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Nutrition Counseling and Educational Skill Development, Bauer and Liou
Chapter 2- Frameworks for Understanding and Attaining Behavior Change

Gemma Bridge

Historically nutrition councilors and educators tried to change food choices by dispensing facts and diets
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So, psychotherapy counseling approaches and theoretical models were turned to instead
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g
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g
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With attainment of health behavior change linked
closely with an individual’s level of self efficacy
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Councilors must help clients improve their self efficacy and help them to see that there is a way out of the situation by
helping them to see that there are workable options to facilitate behavior change
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In order to make a change people must:
 Perceive personal susceptibility to a disease or condition
 Perceive the condition as having some degree of severity/ consequences
 Believe that there are benefits to taking action i
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they can cure or prevent the disease by making changes
 Perceive no barriers that may prevent the health action
 Must be exposed to a cue to take action
 Have self efficacy
All of these beliefs interact with each other and determine a client’s willingness to take action
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g
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Show graphs and clarify consequences
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 Perceived susceptibility and severity:
o Personal risk was addressed by highlighting risk of heart disease and diabetes for all members of the
community
 Perceived benefits:
o Lessons were given to highlight benefits of whole grains over refined carbs
 Perceived barriers:
o Lessons were given to help community understand labels, and on how to cook the grains
 Self- efficacy:
o To increase confidence demonstrations were given and people had the opportunity to practice e
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reading labels

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Nutrition Counseling and Educational Skill Development, Bauer and Liou
Gemma Bridge
 Cues to action:
o Participants were given recipes and educational materials to take home
The Transtheoretical Model (Stages of Change Model)
This model crosses over many different behavior change models
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 The movement between stages is in part based upon a clients views of the pro’s and con’s of making the
changes needed
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 There are 5 levels of readiness
1
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Cons outweigh pro’s
b
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Resists efforts to rectify the problem behavior
2
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Pro’s and con’s are balanced
b
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Long term benefits of the change do not outweigh the short term costs
d
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Preparation
a
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Advantages seen to outweigh disadvantages
c
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Action
a
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Behavior is not considered permanent and relapse is common
5
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New behavior is being consolidated
b
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By knowing that
behavior changes may not be permanent and that it is likely that a relapse will occur allows for interventions to be
planned accordingly
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 Strategies found useful at each stage vary so the treatment must be tailored accordingly
Typically behavior change models have not considered readiness and instead have expected that individuals want to
change
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Intervention strategies vary in their effectiveness as clients graduate through the stages
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 In the early stages cognitive and affective strategies are most effective

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Nutrition Counseling and Educational Skill Development, Bauer and Liou
 In the later stages behavioral strategies are usually most effective
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Precontemplation  intervention should aim to increase information and awareness to encourage emotional
acceptance
2
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Preparation  intervention should encourage commitment and help client to develop a specific action plan
4
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Maintenance  intervention should be collaborative with tailored revisions, and social support
Using the TTM to measure outcomes
Tracking clients through the various stages allows councilors to measure outcomes of their interventions
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The TTM was used in Canada to monitor the stages of change in diabetes patients
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 Significantly better improvements were made in the TTM intervention group
o More participants moved to the action or maintenance stage
o Better blood glucose control
Theory of Planned Behavior
Individual’s health behavior is directly influenced by intention to engage in that behavior
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Dynamic interaction between personal factors (values/ beliefs), behavior (goal setting/ change in activity) and
the environment (cooking equipment/ food available in the home)
A change in one influences the others
o Reciprocal determinism
 E
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Man develops high blood pressure  environmental change
 Change in wife i
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wants to learn about healthy eating  personal factor change
 Wife alters eating behavior by adding more veggies  behavioral change
Application of the SCT
EatFit was a guided goal setting intervention for school children
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However 3 guided the process and allowed for change:
1
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Self regulation (control) was implemented through self assessments
3
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E
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improved appearance, more energy
Client Centered Counseling
Basis of this theory of counseling is that humans are rational, socialized and realistic and that there is an inherent
tendency to strive toward growth, self actualization and self direction
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 Based on the assumption that behavior is learnt and that by altering the environment of internal factors, new
behavior patterns can develop
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 By learning to distinguish between thoughts and feelings, clients can become aware of how their thoughts affect
their feelings and can develop strategies to change harmful thinking
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Behavioral therapies are based on the premise that behaviors are learnt and so new ones can be learnt to replace old
ones
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Classical conditioning
a
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E
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cookie jar in the kitchen encourages unhealthy food choices, so by moving it to the
cupboard the stimuli is removed and the bad behavior is eliminated
2
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Based on the law of effect which states that behaviors can be changed by their positive or negative
effects
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By rewarding a good behavior such as making a dietary change, the individual is motivated to repeat the
behavior for more rewards
3
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Clients are shown videos, or watch a demonstration to encourages them to make changes as a result of
the positive changes they see from their observations

