J Relig Health (2010) 49:32–49 DOI 10.1007/s10943-008-9230-x ORIGINAL PAPER
The Disconnected Values (Intervention) Model for Promoting Healthy Habits in Religious Institutions Mark H. Anshel
Published online: 6 January 2009 Blanton-Peale Institute 2008
Abstract The purpose of this article is to provide an intervention model that can be used by religious leaders for changing health behavior among practicing members of religious communities. The intervention does not require extensive training or licensure in counseling psychology. At the heart of this model is the acknowledgement that a person’s negative habits (e.g., lack of exercise, poor nutrition) and his or her deepest values and beliefs (e.g., faith, health, family) are often misaligned, or disconnected. In addition, the unhealthy outcomes from these habits are contrary to the scriptural traditions of the world religions and thus are especially relevant to individuals who practice their religious beliefs. The Sacred Scriptures of Judaism and Christianity, for example, are replete with teachings that extol the virtues of practicing habits that promote good health and energy. In addition, evidence is mounting in the existing health intervention literature that adopting permanent and desirable changes in health behavior have not been successful, and that adherence to desirable habits such as exercise and proper nutrition is short-lived. The Disconnected Values Model (DVM) provides a novel approach for enhancing health behavior change within the context of the mission of most religious institutions. The model is compatible with skills presented by religious leaders, who possess more credibility and influence in changing the behavior of members and service attendees of their respective religious institutions. The religious leader’s role is to provide the client with faith-based incentives to initiate and maintain changes in their health behaviors, and perhaps to provide resources for the individual to pursue an action plan. A case study is described in which the DVM intervention was used successfully with an individual of strong faith. Keywords Exercise Physical activity Disconnect values model Exercise intervention
M. H. Anshel (&) Department of Health and Human Performance, Middle Tennessee State University, Murfreesboro, TN 37132, USA e-mail:
[email protected]
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Mounting annual health care costs in the US and other countries attest to the ubiquitous practice of unhealthy behavior patterns. One sad outcome of this dilemma is the deteriorating condition of our health, nationwide, with particular concern about increasingly poor health among youth. For example, Dr. Lavizzo-Mourey (2004), President and Chief Executive Officer of the Robert Wood Johnson Foundation, an organization that has spent $500 million dollars annually on attempts to prevent childhood obesity, indicated that for the first time in US history, children today will live a shorter, lower quality of life than their parents. The primary reason is the increased combination of obesity and a sedentary lifestyle, leading to the widespread onset of type 2 diabetes and hypertension (Barrera et al. 2008; Nestle and Jacobson 2000). Livizzo-Mourey reported that since 1980, overweight in children, ages 6–11, and adolescents, has doubled and tripled, respectively. While the causes of obesity are well known, the antecedent habits that cause obesity, such as poor nutrition and lack of exercise, have proven to be very difficult to change. The consequences of an overweight and inactive society include widespread serious deterioration of health and quality of life. For example, most studies indicate that 63% of US men and women are overweight, and about 33% are classified as obese (see Lox et al. 2003, for a review). Despite the widespread belief (82%) that exercise is beneficial to good health, approximately 60–70% of adults who begin an exercise program will quit within 6– 9 months (Marcus et al. 1998), a problem called non-adherence. The problem of non-adherence in maintaining unhealthy habits is not new in the health psychology literature. For example, Sackett (1976) found that scheduled appointments for treatment are missed 20–50% of the time, and that about 50% of patients are remiss in taking their medications as prescribed by their physician. In their review of related literature, Buckworth and Dishman (2002) reported the adherence rate of other health-related behaviors (e.g., smoking cessation, dietary restrictions, weight control strategies) after 6 months was fewer than 50%. As Baranowski et al. (1998) have concluded, interventions to curb low participation and adherence rates in promoting healthy habits, particularly related to exercise and nutrition/diet, have been only moderately successful. One potentially powerful source of health behavior change that has been neglected in the US is religious institutions and their respective leaders. While the need to improve healthy habits to promote good health, reduce health care costs, and provide more energy to devote toward serving God, either directly or through an intermediary (e.g., for Christians through God’s Son, Jesus Christ), changing unhealthy habits must start with self-motivation (Anshel 2003). No one in the community has more credibility and power to change behavior than a person’s religious leader. This role, heretofore neglected by religious leadership, is needed—not only as educators but as models of proper health behavior patterns. The primary purpose of this article, then, is to describe an intervention model for use by religious leaders that is consistent with their mission and with the Scripture they interpret and promote to worshipers and institution members.
