Ron Borland, PhD, is the Nigel Gray Distinguished Fellow in cancer prevention, at the Cancer Council Victoria, Australia. “Understanding Hard to Maintain Behaviour Change” presents a dual process theory of hard-to-maintain behaviours and hard-to-sustain behaviours like exercise. The work is derived from the author’s work on tobacco smoking, but is clearly of relevance to anyone who is concerned to understand why some forms of desirable behaviour are so hard to achieve, and to those trying to help people change.
Borland identifies existing theories of addiction as being “limited in either scope or conceptualisation of the central problem” (p.5). Borland highlights three theories: (i) biologically focused theories which focus on biological mechanisms and learning; (ii) expectancy-value theories which look at the rational appraisal on a cost-benefit basis and (iii) social determinant models which locate individual problems within imperfect social structures. Borland critiques the explanatory power of such theories on the basis that they are not able to explain individual differences and responses to the same set of circumstances.
Borland’s central concern is on hard to maintain behaviour (HTM) changes (both those that are negative and to be eliminated and those that are positive and wanting to be achieved/sustained), and notes that what is required for initial behaviour change is not the same as that needed to maintain such behaviour change. Borland notes that all behaviour change occurs within a particular individual and external context and this then interacts with two internal processes, the operational and executive. Borland names his theory CEOS which is a combination of social context, an adaptive operating system (OS) which controls responses on a moment to moment basis and controls the means by which we act on the world, and an executive system (ES) which is essentially linguistic and logical and is involved in self-regulation and determining preferential future courses of action. Whilst the OS operates automatically and is the locus of action, the function of the ES is to monitor this, particularly in situations that are novel and/or complex and to override this automaticity. Indeed novel situations require the use of the ES in order to be dealt with appropriately. Where addiction and dependence occurs it can be thought of as becoming part of the OS and initial changes require the use of the ES in order to overcome automatic response such as craving states. However, in order for behaviour change to be sustained, the OS needs to take over the function of the ES, so that the newly changed behaviour operates on a more automatic basis. In essence therefore, the focus of Borland’s work is on the relative unimportance of rationality once behaviour change has been instigated.
If CEOS is correct and it does at least appear plausible, then it has implications for relapse prevention treatment and gives some additional theoretical support for mindfulness, acceptance and commitment therapy, along with lifestyle balance programmes more generally. It also allows a more productive discourse to take place with clients who continually represent to services with high levels of motivation and knowledge about the importance of integrated unconscious behavioural patterns. Where things get trickier is where an individual’s neuropsychological functioning has been compromised so that executive functioning and memory systems destabilize effective ES functioning. Whilst the OS can be assumed to take control in such circumstances, this should not underestimate the amount of time and skill-based cognitve remediation and restructuring that may need to take place.
Borland has written a succinct but powerful account of hard to maintain behaviour changes and the next step is to integrate this into services so that the model can be empirically tested and refined.
Robert Hill
Acute Assessment Unit
South London and Maudsley NHS Trust
UK
E-mail: [email protected]