Wellness is “a conscious, deliberate process that requires a person to become aware of and make choices for a more satisfying lifestyle” (Swarbrick, 2015, p. 13). Positive healthy habits and routines are significant contributors to wellness in life dimensions—physical and financial stability, engagement in occupations and purposeful activity that provide a sense of meaning in life, a supportive social network, emotional well-being, and intellectually satisfying pursuits. However, establishing good habits and eliminating bad or harmful habits are difficult, especially for individuals living with or who are at risk of developing mental or substance use disorders.
For individuals with serious mental and/or substance use disorders, the combination of personal history, treatments, symptoms associated with the mental or medical conditions, and poverty often interact to influence habits that negatively impact wellness. In decades of training sessions conducted by two of the current authors (P.B.N., M.A.S.), service providers have expressed frustration at service users who appear “unmotivated”—equating lack of motivation with lack of action, without recognizing the complex interaction of variables that challenge creating and sustaining a set of health habits that impact well-being.
With the advent of integrated health care initiatives within the behavioral health field, nurses, occupational therapy practitioners, and other health and rehabilitation service providers play an increasingly important role in assessing and improving physical health status and lifestyle habits for individuals with serious mental and/or substance use disorders. Nurses are involved in programs promoting lifestyle change for patients using mental health services, with positive effect, yet such programs are not as common as they should be (Duran, 2003; Happell, Platania-Phung, & Scott, 2013, 2014). In addition to needing to provide education and support around lifestyle change for their patients, many nurses could benefit from changing their own health habits, as evident by the prevalence of obesity, poor diet, and lack of physical activity in nurses, along with other health problems and concerns (Blake & Harrison, 2013; Phiri, Draper, Lambert, & Kolbe-Alexander, 2014).
The current article provides a cursory overview of theories, research, and recent popular books related to habits, motivation, and willpower. The article offers an invitation to rethink how to support individuals in their effort to create and sustain habits to promote mental and/or substance use recovery and wellness. Because the focus is on human nature issues, rather than issues specific to disabilities, the current article also invites readers to consider their own habits and routines and how to establish health habits and behaviors that lead to balance and satisfaction in their own lives.
Human behaviors occurring over time can be seen as performance patterns, with the organization of daily tasks into habits and routines supporting an individual’s engagement in activities that have purpose and meaning. Habits are specific behaviors performed repeatedly, relatively automatically, and with little variation (American Occupational Therapy Association, 2014). Habits can be characterized as satisfying, health promoting, or damaging. Useful or healthy habits are patterns of behavior performed at the frequency, circumstance, and quality needed to enhance an individual’s ability to efficiently and effectively satisfy role demands.
Duhigg (2012) describes a habit as a loop, formed through repetitive pairing of a cue, behavior or routine, and a reward. Habits, by virtue of their automaticity, are efficient, as they limit the expenditure of mental effort (Lally & Gardner, 2013, p. 18): “An efficient brain also allows us to stop thinking constantly about basic behaviors, such as walking and choosing what to eat, so we can devote mental energy to inventing spears, irrigation systems, and, eventually, airplanes and video games.”
Many factors that contribute to good overall health are expressed through habits—washing one’s hands, placing keys or a valued possession in the same place, drinking water, flossing and brushing teeth, getting regular exercise, eating a piece of fruit instead of chocolate cake, or reading before sleep. Likewise, many factors that contribute to poor health and early mortality are also habits, including eating snacks while watching television, smoking, and drinking large amounts of alcohol or caffeinated beverages. To create and sustain a wellness lifestyle, it is important to develop positive health habits.
Establishing Good Health Habits
Establishing a new habit and replacing an existing habit considered “bad” or “weak” requires shifting from a conscious behavior to one that happens automatically—first selecting a specific behavior (e.g., brushing teeth, doing yoga, eating vegetables), then having the motivation or intention to establish that behavior, and, finally, making a deliberate effort to perform frequent repetitions in the context of cues that can later serve as regular prompts for the behavior, once it is established (Lally & Gardner, 2013). A positive outcome of the behavior, such as personal satisfaction (Lally & Gardner, 2013) or some sort of reward experience (Duhigg, 2012), will facilitate repetition and help sustain motivation to perform the behavior again. One study (Lally, van Jaarsveld, Potts, & Wardle, 2010) estimated that it takes approximately 2 months of regular performance for a behavior to become a habit—less time, perhaps, for simple actions, and longer for more complex behavior patterns.