The Role of Religious Institutions in Promoting Healthy Habits This article focuses on four premises: (1) that we live in a society whose overall health, and concomitant healthcare costs, is worsening annually, including individuals with strong faith and spirituality, and regular attendees to religious services; (2) that individuals require strong, credible leadership to replace their unhealthy habits with desirable routines that will enhance healthy lifestyle choices; (3) that community religious institutions possess enormous influence on the behaviors of their members and worshipers, but have neglected to
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assume a leadership role in changing unhealthy lifestyle habits in the community; and (4) that religious leaders, drawing upon their sacred texts, should be more proactive and assertive in modeling and prescribing the virtues of living a healthy lifestyle that is consistent with the values of their faith. An intervention model is currently lacking that promotes a value-based health behavior change that expands the individual’s spiritual capacity to provide the individual with a sense of purpose that drives self-motivation and gives life additional meaning and fulfillment. The religious leader is in a unique position to fulfill this role. The concepts of religion and health are not contradictory, as confirmed by the title of this journal. Given the virtual mandate of the Sacred Scriptures of both Judaism and Christianity, as well as the sacred texts of the other great world religions, to take care of our body as the sacred dwelling place of Spirit (the body as Temple in St. Paul’s metaphor), it is surprising that so many people of faith, who hold a strong belief in God, for example, and consistently attend religious services, regularly engage in self-destructive habits that compromise their health, energy, and mental state. Maintaining practices that promote good health is a central theme in Christian Scripture as shown by the following examples: * ‘‘Don’t you know that you are God’s temple and that God’s Spirit lives in you? If anyone destroys God’s temple, God will destroy him. For God’s temple is sacred, and you are that temple.’’ (I Corinthians 3:16–17) * ‘‘Everything is permissible—but not everything is beneficial.’’ (I Corinthians 10:23) * ‘‘Let us purify ourselves from everything that contaminates body and spirit, perfecting holiness out of reverence for God.’’ (II Corinthians 7:1) * ‘‘How much more so am I required to scrub and scour myself, having been created in the image and likeness of God, as it is written. For in the image of God He made human beings.’’ (Genesis 9:6; Leviticus Rabbah 34:3) * ‘‘So whether you eat or drink, or whatever you do, do it all for the glory of God.’’ (I Corinthians 10:31) * ‘‘Do you not know that your body is the temple of the Holy Spirit, who is in you, whom you have received from God. You are not your own. For you were bought at a price; therefore honor God with your body and in your spirit, which are God’s.’’ (I Corinthians 6:19–20) * ‘‘Do you not know that you are the temple of God and that the Spirit of God dwells in you.’’ (I Corinthians 3:16) * ‘‘It is not good to eat too much honey, nor is it honorable to seek one’s own honor. Like a city whose walls are broken down is a man (or woman) who lacks self-control.’’ (Proverbs 25:27–28) * ‘‘The good man eats to live while the evil man lives to eat.’’ (Proverbs 13:25) * ‘‘Do not join those who drink too much wine or gorge themselves on meat, for drunkards and gluttons become poor, and drowsiness clothes them in rags.’’ (Proverbs 23: 20–21) The question, therefore, for the Jewish and Christian traditions (and mutatis mutandis, for the other great world religions) is not whether their Sacred Scriptures condone a healthy lifestyle, but, rather, whether the roles and actions of the religious leaders of Judaism and Christianity, through sermonic content and their congregations’ programs, contribute to the building of a culture of wellness by developing healthy habits among members and worshipers. For a person who attends religious services regularly, there is arguably no individual who has more credibility and influence on that person’s thoughts, emotions, beliefs, and actions than his or her religious leader. Acknowledging the importance of
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religious leaders and their use of effective interventions that favorably influence health behavior has been surprisingly neglected in the existing health behavior literature.
Religious Practice and Healthy Habits: Perhaps a Contradiction in Terms It is well recognized that religiosity plays an important role in the lives of many individuals throughout the world. The results of numerous studies have reported favorable effects of religious practice on health (Atchley 1997; Ferraro and Albrecht-Jensen 1991). The likely reasons for these benefits include improved coping skills, reduced use of addictive drugs, including nicotine, lower rate of alcohol intake, and improved mood state. In addition to improved physical health, however, there is also a concomitant improvement in spiritual health (Holt and McClure 2006). This includes a strong belief in God, maintaining one’s faith, attending religious services, reduced worry and stress, a sense of surrendering to a higher power, and acting in a manner consistent with one’s values and beliefs (Gall et al. 2005). While religious practice has been associated with superior mental health, it is surprising that the relationship between religious practice and good physical health is quite low. Persons of faith (i.e., those who regularly attend religious services) experience rates of obesity and physical inactivity that is similar to their less religious counterparts (Marks 2005; Young and Koopsen 2005). For reasons about which we can only speculate, persons who maintain a strong religious faith do not appear to engage in a lifestyle that promotes good physical health and energy in spite of the extensive endorsement of good health as a religious value in the scriptural traditions of Judaism and Christianity. One possible explanation for the ‘‘disconnect’’ between the religious practice of individuals and their lack of healthy lifestyle choices may be what Gall et al. (2005) call their surrendering style. To Gall et al., ‘‘a surrendering style involves an active decision to release personal control to God over those aspects of a situation that fall outside of one’s control’’ (p. 92). Therefore, the person believes that ‘‘God is now in charge of the situation’’ (p. 92). This disposition promotes spiritual well-being and a deepened sense of faith, especially under conditions of high stress. The authors do not suggest that a person’s surrender style gives him or her license to engage in a carelessly unhealthy lifestyle because, after all, ‘‘God is in control.’’ However, it is plausible to speculate that for some individuals, a strong religious surrender style provides the incentive to maintain behavior patterns that medical science would consider unhealthy, such as lack of exercise and poor dietary habits. Surrender style may explain an individual’s relatively passive attitude toward taking responsibility for maintaining a healthy lifestyle. While individuals are entitled to their religious beliefs, low self-control is often associated with severe weight gain and other unhealthy outcomes. Perhaps the most credible source of information to a person of strong faith for health behavior change in living a life consistent with one’s values is the religious leader. Thus, a brief intervention is needed that can be used by religious leaders to replace a person’s unhealthy lifestyle with more desirable (positive) routines, particularly among individuals who maintain a strong spiritual life.