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Nutrition Counseling and Educational Skill Development, Bauer and Liou
Gemma Bridge
Solution Focused Therapy
Therapists work with their clients to concentrate on solutions that have worked for them in the past and identify
strengths to be expanded upon and used as resources
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 Motivational interviewing complements the Transtheoretical Model because it focuses on strategies to help
motivate the client to build commitment to make a behavior change
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MI is particularly useful in the beginning of the process of behavior change as there is typically a lot of ambivalence
about making any changes
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Collaboration
a
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Knowledge of both parties are respected
2
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Clients have an intrinsic desire to make healthier changes
b
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Autonomy
a
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Counselor can create an atmosphere to make client feel comfortable with making those changes
Guiding principles of MI
Motivational interviewing is like dancing, not wrestling
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Resist the righting reflex
a
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Ambivalent clients will likely rebel with defensive behaviors, giving reasons why not changing is also
good, if told what they must change and why
c
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Better to back off, maybe brain storm some ideas with the client or acknowledge resistance and try
something else
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Understand and explore motivations
a
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Client is encouraged to use change talk
b
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Listen with empathy
a
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By disagreeing with a client it creates resistance to change

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Nutrition Counseling and Educational Skill Development, Bauer and Liou
Gemma Bridge
4
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Belief in the ability to change is an important motivator
i
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Client should be reminded that they are the one who is responsible for making changes  client
will feel like they are capable of the take and therefore their self efficacy will be increased
Change talk in MI
Objective is to resolve ambivalence by providing opportunities and encouragement for the client to make arguments for
change
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 With strengthened change talk, commitment will increase and so will the likelihood of behavior change
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Cognitive- Problem recognition
2
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Affective- Expression of concern
4
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Evaluate importance and confidence
a
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Clients are then asked to rate how confident they are about making that change on the same scale
i
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Normally the lowest scores of readiness are associated with the lowest scores of importance of change
2
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Tell the client to change rolls and ask the client to try and convince you why you should make the
contemplated behavior change
Reinforcing change talk
When clients make change talk statements, the counselor should reinforce their meaning
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 Can request clarification
 Can reinforce change talk non verbally
OARS- Foundation skills
Acronym for the most useful skills in MI:
 Open ended questions
o Explore and gather information from the clients perspective
o Allow the client to talk
o E
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ask about the pro’s and con’s of the clients current eating pattern
 Affirmations
o Recognize client efforts and strengths and provides motivation to encourage continuation of changes
o Focus should be on the client
 Summaries
o Help to organize thoughts, reinforce change talk and clarify discrepancies
 Reflective listening
o Listen to the client, and reflect the interpretation back to the client
o Act as a mirror  sign of empathy and interest
o Can help encourage client to continuing talking

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Nutrition Counseling and Educational Skill Development, Bauer and Liou

Gemma Bridge

Integrating MI with other behavior change approaches
MI is a communication style  can be incorporated with other behavior change approaches
 Additionally small parts of/ the spirit of MI can be used even when time is short
Behavior change attributes: summary
Councilors will help clients to make successful behavior changes
Good counselors will:
 Ask open ended q’s
 Make affirmations
 Summaries client statements
 Ask permission
 Encourage choice and responsibility in decision making
 Provide advice
 Make reflective listening statements
 Elicit change talk in the client
 Roll with resistance- do no argue or it will create more resistance
 Help client articulate deeply held values
Clients will make successful behavior changes when:
1
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They face minimal obstacles to change
3
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Feel positive about the change and believe it will have meaningful benefits
5
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They receive encouragement, support and reminders to make the changes possible

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Nutrition Counseling and Educational Skill Development, Bauer and Liou

Gemma Bridge

Summary of Behavior Change Models and Approaches
Behavior Change Model/ Approach
Self efficacy

Health Belief Model

The Transtheoretical Model

Focus
Component of many other models;
Confidence in ability to perform a
behavior
Perception of health problem and
awareness of benefits and barriers to
the new behavior are central to
decision to change
Behavior change is explained by
readiness to change

Theory of Planned Behavior

Intention influences behavior

Social Cognitive Theory

Learning occurs through observations
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Client Centered Counseling

Clients clarify issues and explore
solutions
Behavior is learnt, so it can be
unlearnt
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Cognitive Behavior Therapy

Solution Focused Therapy
Motivational Interviewing

Strengths are identified and past
successes are expanded
Explore and resolve ambivalence
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Key Concepts
Positive self efficacy increases
probability of making a change
Perceptions of: susceptibility, severity,
benefits and barriers
Affected by: cues to action and self
efficacy
Behavior change occurs via a series of
changes  Takes time
Specific strategies are identified at
each stage
Intention is the result of attitude,
subjective norm and perception of
behavioral control
Self efficacy, knowledge and skill
development, social support and
observations are all needed to allow
for change
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Councilors help clients to feel safe to
encourage discussion and openness
Thoughts and feelings must be
distinguished and patterns of thinking
are challenged
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Consequences
of
change
are
emphasized
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Problem solving
is not the focus of the session
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Aims to
develop discrepancy and reduce
resistance
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Councilor must listen reflectively

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