Developing a treatment plan for changing behavior
Whether you want to increase some desired behavior or decrease some unwanted behavior, the 20 methods above must be considered. Many of these self-help methods have already been discussed in this chapter. However, we will review the methods and provide examples for coping with consummatory responses--eating, smoking, and drinking. The self-control methods for all three problems are very similar. If none of these three areas is a problem for you, the description of the methods could still help you devise a plan for changing any behavior (or you can move on to a more relevant chapter).
The major intent in this section is to give you a brief description of each of the 20 self-change methods. More details about how to apply these methods are given in chapter 11. Also, more information is given below about the frequency, causes, effectiveness of treatment programs, and best available books and Web sites for these three problems: Addictions and Alcoholism, Eating Disorders, and Smoking.
First, let's consider the big picture of what goes in our mouth. Concerning food, about 25%-30% of adults in the US are overweight, another 12% are severely overweight (Brownell & Rodin, 1994). These Americans are obese in spite of health risks and a national preoccupation with dieting. Almost 40% of adult males and 50% of adult females feel they are overweight; 25% of males and 40% of females are dieting right now. Even in my college classes, close to 75% of 18 to 22-year-olds want to lose some weight or to tone up. Fat tends to be a long-term problem; 70% of over-weight teens become over-weight adults. One in 5 children are over-weight; 50% of 4th grade girls have already dieted. Fat costs insurance companies $130 billion in medical expenses every year. Look at all the magazine articles and books about dieting; yet, it is simply eating more than we burn up.
Considering cigarettes, over 45 million Americans still smoke cigarettes although about as many have stopped smoking (mostly on their own). 80% of smokers would like to quit, 35% try each year but only 2-3% succeed. Nicotine is highly addictive, so there are many relapses. It usually takes several tries before the habit can kicked (Curry, 1993). We smoke in spite of proven health hazards to ourselves and others, including cancer, heart disease, and 6-8 fewer years to live.
Now, adding in alcohol and drugs, about 1/2 of all Americans have had experience with an alcohol problem in the family; 17 million of us are severely dependent on alcohol and millions more young people are "preparing for the role." There are 3 to 7 times as many "problem drinkers" as "serious alcoholics." Even moderate alcohol intake may hurt our health, our job performance, our driving record, and our relationships. Alcohol is involved in 30%-45% of all suicides, in 50% of all emergency room admissions, and in 50% of all physical assaults on others. More than half of all Americans have used illegal drugs or prescription drugs sometime in their lives for pleasure, 15% during the last year and 2% are addicted to drugs. And, drug use is increasing--over 40% of all high school seniors used some illegal drugs just during the last year. Still more millions of us are "hooked" on coffee, soft drinks, sugar, salt, sweets, fat-laden red meat, junk food, and on and on. In summary, we, the "haves," put an incredible amount of unnecessary--even harmful and costly--things in our mouths, while 1,500,000,000 people on earth are hungry. Think about the 42,000 malnourished children who die every day!
These eating, smoking, and drinking habits have usually developed over a period of years, often when we were young and unaware. But, we now want to change the habits instantly and quickly lose the accumulations of the old habits, such as fat. Sorry, it can't be done. It is easy to gain seven pounds a year by doing 20 minutes less light work or play per day. It takes 3500 calories to make one small pound; that's starving for two days if you are on a 1700-calorie a day diet! Don't think you can easily work it off either: you have to jog for 6 hours at 5 1/2 miles per hour to lose 1 pound! This is no piece of cake, you must persist. The behavioral methods help you persevere and make it as easy as possible.
It used to be thought that over-weight people didn't eat any more than a thin person (that's what fat people tell us) but it isn't true. They "forget" or underestimate how much they eat. Also, they tend to be binge eaters and don't exercise (Brownell & Wadden, 1992). It is true that weight distribution and number of fat cells may be inherited, but the fat has to go into the body before it accumulates under our skin. Dieting may be risky, e.g. some claim repeated dieting--yo-yo dieting--causes problems and increases the chances of relapse. This hasn't been proven (Brownell & Rodin, 1994). However, being seriously overweight is clearly unhealthy.