Justifying a New Intervention Model for Changing Health Behavior Religious leaders are in the business of changing behavior related to following one’s faith and leading a life consistent with the norms of the Scripture and Tradition of one’s faith
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community. It is rare, however, for leaders of religious institutions to suggest ways to replace unhealthy behavior patterns with healthier alternatives that is consistent with the teachings of one’s tradition and one’s own values, particularly faith, family, and health. Communication from religious leaders on maintaining healthy habits, including their own dietary and exercise habits, is apparently scant. The Disconnected Values Model (DVM) is a novel approach to health behavior change by addressing one’s values, and the evidence that one’s lifestyle habits are inconsistent with those values. Given the ubiquitous condition of obesity in the US (and other countries), and the limitations of existing interventions that have not successfully tackled the problem of changing unhealthy behaviors, a new applied intervention model that promotes healthy habits, particularly related to increased physical activity and changes in dietary habits, is needed. This need is particularly relevant among individuals who have strong spiritual values.
Limitations of Intervention Research Before explaining the model, it is important to discuss the limitations of previous attempts to change health behavior. Selected limitations of the extant exercise intervention literature have been reviewed by Buckworth and Dishman (2002); Dishman and Buckworth (1997); Morgan (1997); and Sallis and Owen (1999), among others. These include the absence of a theoretical framework or model to examine the efficacy of an intervention intended to promote exercise participation and adherence; the use of exercise interventions that have relied on one-dimensional techniques; a small sample size of highly selected participants (e.g., clinical populations, individuals already engaged in a specific program), thereby limiting the generalizability of findings to the community; the use of specific cognitive (e.g., positive self-talk, imagery, cognitive appraisal) and behavioral strategies (e.g., goal setting, music, social support) rather than a coherent intervention program; the imposition of strategies and programs on the individual without controlling for the exerciser’s motives, rationale, and personal commitment to begin and maintain an exercise program; and the assumption that the person actually desires a change in behavior. Thus, exercise participants often lack personal involvement in voluntarily choosing and committing to the type and schedule of exercise involvement, a strategy referred to as perceived choice (Markland 1999), or what Ajzen (1985) calls perceived behavioral control. In typical exercise adherence studies, exercisers are required to attend group sessions, often at specific times, performing predetermined exercise routines. In addition, previous intervention research has focused on outcomes (e.g., changes in attitude toward exercise and level of exercise adherence) rather than the mechanisms and processes by which changes in exercise-related attitudes and behavior occur. Not addressed in these studies is the process (i.e., mechanisms) by which improvements in fitness occur. For instance, providing educational materials, personal coaching, and social support, either combined or separately, may improve adherence—at least temporarily (Sallis and Owen 1999). As Glasgow et al. (2004) have concluded from their related literature review, ‘‘it is well documented that the results of most behavioral and health promotion studies have not been translated into practice’’ (p. 3). Perhaps the most commonly neglected research area related to behavior change is the contrast between the lack of an exercise habit in contrast to the person’s values and beliefs about what they consider important in their life (Dunn et al. 1998). The inconsistency between values such as health, family, performance excellence, and a sedentary lifestyle forms an essential source of incentive to change exercise habits. As Ockene (2001)
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correctly concludes, ‘‘…change is a process, not a one-time event, and we can’t expect people to make changes at a level for which they’re not ready. Our interventions need to be directed to where the individual is’’ (p. 45). Values, then, form a relevant component of the present model.
The Importance of Values for Exercise Interventions Rokeach (1973) defines values as core beliefs that guide behavior, provide impetus for motivating behavior, and provide standards against which we assess behavior. Values are highly relevant to establishing a person’s individuality and help our understanding of behavior. A person who values a living faith, for example, will tend to develop daily rituals and long-term habits that enhance his/her devotion to God, and to live a life consistent with his or her faith, and usually consistent with the religious authority of Scripture and Tradition. Crace and Hardy (1997) recognize that values guide behavior, and that sharing values with others strongly affects the commitment to sacrifice personal, self-serving needs for the benefit of others. Values are more central determinants of behavior than are interests and attitudes (Super 1995), the latter of which are more situational and derived from a core set of values. Thus, a plethora of interests and attitudes are derived from a relatively reduced number of values. In addition, interests, attitudes, and needs are transitory and, once satiated, may not influence behavior. Values, on the other hand, are almost always firmly entrenched and stable, and, therefore, transcend situations and guide behavior over a long period of time. While research on values and changes in health behavior (e.g., exercise, nutrition) is lacking, ostensibly values predict behavior (Brown and Crace 1996; Hogan and Mookherjee 1981). Thus, individuals who value health are more likely to engage in behaviors that enhance health. If faith is an important value, than predictably, more time and effort will be devoted toward engaging in religious behavior and deepening thereby one’s commitment to serving God or a Higher Power. If, however, the value of good health is a primary value, and that the individual’s behaviors are inconsistent with this value (e.g., no exercise, poor nutrition, lack of sleep), the link between value and behavior is disconnected. This ‘‘disconnect’’ forms an important segment of the current model to enhance exercise behavior. The extent to which individuals value their health, as opposed to how much effort and time they expend on health-related behaviors, is one indicator of a disconnect between their negative habits (e.g., not exercising regularly) and the value they place on their health (Loehr and Schwartz 2003). There may be a high degree of consistency between the person’s stated importance of their health and the time they invest in it if they are regular exercisers. There will be a large discrepancy, however, between persons who state that health is an important value, yet lead a sedentary lifestyle. That is, individuals may value their health; however, the amount of time they spend improving and maintaining good health may not reflect this value. To Loehr and Schwartz, this is called a disconnect, and forms the basis for helping individuals change their exercise behavior. Perhaps the misalignment between one’s behaviors and one’s values is best represented in Festinger’s (1957) cognitive dissonance theory. The theory posits a tendency for individuals to seek consistency among their cognitions (i.e., beliefs, personal views, emotions, values). An inconsistency between attitudes or behaviors (dissonance) results in an individual’s drive to change the attitude to accommodate the behavior. The most relevant factors that influence this drive for change are the number of dissonant beliefs and the importance a person attaches to each belief. For example, the importance of family may be
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dissonant from ignoring family members, not taking the time to mentor children, or failing to develop positive relationships. Dissonance may be reduced or eliminated by reducing the importance of the conflicting beliefs, acquiring new beliefs that change the balance, or removing the conflicting attitude or behavior. While cognitive dissonance theory provides a valid theoretical foundation for the current model, the DVM goes beyond the recognition of dissonance by asking individuals to acknowledge the costs and long-term consequences of their negative habits, and to develop a self-regulation action plan that carries out cognitive-behavioral strategies to replace the negative habit with new, positive rituals. The individual may conclude that the ‘‘benefits’’ of an inactive lifestyle and not exercising (e.g., having more time to do other things, not experiencing the discomfort associated with vigorous exercise) are greater than the ‘‘costs’’ of remaining sedentary (e.g., weight gain, poorer health, reduced lifespan). Only when these costs are greater than the benefits and the person perceives the costs as ‘‘unacceptable’’ will there be the proper ‘‘ignition’’ to begin and maintain an exercise habit.
