) goes first:
Psychological defence mechanisms
• Denial
• Rationalization
• Intellectualization
• Suppression
• Repression
• Projection
• Displacement
• Acting out
• Aim inhibition
• Avoidance
• Altruism
• Passive aggression
• Compensation
• Undoing
• Dissociation
• Fantasy
• Humour
• Reaction formation
• Sublimation
• Regression
Elements of promoting change
̶ Consciousness Raising - Increasing awareness about the healthy behavior.
̶ Dramatic Relief - Emotional arousal about the health behavior, whether positive or negative arousal.
̶ Self-Reevaluation - Self reappraisal to realize the healthy behavior is part of who they want to be.
̶ Environmental Reevaluation - Social reappraisal to realize how their unhealthy behavior affects
others.
̶ Social Liberation - Environmental opportunities that exist to show society is supportive of the healthy
behavior.
̶ Self-Liberation - Commitment to change behavior based on the belief that achievement of the healthy
behavior is possible.
̶ Helping Relationships - Finding supportive relationships that encourage the desired change.
̶ Counter-Conditioning - Substituting healthy behaviors and thoughts for unhealthy behaviors and
thoughts.
̶ Reinforcement Management - Rewarding the positive behavior and reducing the rewards that come
from negative behavior.
̶ Stimulus Control - Re-engineering the environment to have reminders and cues that support and
encourage the healthy behavior and remove those that encourage the unhealthy behavior.
RATHER THAN
ABILITY OR SHEER
REFLECTION OF
“MORAL
STRENGTH”, SELFREGULATION
IS A
SKILL.
A CONSTRUCTIVE APPROACH:
PROGRESS IS NOT LINEAR!
The main predictor of a successful long-term behavioural change is persistence in
the face of setbacks and failures and ability to learn from mistakes.
A self-deprecating and judgmental attitude is not helping.
How to build
healthy habits
Human motivation system is reactive in nature...
Principal, “automatic” motivators:
̶ Rewarding feeling
̶ Security
̶ Safety
̶ Familiarity and predictability
̶ Avoiding pain and uncertainty
• HABITS – HABITUAL (“AUTOMATED”)
BEHAVIOUR REQUIRES MINIMUM ENERGY
AND IS LINKED TO THE SENSE OF SAFETY,
PREDICTABILITY AND CERTAINTY OF
BEHAVIOURAL OUTCOMES/
CONSEQUENCES (E.G., REWARDING
FEELING)
The arguably greatest shaper of our behaviour
How are habits formed?
Classical conditioning –
learning of physiological responses
Operant conditioning –
learning of specific behaviours
Human motivation system is reactive in nature...
Principal, “automatic” motivators:
̶ Rewarding feeling
̶ Security
̶ Safety
̶ Familiarity and predictability
̶ Avoiding pain and uncertainty
Motivational and emotional processes triggered by long-term goals do NOT by
themselves lead to goal attainment! Self-regulation is needed – the ability to plan a
complex action sequence directed towards the goal, and to motivate oneself to complete
each step, one by one.
Building new intentional habits
(J. Clear: Atomic Habits)
̶ Cue: “Make it obvious.”
̶ Craving: “Make it attractive.”
̶ Response: “Make it easy.”
̶ Reward: “Make it satisfying.”
HOW TO BUILD A NEW HABIT
• Regularity – determine time intervals you want to maintain
• Determine the lead behaviour that will start the sequence (clear and simple, easy
to do) – this is your “core habitual behaviour”
• Find an effective key habit trigger to match the time intervals you decided on –
unambiguously connected to other activities (“When do I start?”; setting
implementation intentions)
• Making implementation easier – minimize disruption of daily routine
• Making remembering easy – “nudges” and accessibility – triggers and tools are
easy to see and reach
• Rewarding feeling (self-praise; rewarding sense of achievement, control and
pride); maybe occasional (healthy) external reward
• Do NOT give up if you fail from time to time! (“Do not miss twice” rule)
• Exposure to positive role models (inspiration and conformity)
AVERSIVE
CONDITIONING IS
ESPECIALLY
POTENT...
Why is it important
to keep that in
mind?
AVERSIVE
CONDITIONING IS
ESPECIALLY
POTENT...
What if I do not see
any contingency
between my
behaviour and the
consequences
(reward /
punishment)?
What if I do not see any contingency between my
behaviour and the consequences (reward / punishment)?