If consumption is a personal concern for you as it is for me (I'm on a 100-year diet), the task is to permanently modify your eating and exercise habits. Caution: Some researchers (Foreyt, 1994) believe it is unethical to suggest any diet plan because "diets just don't work." It's true that crash diets, diet pills, fasting, short-term exercise programs help you lose weight but the effects are often only temporary. No diet has been developed that is dependably effective over a long period of time. When the controlled diet is over, gradually our cravings for sweets, fatty food, large helpings, etc. overpower our will power (unless we watch it very vigilantly). Most participants, at least 95%, are back to their original weights one to three years after terminating a commercial weight loss program. But, often it isn't the diet plan that fails, it is the maintenance plan. So, after working hard to reduce your weight or drinking or smoking, you must be just as diligent to maintain your gains (see chapter 2 and "relapse prevention" above).
Actually, there may be more hope than previously thought. Recently, low-calorie-diet programs providing intensive education (emphasizing some of the self-control methods described below) are getting good long-term results (Brownell & Rodin, 1994; Masters, Burish, Hollon & Rimm, 1987). Most encouraging, however, has been a finding by Consumer Reports that 25% of 90,000 readers reported losing weight on their own and keeping it off! The successful dieters probably made many attempts to lose weight. Nevertheless, these results are almost 5 times better than the weight loss outcomes reported by weight loss programs. Don't give up.
Here is a review of the behavioral methods for changing behavior. The illustrations used here focus on altering your "oral" habits, but all these methods can be applied to all behaviors:
1. Change your environment: Buy only limited amounts of wholesome food, no sweets, soft drinks, alcohol, or high-fat food. This is easier if you never shop when you are very hungry and limit yourself to exactly what is on your shopping list, no matter how cheap the ice cream is. Avoid situations where you will be pressured to eat, drink, swallow, or smoke something you don't really want, such as bars, parties, dinners, certain friends or relatives, etc., at least until you are under good control. (Some people are in better control when they are with people, so arrange that.)
Warning signs can be very effective. Place a picture of a fat person on the refrigerator or a picture of lung cancer on each cigarette pack. Write a reminder on each cigarette in the pack, e.g. "bad breath," "heart attack," "cough," "cancer," "early death," "8 years," and the names of people who will miss you when you die 8 years before you would have without cigarettes!
Prepare your plate with the accurate amounts; don't put out bowls of food. Keep fattening food out of the house or, at least, in a inconvenient form or in a hidden place or perhaps frozen so it can't be eaten impulsively.
Ask your friends to help you change--at least not encourage you to keep on harming yourself. Friends supporting and praising your self-control are powerful. Someone nagging you, however, will probably harm, not help.
Note: don't forget to look up the detailed instructions for each of these methods in chapter 11.
2. Develop new behavior: Set up an exercise program (for weight loss or smoking--and maybe drinking). You are 54% less likely to have a heart attack if you walk 21 miles a week. Develop a set of self-instructions that will control your eating: Before eating--"I will record the calories." While eating--"I'll notice how good and filling each bite is." Forget about "clean up your plate," in fact tell yourself--"Leave some every time." When one stops eating as planned--"I'll immediately put the money I saved in a jar for my foster child in Mexico." When tempted to snack--"I feel so good and look so much better when I don't overeat. I won't eat, I'll (walk?) instead."
Develop competing, incompatible responses to hunger, e.g. talk to a friend on the phone, exercise, write in your diary, drink water or a large glass of high fiber, low calorie drink for regularity (see # 11).
Overindulging can be prevented (and a new response learned) by calling on friends when tempted, such as done by members of AA or Overeaters Anonymous. You could have someone with you constantly to guard against cigarettes or eating or drinking (see compulsions in chapter 5).