The Disconnected Values Model (DVM) As indicated earlier, the process of behavior change is a challenging process because habits and routines, in this case, lack of regular exercise, are firmly entrenched in the person’s lifestyle (Ockene 2001). Attempting to increase exercise behavior is particularly difficult because it is accompanied by an array of long-held feelings and attitudes that may reflect negative previous experiences (e.g., the physical education teacher who used exercise as a form of discipline, burnout from too much physical training as a former athlete, injury from previous exercise attempts). Further, vigorous exercise requires effort and some degree of physical discomfort, often measured as ‘‘ratings of perceived exertion’’ (Borg 1998), in order to obtain the well-known benefits. Thus, a new approach for effective intervention outcomes is needed. The DVM is predicated on two postulates that define self-motivated behavior that have strong implications toward promoting exercise behavior, which is often missing from existing exercise intervention research. Postulate one. Self-motivated behavior reflects a person’s deepest values and beliefs about his or her passion, that is, the power of purpose (Loehr and Schwartz 2003). Purpose prompts the desire to become fully engaged in activities that ‘‘really matter’’ in meeting personal goals and future aspirations. Postulate two. The primary motivators of normal human behavior are: (a) to identify a deeply held set of values, (b) to live a life consistent with those values, and (c) to consistently hold ourselves accountable to them. Ostensibly, then, an individual whose values include health, family, and faith—examples of three common values—should be selfmotivated to exercise because it is consistent with these values. A deeper sense of purpose consists of shifting one’s attention from fulfilling one’s own needs and desires to serving and meeting the needs of others. Exercisers who value family, for instance, realize that they will have more energy and lead a higher quality of life in meeting the needs of family members. Perhaps, then, the self-motivated drive to develop an exercise habit rests, at least in part, on recognizing the inconsistency between one’s negative habits (i.e., lack of regular exercise) and their values, and then to institute a new, positive habit of exercise that is strongly connected to one’s values. As Loehr and Schwartz (2003) conclude, ‘‘deeply held values fuel the energy on which purpose is built’’ (p. 140). The DVM, the foundation of which consists of acting in a manner consistent with one’s values, is illustrated in Fig. 1.
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The Disconnected Values Intervention Model
Negative Habits
Cost & Benefits
Disconnect between negative habits & deepest values & beliefs
Values
Acceptable
Continue Negative Habit
Adherence to Rituals (self-regulation)
Performance Barriers Unacceptable
Quantitative Data (testing)
Action Plan— Replace negative habits with positive rituals
Personal Coaching & Social Support
Routines (time mgt.)
Remove (self Performance Barriers regulation)
Values
Fig 1 Disconnected Values Model
The DVM is based on the interaction between health care or mental health professionals and the client. The interaction reflects receiving information (e.g., facing the truth about who you are and how you live), self-reflection (e.g., acknowledging the costs and longterm consequences of living a sedentary lifestyle), determining personal goals (e.g., knowing what I want or need), and identifying the strategies needed to reach those goals (e.g., generating an action plan that replaces negative habits with positive routines). The DVM includes a component virtually ignored by researchers—providing intervention content that includes a sense of purpose, that is, ‘‘the energy derived from connecting to deeply held values and a purpose beyond one’s self-interest’’ (Loehr and Schwartz 2003, p. 131). The authors explain self-destructive behaviors and negative habits (e.g., poor nutrition, lack of exercise, high stress) as reflecting a ‘‘lack of…firm beliefs and compelling values (that are) easily buffeted by the prevailing winds. If we lack a strong sense of purpose (i.e., what really matters to us; our passion) we cannot hold our ground when we are challenged by life’s inevitable storms’’ (p. 133). Thus, previous interventions have heretofore consisted of selected cognitive (e.g., mental imagery, positive self-talk) and behavioral strategies (e.g., goal setting, social support), while ignoring the antecedent emotions and values that each participant brings to the exercise venue. As discussed later, taking into account a person’s values and beliefs forms a foundation on which future intervention research is needed. Finally, the model does not consist of pre-determined cognitive and behavioral strategies, although strategies may embellish the person’s ‘‘action plan’’ in carrying out the intervention. While the DVM is explained in a previous published study (i.e., Anshel and Kang 2007), a brief explanation of the model within the context of religious practice is warranted here.