Eliminating (extinguishing) a dominating habit is another matter entirely. Engaging in repeated patterns of behavior creates changes in the brain, and the resulting habit is likely to persist, regardless of whether it continues to result in a reward (Yin, 2008). Habits are cued automatically, making them difficult to interrupt, regardless of one’s desire to change (Lally & Gardner, 2013) or the recurrence of unpleasant outcomes or adverse effects on oneself or others. Sometimes habits, once useful to role performance, are ingrained and continue even if after they become undesirable or destructive following a change in role, circumstances, or personal values, beliefs, or goals.
Substituting a new habit for an old habit may be more effective than trying to be mindful and stoic enough to resist the old habit (Hagger & Luszczynska, 2014; Lally & Gardner, 2013)—meaning that “do more” goals are easier to achieve than “do less” goals. A “do less” or “stop doing” goal may have a paradoxical effect (Hagger & Luszczynska, 2014), where the mental efforts to control actions, and to monitor for the possibility of failure, result in the very action the individual is trying to avoid.
Existing habits often occur outside of awareness, such as the example of getting off at one’s usual exit even when intending to continue further on the highway. Establishing a new habit requires heightened awareness and deliberate sustained effort. Appreciating the effort required makes it clear why making big changes over a short period of time generally results in temporary success and long-term failure, such as in the typical crash diet story, where an impressive weight loss is fully reversed in a matter of months. A focus on “small wins” and “keystone habits” (Duhigg, 2012, p. 109) makes success more likely. Keystone habits are the foundation stones that hold up other healthy habits, such as getting regular exercise or logging food intake, which often lead an individual to make subsequent changes. Relatively small, challenging, attainable goals or wins make it possible to concentrate on making change without being overwhelmed and in a way that allows the sustained effort needed to make a new behavior into a habit.
Linking new behaviors to strongly established habits can facilitate adoption (Duhigg, 2012). For example, if an individual constantly forgets to take his morning medication or daily vitamin, yet routinely and automatically operates the coffee pot while still half asleep, he could establish a habit of taking his pills after starting the coffee but before it has brewed.
Controlling the environment can help eliminate some habits (e.g., “I can’t snack on something that I don’t have in the house”) and can help control, prompt, or cue others (Wansink, 2010). Simple changes in the environment can add up to a big difference, such as eating meals off a smaller plate (Wansink, 2010), prepackaging snack foods, or always keeping a gym bag in the car filled with clean workout clothes.
Motivation, willpower, and rewards are three of many contributors to behavior change and habit formation that seem useful in helping individuals with mental and/or substance use disorders create and sustain health habits that promote wellness. These factors are discussed in the context of promoting self-guided change, not externally controlled behavior change. The focus on self-guided change is congruent with recovery and psychiatric rehabilitation principles and values, including self-determination and choice.
The first of the three contributors to behavior change and habit formation is motivation. Motivation itself remains somewhat of a mystery, as it is an internal state, but theories and research suggest some factors that facilitate taking action to make a change. Often, action is falsely equated to motivation (no action = no motivation). However, motivation can exist in the absence of action; action is likely to be initiated only after reaching a certain threshold that tips the balance toward making a change (Miller & Rollnick, 2013). Relevant motivational factors discussed briefly herein are need, interest or desire, beliefs, expectations, and initiation.
Need must be considered from the perspective of the individual who would be making a change (Duran, 2003) and represents an external pressure to make things different (Farkas, Cohen, McNamara, Nemec, & Cohen, 2000; Miller & Rollnick, 2013). Interest or desire, in contrast to need, is an internal pressure to make things different (Farkas et al., 2000; Miller & Rollnick, 2013). An individual can have a high need plus a low desire (e.g., being evicted from an apartment where the individual was content) or a low need plus a high desire (e.g., a wish to leave a satisfying job to experience new challenges through work and/or school). A low need plus a low desire makes change unlikely.
Beliefs are discussed at length in the Theory of Planned Behavior (Ajzen, 2011) and the Health Beliefs Model (Carpenter, 2010). The beliefs relevant to changing behavior include a belief in the likely effectiveness of the new behavior (Will it really accomplish what I want?), norms (What I think I should do, what I think others expect of me), and control beliefs (self-efficacy and locus of control—Can I really make this change happen, given my current circumstances?). These factors all contribute to whether someone intends to change, which, in turn, predicts whether the individual will take action to change.