3. Controlled or conditioned responses: A "controlled" response is one early in the chain and easier to control (such as deciding not to buy a cake in the store) than a response later in the eating-sweets chain (when you have already accepted a piece of cake at a party and asked for a big scoop of ice cream on it, it is too late). If you limited eating to one chair and only sat there while eating moderately (No TV! No talking! No reading!), good eating habits would become conditioned to that one place. Urges to eat other places would gradually extinguish. It is an especially good idea to work or study in one place and only study there.
4. Relapse prevention: We tend to think of relapses occurring sometime after a self-improvement project is done. That certainly happens--frequently with weight loss and drinking--but the most common time to relapse is early in the project. Over half of New Year resolutions are broken by February. Bad habits are strongest right after you stop them: one puff or one drink and you are at risk of being a smoker or drunk again. It is important to know your high-risk situations and avoid them or practice handling them (see earlier discussion in this chapter). You need to create a new life style. Dieters must permanently change how they eat, their food environment, and how they exercise.
Cue exposure or temptation resistance training is when, for example, a person who loves ice cream makes their favorite hot fudge sundae with nuts and then looks at it, sniffs it, takes a tiny taste but leaves it alone until it looks yucky, and then triumphantly throws it away. During this experience, the person says, "I'm certainly strong enough to control myself, it would be stupid to be dominated by these childish, disgusting, fattening urges to eat unhealthy food. I'm in control." They could also practice distracting themselves from the tempting food.
A similar procedure has been done with budding alcoholics; after being given one drink, they were urged to practice refusing more drinks. This seemed to reduce the craving for more alcohol in that setting. They also were gradually exposed to high-risk settings, so they could learn better self-control. It is simply practice at self-control. It is critical to stop a little lapse as soon as possible before it becomes a serious relapse (see Method #4 in chapter 11).
5. Motivation Training: Spend 5 minutes each day thinking about how you will look and feel after you lose weight. At the end of each meal give thanks for having the strength to control your eating and remind yourself how important it is. See motivational methods in chapter 14.
Horan (1971) used Homme's "ultimate consequences" technique. This consists of repeating and imagining a positive and a negative consequence of eating behavior, e.g. "look better" and "shortened life," every time some frequent behavior occurs, such as sitting in a favorite chair or drinking something. This keeps the long-range consequences in mind. Likewise, Prochaska, Norcross & DiClemente (1994) recommend motivating yourself by thinking about the dire consequences of your habit, such as a smoker who has lung cancer or an alcoholic with cirrhosis of the liver, as well as remembering all the other health and social reasons for changing. Throw yourself into becoming more healthy and wholesome.
6. Basic needs: If a person overeats as a way of reducing anxiety about a love relationship, the relationship can be worked on, perhaps by talking, getting counseling, or joining a marriage enrichment group. If stress, loneliness, or anger is a problem, work on the emotion underlying hunger. Attend to your physical and safety needs, your self-esteem and need for friends, and your need for love. Without these needs being met, you will find it hard to pursue higher missions in life.
Positive addiction was discussed earlier; did you know that people who exercise (a little sweat please) at least 4 or 5 times a week lose weight three times faster than people who only exercise 3 times a week?
7. Guard against self-deception: Some people do not realize how overweight (or underweight) they are; believe your scales and the weight charts. Don't excuse your fat by saying "Oh, I'm big boned." Many smokers don't think they are addicted, but if you smoke within 30 minutes of awakening or if you smoke 20 cigarettes a day, you are addicted to nicotine. Fishbein (1980) found that smokers acknowledged that smoking was harmful to other people's health but didn't believe their smoking would hurt their health. This is a self-con; it's living a lie. Smoking contributes to 18 or 20 serious, often deadly, diseases. Confront yourself with the facts--the health hazards of smoking, drinking, overweight or drugs, the unsightly roll of fat around your waist or on your thighs, the importance of vigorous exercise every day, etc. Get angry at the cigarette, alcohol, and food industries that harm your health. You were probably enticed into your habit as a young person; of course, you have to take some responsibility but so do the merchants of death.