LEARNED HELPLESSNESS
̶ Developed when behaviour does not affect the
(emotionally significant) situation
̶ Eliminates motivation
̶ Inhibits learning
̶ Impairs cognitive performance
̶ Can result in depression
̶ Hard to “unlearn”
IN HUMANS: Can be overrun by other types of learning
– stable beliefs moderate the effect of experience on
sense of control (learned optimism)
How to break
a bad habit?
Breaking an undesirable habit
̶ Change environment and avoid triggers
̶ Deliberate practicing of a new behaviour in response to the trigger or when dealing with situations
that lead me to the trigger – should be similar but healthier (desirable) – the new behaviour should be
motivating enough to shift our focus to perfecting that new behaviour rather than simply doing it to
remove the unwanted behaviour (the “Pink Elephant Effect”)
̶ Punishing the unwanted behaviour can help but often causes distress and might be hard to arrange
(either depends on our willpower, or is out of our control)
̶ Deliberate planning and structuring of behaviour; practicing mindfulness in everyday situations (=
noticing what is happening inside and outside)
̶ Developing new, more effective emotion regulation strategies
̶ Revise and supplement my set of coping strategies in general (bad habits are often developed as
short-term, inefficient coping mechanisms and are also triggered in situations of increased stress)
FUNCTIONAL ANALYSIS OF BEHAVIOUR
BEHAVIOURANTECEDENT REINFORECEMENT
Hypothesis Hypothesis
When and where is the
behaviour triggered? In
which circumstances
exactly is it NOT triggered?
What does the behaviour look
like? How does it proceed? Is
it a single action of a chain of
actions? What exactly do I
want to change?
What is the outcome of the
behaviour? What makes it
pleasurable? Which need is
satisfied through the behaviour
and how?
Positive/negative
FUNCTIONAL ANALYSIS OF BEHAVIOUR
ANTECEDENT REINFORECEMENT
Hypothesis Hypothesis
When and where is the
behaviour triggered? In
which circumstances
exactly is it NOT triggered?
What does the behaviour look
like? How does it proceed? Is
it a single action of a chain of
actions? What exactly do I
want to change?
What is the outcome of the
behaviour? What makes it
pleasurable? Which need is
satisfied through the behaviour
and how?
Maladaptive thoughts Which beliefs hinder my behavioural change?
How do I justify my behaviour?
BEHAVIOUR
Positive/negative
Emotion regulation
Response suppression
Cognitive reappraisal
Attention deployment
Change of situation
Avoidant behaviour
How effective and feasible each strategy is depends on circumstances. However, people often employ coping
strategies that are most easily available to them rather than those that are most adequate for that particular
purpose.
AVAILABILITY = what I am used to; what I know. People will not do something they have not learned (= have never
encountered; are prejudiced about...)
Emotion regulation skills – at different levels of specificity – can be trained.
Effectiveness
Coming up with an effective plan
1. Evaluating possibilities – how much can I do? When and how exactly can I do? Which activities can I
replace? How can I fit different activities together?
2. Mental contrasting – What do I want to achieve, and which steps need to be done to do it? SMART
approach (“step by step” goal achievement).
3. Self-motivation and adjusting environment – What might help increase my interest, joy and
engagement? How can I make it easier to start/continue and resist the urge to postpone/give up?
(„nudging“) Which obstacles and distractions are better removed? → habit
4. Timing – time schedule with specific points in time marking when to start with the activity („implementation
intention“) → habit
5. Progress monitoring and positive feedback – what has worked and what has not; acknowledgement of
“hidden” progress (learning from setbacks)
6. Constructive emotion regulation – e.g. cognitive reappraisal – viewing difficulties as challenge, learning
opportunities, path to progress; developing self-regulation as a new set of skills...
METACOGNITIVE SKILLS = recognize, reflect on and
regulate your behaviour as well as your mental
processes – examples:
• Which of my habits are working out well for me and which are harmful?
• Why didn’t my chosen strategy work out? Did I implement it correctly?
• Which factors have a positive and negative impact on my ability to focus /
my mood / my performance?
• Why did my attempt at behavioural change fail?
• Why do I feel like this about the activity/recommendation? What makes me
annoyed? What makes me anxious / stressed? Why do I constantly feel like
giving up?
• What is my opinion of myself? Do I believe I can do it? Where does the
belief come from? What do I miss? What do I need?
• How much willpower can I exert? What can I do to make the task less
dependent on willpower (more enjoyable, more habitual...)?
Lékařská fakulta Masarykovy univerzity
2024
Thank you!