Although some expectations are captured in the concept of beliefs, such as belief in the likely effectiveness of the behavior and self-efficacy beliefs, other expectations relate to possible payoffs for making the change and possible consequences for not making a change—often referred to as the pros and cons of change (Miller & Rollnick, 2013). The anticipated payoff can be a clear and specific outcome with a guarantee of delivery (e.g., insurance premiums going down when an individual stops smoking) or a vague hope (e.g., the idea that weight loss will lead to finding a new romantic partner).
Initiation of action (i.e., getting started on making a change) may follow from a carefully reasoned decision or can appear to be impulsive or spontaneous, sometimes resulting from a significant event. Although some actions occur as a result of careful reasoning and considered decision making, resulting in an intention to seek health care or to change behavior, much of human behavior can be described as irrational and/or mindless (Wansink, 2010). Environmental factors influence behavior to a greater extent than most people recognize (Wansink, 2010) and, of course, the degree to which an individual can actually control his or her behavior is also relevant (Ajzen, 2011). For example, individuals who live in a poor community and lack access to affordable healthy foods will find it difficult to create healthy eating habits.
Like motivation, willpower is often invoked in ordinary discussions about developing good habits, yet remains a poorly understood construct. Defined as self-control, or the ability to resist temptation, willpower seems to be an important component of initiating change as well as providing the perseverance needed to persist in the efforts needed to change or establish habits (Baumeister & Tierney, 2011). Positive health habits, such as refusing dessert and exercising outdoors in bad weather, require sacrificing momentary comfort or pleasure for the possibility of a long-term future benefit. The ability to delay gratification has been found to be related to success in many arenas of life, as captured in the oft-replicated “marshmallow test” (Mischel, 2014), where children are asked to resist eating a marshmallow with the promise of two marshmallows if they can wait. The newer concept of “grit,” related to willpower but possibly a different trait or ability, refers to “passion and perseverance toward especially long-term goals” (Duckworth & Gross, 2014, p. 319), in contrast to the moment-to-moment resistance of willpower.
Goals representing a larger purpose or personal life values can fuel willpower (Carver & Scheier, 2001; Deci & Ryan, 2008; Duckworth & Gross, 2014; Miller & Rollnick, 2013). During the exposure to temptation, reminding oneself of the big picture can provide support to do the right thing. For example, if building an exercising habit to control depression or chronic pain, reminding oneself of those reasons might get one out of the house on a cold winter morning. Linking symptom control to larger life goals and values, such as caring for family or being effective at work, can help put out the effort to exercise.
Willpower actually requires energy. In laboratory studies, even a “small exercise of self-control was associated with a big drop in the brain’s fuel of glucose” (Baumeister & Tierney, 2011, p. 48). In addition, resisting temptation and making decisions seem to require similar cognitive functions, and energy spent on one appears to deplete the energy available for another (Baumeister & Tierney, 2011). Considering that a person makes, on average, more than 200 food-related decisions each day (Wansink, 2010), and countless more choices in other life arenas, it is no wonder that many individuals find themselves vulnerable to food temptations in the evening. Some strategies may reduce the willpower drain. For example, limiting food choices may help sustain efforts to change one’s diet; exercising with a partner or in a class at a scheduled time may reduce the temptation to skip.
For individuals who describe themselves as lazy or lacking willpower, a “strengthening” program may be valuable prior to embarking on larger changes to reduce impulsivity or increase tolerance for delayed gratification. Even something as simple as working on one’s posture can make a difference (Baumeister & Tierney, 2011, p. 131):
By overriding their habit of slouching, the students [who participated in the study] strengthened their willpower and did better at tasks that had nothing to do with posture. The improvement was most pronounced amongst the students who had followed the advice most diligently.
Behavior change occurs in response to rewards—both short-term and long-term payoffs. The importance of reward is captured in the literature on behavior modification, the notion of expectancies (Bandura, 1997), and self-determination theory (Deci & Ryan, 2008). Although contingent rewards have long been established as effective in eliciting and maintaining behavior, external (extrinsic) rewards tend to have limited effectiveness over the long term in helping individuals develop and maintain positive behaviors (Deci & Ryan, 2008). Autonomous choice to perform actions that are intrinsically rewarding likely will result in greater long-term success (Deci & Ryan, 2008), although direct rewards can be effective, as shown in work on contingency management (Drebbing et al., 2007).