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Negative Habits The model begins by individuals acknowledging their negative habits, defined as selfcontrolled thoughts, emotions, or tasks regularly experienced that are perceived as unhealthy or not in the person’s best interests. The negative habits are maintained despite recognizing they have costs and consequences to health, well-being, or quality of life. In the present context, maintaining unhealthy habits (e.g., not exercising, poor nutrition) or failing to maintain religious practice are examples of negative habits. A habit does not exist without benefits. Therefore, the primary reason individuals engage in negative habits is because the perceived benefits of maintaining the habit outweigh its costs and long-term consequences. For example, attending religious service or following the rituals of one’s faith requires effort, commitment, and time. Not maintaining these actions results in time to do other things and being able to maintain a lifestyle with fewer restrictions. The cost of not practicing one’s religious teachings often lead to a lifestyle void of spirituality, often defined as a union or connection with God or the divine (Levin 2001). Levin contends that spirituality is a subset of religion and is sought through religious participation. Long-term consequences, according to numerous epidemiological studies (see Levin 2001, for a review), include higher incidence of illness, disease, and lower quality of life. Because short-term benefits are immediate and long-term consequences are delayed, often for years, the negative habit persists. Performance Barriers Performance barriers are operationally defined as a persistent thought, emotion, or action that compromises and creates obstacles to high quality performance (Dunn et al. 1998). Whether these barriers can be actual (e.g., injury, anger) or perceived (e.g., time restraints, discomfort, anxiety), they are always controllable and, thus, changeable. The importance of performance barriers in the DVM is their root cause—negative habits. These behavioral tendencies, or habits, are labeled ‘‘negative’’ because it is generally acknowledged that they have a deleterious effect on the person’s quality of life, or some aspect of it, and that continued expression of the negative habits is directly linked to problems and limitations in work performance (e.g., lack of exercise leading to low energy and fatigue). One function of the model, then, is to help the clients detect their negative habits and how they lead to undesirable outcomes in various aspects of their life, including health and faith. Perceived Benefits of Negative Habits There are benefits to every negative habit we have. If there were no benefits to a negative habit, the negative habit would not likely continue. The benefits of not exercising, for example, include more time to do other things, not experiencing the discomfort of physical exertion, and having expenses related to purchasing fitness club memberships and exercise clothing, including shoes. Of course, there are possible costs to not exercising.
Costs and Long-term Consequences of Negative Habits The costs of maintaining the negative habit of leading a sedentary lifestyle include reduced fitness, weight gain, and higher stress and anxiety (both of which are reduced due to
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Table 1 Perceived costs and benefits of selected common negative habits Current habit
Benefits now
No
exercise
Poorer
health, More disease physical mental capacity less cost for more rapid aging and low quality of life.
Poor diet
Costs Now
Long-Term Consequences
More time for other tasks, less Less energy, weight gain, reduced mental capacity, effort and discomfort, more susceptibility to injury, reduced chance of injury, poorer sleep, negative special clothing and shoes. emotions.
Rapid gratification, saves time, High fat & LDL cholesterol, increased weight/obesity, good taste, low cost, poor concentration/energy. convenience.
Increased risk of heart disease, poor quality of life, shorter lifespan.
exercise). The long-term consequences of these costs include poorer physical and mental health, reduced quality of life, and, in some cases, shorter lifespan. Are these costs acceptable? If they are, the model posits, then the negative habit of not exercising and maintaining a sedentary lifestyle will likely continue. However, if the costs are far greater then the benefits, and the person concludes that these costs are unacceptable, then a change in behavior is far more likely (Strelan and Boeckmann 2003). Table 1 provides examples of perceived costs and benefits of selected negative habits. The model’s central feature in promoting health behavior change—the ‘‘ignition point’’—is linking the costs of the person’s negative habit, in this case, lack of exercise, to the person’s deepest values and beliefs.
Determining One’s Deepest Values and Beliefs If you were to give individuals who attend religious services a list of their deepest values— what they consider to be their beliefs about what is really important to them—they would probably rank faith, health, and family near the top. Perhaps integrity, character, compassion, happiness, humility, concern for others, honesty, excellence, commitment, generosity, service to others, and kindness would be other highly rated choices of values. In summary, according to the DVM, the decision to begin and maintain an exercise program is more likely if: (a) a person acknowledges that the costs and long-term consequences of a negative habit are greater then the benefits, (b) that these costs run counter to the person’s deepest values and beliefs about what the person considers important in life, and finally, (c) that the discrepancy between the individual’s negative habits and the person’s values is unacceptable. Thus, behavior change is more likely to be permanent when the person concludes that life satisfaction is linked to behaving in a way that is consistent with the individual’s deepest values.
Establishing a Disconnect To help individuals detect an inconsistency between their values and their negative (selfdestructive) habits, the non-exercising client is asked, ‘‘To what extent are your values
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consistent with your actions? If health is one of your values, for instance, do you have habits that are not good for your health, making this habit and your value of health inconsistent? What about your family or the Lord? Do you value your spouse, children, parents and God, who, according to the Jewish and Christian traditions, has created us to live in relationship? If you lead a sedentary lifestyle and you are not involved in an exercise program or lead a sedentary lifestyle, yet one of your deepest values is to maintain good health, to what extent are your values (e.g., health, family, faith) inconsistent with your behavior? Is there a ‘disconnect’ between your beliefs about good health or your family or faith and your unhealthy behavioral patterns?’’