Praise from others can serve as a reward, but some research suggests that how the praise is offered matters, at least for children. For example, too much emphasis on effort (e.g., “I know you worked really hard on this”) can reduce self-efficacy (Bandura, 1997, p. 102), although research findings are contradictory regarding the effects on children of “effort praise” or “ability praise” for educational achievements (Lam, Yim, & Ng, 2008, p. 695). Overblown or inflated praise can be problematic for children with low self-esteem (Brummelman, Thomaes, de Castro, Overbeek, & Bushman, 2014). Praise focused on traits, such as intelligence, in contrast to praise focused on strategies also may have different effects, and one long-time researcher on the effects of praise on children (Dweck, 2007, p. 37) recommends praising “engagement, perseverance, strategies, improvement, and the like” to boost motivation, as it tells individuals “what they’ve done to be successful and what they need to do to be successful again in the future,” whereas praising individuals for their intelligence or other apparently unchangeable traits “hands them not motivation and resilience but a fixed mind-set [a static and unalterable characteristic] with all its vulnerability.” The jury is out on exactly the best way to praise adults in general, or to praise adults with mental and/or substance use disorders, but it seems best to avoid inflated trait-based cheerleading and it seems a safe bet to offer (in a neutral tone) specific feedback on positive actions taken, a technique consistent with a strengths-based approach.
Strategies to Recreate New Health Habits
Many strategies have been found useful in changing behaviors to develop or eliminate habits, including developing awareness, identifying reasons to change, and creating a plan.
Developing awareness of one’s current behavior and situation (Duhigg, 2012) involves taking note of existing habit loops—what cues the behavior, what routine follows the cue, and how payoffs reward the behavior (making it more likely that it will be repeated). If the goal is to eliminate or reform a bad habit, then developing awareness includes considering the location where the habit occurs, the time of day and days of the week, one’s emotional state before and after the habit, what others may be doing to prompt or shape the behavior, and any antecedent behaviors that occur before engaging in the bad habit. Limiting options, such as getting rid of tempting junk food or moving the television out of the bedroom, can help avoid expending needed energy on unnecessary decisions, while increasing the willpower and grit needed to persist.
Newly available electronic wearable fitness tracking devices (e.g., Fitbit® or Jawbone® UP24™) can bolster habit formation through increased awareness of one’s current performance, facilitating setting specific and measurable goals and tracking progress. In the current authors’ experience, many individuals find the feedback of an electronic monitor beneficial for increasing motivation, supporting sustained efforts, and providing a sense of reward or accomplishment.
Identifying Reasons to Change
Identifying reasons to change begins with exploring interest and desire to increase or decrease the target behavior. It is important to determine the deep reasons for change, not just a superficial rationale. Reasons to change include the immediate payoffs of achieving the change goal, as well as aligning behavior with personal values, achieving long-term goals, and maintaining health for increasing functioning or longevity in relation to some important life role, such as continuing to work or living long enough to get to know one’s grandchildren. Messages and reminders of the reasons and rewards can prompt action and support perseverance at times when motivation wanes.
Creating a Plan
Developing a change plan begins with a goal. Having only a general idea of the change, rather than a specific goal, makes it harder to determine steps toward success. Small and short-term goals support success; therefore, useful goals identify the small changes that can serve as a foundation for future change while still feeling like a significant victory.
Once the vision of the new habit is clear, analyzing one’s existing good habits can build self-efficacy and suggest both goals and ways to link new actions to existing behavior patterns. Strengthening efficacy beliefs about one’s own ability to make a change can add to a sense of hope that things can be better by envisioning the possibility of making that hope a reality.
The change plan includes the goal or objective, written in a specific and measurable form, the smaller action steps to be taken on the road to that goal or objective, and any rewards for accomplishing each step. Effective action plans enlist supports to build in the company, encouragement, and practical help needed to complete the steps. Planning might include the use of personalized implementation intentions (Gollwitzer & Sheeran, 2006) that specify, for example, “when Barrier X occurs, then I will take Action Y.” Implementation intentions (Gollwitzer & Sheeran, 2006) support goal achievement through problem-solving and planning to prevent becoming derailed, and have been found to contribute to health behavior change in a variety of areas (Hagger & Luszczynska, 2014).
The process of developing an action plan for change may benefit from working collaboratively with another individual as well as ongoing meetings or booster sessions to revise the plan, problem-solve around barriers, and develop new plans (Hagger & Luszczynska, 2014).