Acceptability of the Disconnect If individuals acknowledge that the negative habit of not engaging in exercise is inconsistent with their deepest values and beliefs about what is really important to them, the follow-up question to ask is whether the disconnect is acceptable. The individual is asked, ‘‘Is this ok, especially after knowing the costs and long-term consequences of this negative habit?’’ If the person responds that the disconnect is acceptable—and for many individuals who feel that changing the negative habit is either undesirable, unnecessary, or beyond their control—then no change in behavior will likely occur. It is necessary, therefore, to identify second and third disconnects between their negative habits and values that might be more realistic or desirable for change. Only when individuals conclude that at least one disconnect is unacceptable are they prepared to commit to changing their behavior and engage in developing and carrying out an action plan that replaces the negative habit with one or more positive routines.
Developing a Self-Regulation Action Plan The decision to launch an exercise program, ostensibly because of an unacceptable disconnect between one’s negative habits (e.g., non-exercise) and one’s deepest values and beliefs, is followed by developing a self-regulation detailed action plan. The plan consists of determining ways to create an exercise habit during the day and week. Specifics include the availability of social support (e.g., exercising with others, transportation to the exercise venue), days of the week and times of day to exercise, the exercise location, scheduled fitness coaching—to include testing, prescription, instruction, and monitoring progress, scheduled nutrition coaching with a registered dietician, and blood testing to assess one’s lipids profile (cholesterol), the results of which should improve with change in diet and exercise. The results of past studies indicate that specificity of timing and precision of behavior dramatically increases the probability of successfully carrying out a self-regulated action plan. The action plan is not unlike a professional golfer who engages in a set of between-shot and pre-shot routines (Bull et al. 1996). The action plan consists primarily of three factors that will markedly enhance the individual’s permanent commitment to regular exercise: (a) a specific time within a 24-h period for exercise engagement; (b) a set of routines that support the exercise habit (e.g., selected thoughts and behaviors prior to, during, and following the exercise session, exercising with a friend and promoting other forms of social support, minimizing distractions that will interfere with exercise plans); and (c) linking these specific times and
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routines to the individual’s deepest values and beliefs about what he or she considers to be very important, thereby removing the existing disconnect. The role of developing routines is essential to successfully carrying out and adhering to the action plan. Oldridge (2001) refers to the concept of developing routines as ‘‘regimen factors.’’ Exercise adherence is far more likely, however, if the strategies are implemented as an integral part of one’s daily routine. In particular, he suggests ‘‘keeping the regimen straightforward, providing clear instructions and periodic checks, promoting good communication with the patient, and reinforcing their accomplishments’’ (p. 322). Oldridge contends that adherence strategies are seldom very effective on their own. Sometimes it is essential to start a routine relatively soon rather than to let the new habit or routine evolve over time. These ‘‘immediate’’ routines are called one-time action steps. Examples include finding a mentor, becoming someone else’s mentor, joining a spiritual center or other organization, donating money or time to charity, spending more time with family, starting ‘‘date night’’ with one’s partner, and prayer. Finally, a self-regulation action plan is developed consisting of new routines that are built into one’s workday. This requires strong time management skills. For example, a 24-h timesheet should incorporate activities scheduled at specific times that are connected to or reflect the person’s values. These normally include pre-sleep rituals (e.g., no food, alcohol, or stress within 1 h of bedtime, planned relaxed activity, positive communication with family members, prayer), times for sleep and planned awakening, time for exercise, meals and snacks, recovery breaks, times to connect with family/significant others, and other rituals linked to each dimension and the client’s values.
Application of the DVM: A Brief Case Study Brian (a pseudonym to protect his privacy) is a non-smoking 34-year-old married male with one child, standing 5 ft, 9 in. and weighing 260 pounds, with 39% body fat (the average for males is 20–25%), and a waist circumference of 46 in. Brian’s two main problems, perhaps not surprisingly, were the absence of regular (daily) exercise and overeating. He admits to eating a high fat, low fiber diet; he does not like raw vegetables. Three years earlier he lifted weights three times a week, but quit soon after the birth of his child. He claims that his excessive weight makes aerobic exercise very uncomfortable, although he has not received coaching on ways to gain aerobic fitness with minimal physical stress. His goals were to lose weight, increase muscular strength, and to have more energy, but he now realizes that losing weight is more expedient if his exercise regimen includes an aerobic component. Three ‘‘coaches’’ were involved in Brian’s 12-week program, a fitness coach (who was employed at a local fitness club), a registered dietician, and a ‘‘life skills coach,’’ who was actually a licensed psychologist. The fitness coach provided fitness tests (e.g., cardiovascular—walk—test, upper and lower body strength, percent of body fat, blood pressure, waist circumference) and the proper fitness program prescription, and worked with him once per week on improving both strength and cardiovascular conditioning. The registered dietician recorded Brian’s current diet, and helped him make proper food choices that were sensitive to his highly restricted dietary preferences. In addition, Brian supplied a recent blood test that included a lipids profile of his cholesterol measures. The blood test results served two purposes: (a) to provide an incentive for health behavior change based on relatively ‘‘poor’’ scores, and (b) to serve as a pre-intervention measure. All tests were conducted immediately prior to and following the 12-week program.
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The life skills coach did not engage in counseling or therapy, but rather, examined possible issues that might impede Brian’s long-term commitment to the program. Issues that could potentially be addressed included, but were not restricted to, dysfunctional eating patterns (e.g., emotional and passive eating), and evidence of psychopathology that would impede progress in the program and would require psychotherapy (e.g., chronic anxiety, depression, low self-esteem, irrational thinking). Although Brian was required to engage in three-one-hour sessions of exercise per week, fitness coaching instruction was provided only one hour per week; he was expected to exercise on his own the other two times. The program began with a private meeting between Brian and the program’s coordinator (i.e., this author) by introducing Brian to concepts in the DVM. This included six steps. First, Brian was to develop a mission statement about the intended outcomes of this 12-week program. He needed to identify the physical, mental, emotional, and spiritual reasons for improving his health and energy. Loehr (2007) uses the concept, ‘‘ultimate mission,’’ to reflect ‘‘the thing that continually renews your spirit…the indomitable force that moves you to action when nothing else can’’ (pp. 43–44). Brian was asked to indicate the most important goals he wanted and needed to achieve during his lifetime. In other words, he was asked, ‘‘What makes your life worth living?’’ ‘‘In what areas of your life must you truly be extraordinary to fulfill your destiny?’’ Making more money or achieving a higher status lacks the most basic and fundamental level of one’s purpose in life. Better choices would be to serve God (or Jesus) or to follow the teachings of his own scriptural tradition, to be an extraordinary father, husband, wife, professional, or leader in the community, or to be a role model or mentor for others. Brian’s second task, the model’s cost–benefit tradeoff segment, was to identify the negative habits that he felt most impaired his quality of life, energy, and professional career. In order to understand the reasons he persisted at those undesirable habits, he listed their benefits. For example, the ‘‘benefits’’ of eating a fast food breakfast almost daily included good taste, low cost, convenience of the restaurant’s location (i.e., on his way to work), convenience of not having to prepare a meal at home, and feeling full until lunch. Then he listed the ‘‘costs’’ of these habits. These included high fat content and a high number of ingested calories, higher food costs as compared to eating at home, weight gain, less nutrition than a properly prepared homemade breakfast, and less time to share time with his family over breakfast. Long-term consequences of his negative habit were increased ‘‘bad’’ cholesterol, reduced ‘‘good’’ cholesterol as shown in his blood (lipids) test, weight gain (obesity), premature heart disease, and even some cancers. Perhaps the most important disadvantage (consequence) was not living long enough to enjoy his fatherhood and even grandparenthood (e.g., not experiencing his child’s graduation, marriage, and other family life experiences). In the third segment, Brian was asked to identify five of his most important values taken from a list of 40 values. He designated family, faith, health, work quality/career, and character. He was then asked to make two lists, placed adjacent to each other. The left column consisted of his unhealthy habits and performance barriers (e.g., overeating, eating two ‘‘fast food’’ meals a day, avoiding fresh vegetables, not exercising, eating pastry and ice cream before bed). The right column consisted of his values, that is, issues about which he felt passionate, and had influenced his behaviors. He was then asked to compare the contents of each list, and to identify evidence of any areas that were misaligned. In other words, he looked for evidence in which a negative habit was inconsistent with a particular value. Brian detected four ‘‘disconnects.’’ He was then asked to contemplate the following statement: ‘‘Given the costs and long-term consequences of this disconnect, do I find the
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inconsistency between my negative habits and values acceptable?’’ If he answered ‘‘yes,’’ that is, the disconnect was acceptable, then he was informed it was likely he would maintain the negative habit, and that changing that particular habit was very unlikely, at least anytime soon. However, if he concluded that the disconnect was unacceptable, given the costs and consequences of this disconnect, it was more likely he was ready to engage in an action plan that consisted of replacing the negative habit (e.g., daily fast food breakfasts, lack of exercise, lack of prayer) with positive, healthier routines. Acknowledging the ‘‘unacceptability’’ of the disconnect, in which the costs and consequences of continuing to practice habits are incompatible with one’s values, is at the core of the DVM. Brian maintains a strong religious practice and faith, which contributed to the conclusion that his current lifestyle was inconsistent with his belief in God, and his Christian affirmation of Jesus as the Son of God and the love of his family. In addition to taking better care of his ‘‘temple’’ and Jesus as Lord, he also wanted to have the energy to enjoy his relationship with family members. In other words, Brian concluded that maintaining a disconnected lifestyle was unacceptable; he was ready to replace unhealthy habits that were depriving him of energy, happiness, and quality of life. For example, he agreed that his wife would fix a healthy breakfast at least three workdays per week rather than eat the fast food restaurant’s breakfast each day. Another example of Brian’s decision to lead a life more consistent with his values was meeting with each of the three coaches during the 12-week program, with a particular emphasis on the exercise segment.