Implications and Application
For individuals with mental and/or substance use disorders, challenges related to attention, organization, and planning may impact goal setting, action planning, and persistence; however, established habits can help sustain behavior despite these challenges. Other challenges, such as chronic fatigue from ill health, poor sleep, or medications, sap the willpower and limit the energy needed to create and maintain healthy habits. Nurses can provide specialized assistance in these areas through health assessment and health education for patients using services and also for their service teams. Other interventions that could be effectively led by nurses working in behavioral health include monitoring antipsychotic drug use to reduce (or at least optimize) dosages, teaching illness self-management strategies, initiating conversations about and providing education on sexuality and sexual health, and serving as a critical communication link between primary care and behavioral health service providers—both as a translator and advocate (Happell et al., 2013). Within these areas, assessing and promoting positive health habits can be a central theme.
A specific practice implication that follows from reviewing the literature on promoting health behavior change and positive habit formation is that current service planning and documentation procedures are not always a good match for best practice. In the current authors’ experiences as trainers, consultants, educators, and supervisors, it has been found that service plans generally do not focus on basic health habits from the patient’s perspective. In addition, treatment plans focus on vague goals and objectives with timelines of 6 months or longer, in the hope that this will reduce the frequency of documentation, while allowing the greatest variety of service provider actions to be captured as relevant to the service plan. Unfortunately, such broad-brush planning rarely results in change, especially around building good health habits, as such change is facilitated by specific and short-term goals and action plans. When the current authors have suggested the use of short-term goals, objectives, and plans, many service providers balk at the idea of adding paperwork to their day, not realizing that they should be using such an approach regardless of whether it matches existing documentation standards if they wish to increase the likelihood of successful outcomes.
Nurses are in a position to build the rapport needed to explore an individual’s needs and priorities (Duran, 2003). By adopting a collaborative person-centered approach, nurses, in collaboration with the integrated health care team, will be able to resist the tendency to prescribe goals and prematurely narrow the focus of health behavior change (Duran, 2003; Miller & Rollnick, 2013).
Service providers can, at times, become discouraged and confused at the lack of significant progress they see in patients they serve. Occasionally, service providers may find themselves losing hope, blaming a service user, or despairing that circumstances simply cannot be changed. They do not always explore options and strategies for new approaches, possibly because innovative approaches require a breadth of knowledge that they lack—an understanding of the complexity of habit formation, behavior change, and the influence of other factors, such as addiction, on choices and actions. The current authors hope that this article will provide a wellness habit formation framework to inspire practitioners to learn more and try new ways of engaging and supporting the individuals they serve.
Nurses and other service providers may benefit from specific training, such as wellness coaching (Swarbrick, 2006, 2015), action planning (Hagger & Luszczynska, 2014), and motivational interviewing (Duran, 2003; Miller & Rollnick, 2013) to learn how to best support and guide individuals to set wellness goals and pursue health habits and routines that they identify as meaningful and rewarding.
Nurses and other service providers may benefit from training and work-based supports to develop and apply the knowledge and skills overviewed, both personally and professionally. When service providers explore their own habits and work on implementing behavior change in their own lives, they find that they enrich their appreciation for the human nature issues involved—recognizing that everyone struggles with change. Because the goal of training on this topic would be to change service provider behaviors (habits), the process of training needs to be based on many of the principles and practices noted herein. Most specifically, as new habits require extended time periods for development, training initiatives need to include practice with feedback, periodic retraining, supervision and guidance, monitoring, encouragement, and rewards.
Habits can be difficult to establish, eliminate, or improve. Given the importance of good habits and routines to overall health and wellness, nurses and other health and rehabilitation practitioners need to understand the force of habits (both positive and negative), the challenges in eliminating bad habits (they are easier to replace than decrease), some factors that affect behavior change and habit formation (e.g., motivation, willpower, rewards), and approaches that are likely to facilitate building and maintaining good habits. Once they have the foundation knowledge needed, nurses are in strong positions to educate other providers and individuals using mental health and substance use services. Nurses may be able to address the lifespan disparity facing individuals living with mental and substance use disorders by implementing a wellness habits formation framework. Nurses can play an important role helping individuals create and sustain health habits that enhance overall wellness by exploring willpower and motivation. Nurses can carefully assess an individual’s current habits and health behaviors and use this framework to collaboratively help him or her set specific and measurable short-term goals or objectives and a detailed plan that relates to what the individual served identifies as larger reasons or purposes.
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