Test Results One component of effective interventions for changing selected health behaviors is testing, that is, establishing quantitative data in which the individual compares scores on tests that detect favorable changes in selected health measures (Anshel and Kang 2007). Examples of such scores include fitness, blood lipids, weight, waist circumference, and body mass index. The tests, conducted immediately after the program, indicated improved lipids profile scores (i.e., no score was listed under the column labeled ‘‘abnormal’’), significant improvements in upper and lower body strength and cardiovascular fitness (i.e., submaximal VO2 score), reduced systole and diastole blood pressure, a loss of 3 inches on his waistline, and reduced percent body fat to 29%. Self-report statements indicated Brian experienced improved energy for work and family, and a generally positive feeling of well-being. Perhaps most significant was Brian’s high rate of adherence to his exercise regimen. Full adherence was defined as attending exercise sessions a minimum of three times per week over the 12-week program, a total of 30 sessions. Brian attended 26 of the 30 sessions, or 87%. A post-program interview revealed that a combination of prayer and remembering to overcome his disconnected value system were imperative to maintaining his new set of routines related to eating behavior and exercise. In a post-intervention interview, Brian was asked to indicate the ways in which the program contributed to his decision to initiate and maintain changes in his exercise and eating behaviors. He listed four factors that lead to his commitment to health behavior change. First, he had positive feelings toward his coaches, a finding that likely promoted improved fitness, nutrition, and mental health. He established a meaningful relationship with them and respected their skills. The coaches provided detailed guidance, instruction, and emotional support that encouraged him to maintain his progress and provide positive
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and constructive feedback on his new (desirable) behaviors. As Rollnick et al. (2008) assert, establishing good rapport is among the primary objectives of effective interventions because changing behavior begins with establishing trust with a client. A second factor that influenced Brian’s behavior changes were test scores he received prior to the program. In addition to poor fitness (which did not surprise him), he was ‘‘shocked’’ by the extent of his poor blood lipids, test results which reflected the potential for advanced heart disease and the likelihood of serious health-related consequences. His wife, who was present at several sessions with the dietician, was especially alarmed. The use of quantitative data is an important aspect of the intervention’s action plan because, as Loehr and Schwartz (2003) assert, people are motivated by numbers, usually in the form of test data. The third factor, consistent with the DVM, was remembering his values, particularly his desire to serve the Jesus as Lord, to maintain energy and good health for his wife and child, and to be effective in his career. His obesity was creating other health problems that were clearly compromising his mission to be available for the people who mattered most, and who loved him. A fourth issue that promoted adherence to the new behaviors was establishing routines based on actions that were planned and supported by others. Brian’s action plan included a 24-h time management schedule in which his full weekday was extensively planned. Planned activities included times for exercise, meals, snacks, recovery breaks, contact with loved ones and colleagues, pre-sleep rituals, scheduled times for sleep and waking, and other activities that were consistent with his most important values. Adherence to Brian’s action plan was for his support group to hold him accountable for being consistent with his primary values of faith, family, and health. His wife, work colleagues, other members of his church, and his coaches reminded him regularly that his values should drive his lifestyle, and the behaviors that support a healthy lifestyle. Improved fitness and nutrition, he agreed, provide the energy needed to lead a spiritually fulfilling life. This included his devotion to Jesus Christ and to his family and work colleagues. Brian found several citations from Scripture that confirmed the divine expectation in St. Paul’s metaphor, that we ‘‘look after our temple’’ with behavior patterns that promote good health. As a measure of long-term adherence to the program, Brian persisted in performing his exercise and eating habits 3 months after the formal completion of the 12-week program. He also established rituals with his wife and child that brought him closer to his wish to be an extraordinary husband and father.
Implications for Religious Leaders The DVM provides an opportunity for religious leaders to address a growing, yet unmet, need in promoting healthy habits to the community through local religious institutions. This has taken on an increasingly important role in a population experiencing debilitating health and skyrocketing healthcare costs. While teaching Scripture and promoting a lifestyle consistent with a particular religious faith has been a priority mission among religious leaders, less common is the leader’s role in pontificating the virtues of a healthy lifestyle. If we have our health, then we also have more energy to devote to following the values of particular religions, our devotion to God or a Higher Power and leading a spiritual life. One implication for religious leaders in applying the DVM is the behavioral nature of this intervention. Assessing the model’s efficacy, in this case, helping clients improve their
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participation in and adherence to exercise behavior, requires behavioral assessments. According to Tkachuk et al. (2003), ‘‘behavioral assessment involves the collection and analysis of information and data in order to identify and describe target behaviors, identify possible causes of the behaviors, select appropriate treatment strategies to modify the behaviors, and evaluate treatment outcomes’’ (p. 104). The authors’ examples of behavioral assessment are well within the training and experience of religious leaders, who are not usually licensed mental health professionals. Skills needed in carrying out the DVM intervention include behavioral interviewing (e.g., identifying negative habits, such as not exercising), behavioral inventories (e.g., determining selected psychological dispositions that are associated with inactivity), behavioral checklists (e.g., self-monitoring that provides instructional feedback on proper exercise skills or executing an effective fitness program), and performance profiling (e.g., asking clients to self-examine their attitudes, perceived barriers, level of mastery, and other factors that might promote or impede future exercise participation). Perhaps the most serious obstacle to health behavior change within religious communities is persuading the people of faith within those communities that is, to their scriptural traditions and the divine intention that they live full, healthy lives. As Omartian (1996) contends, ‘‘The main reason to exercise is for your health. Without good health you cannot do all the Lord has for you to do and you cannot be all the Lord wants you to be’’ (p. 117). In support of the need to exert greater self-control over one’s destiny from a religious context, Koenig (1999) asserts, ‘‘The world’s religions encourage healthy living…. All established religions discourage …any habit or activity harmful to the human body, which has traditionally been viewed as sacred, created in the image of God’’ (p. 72). It is apparent, then, that the greatest challenge to changing unhealthy habits among those who have a strong faith and engage in religious practice is to understand the balance between two thought processes: surrendering one’s life to God on one hand, and maintaining free will and living a life consistent with good health and longevity on the other. As Omartian (1996) contends, ‘‘The biggest problem with excess weight is not whether God still loves you. He does, and so do other people. Nor is the biggest problem whether you look good in your clothes. The most important thing is whether you’re going to be incapacitated by fat-related diseases and die prematurely’’ (pp. 89–90). One area that requires attention in determining the role and effectiveness of religious institutions in promoting community health and wellness is for religious leaders to develop and maintain their own healthy habits, and to serve as role models for their congregations. The credibility of pastors, priests, rabbis, and other religious leaders will be further enhanced if their messages of ‘‘taking care of your temple,’’ as pontificated in their sermons and programs, are reflected by their own proper behavioral patterns. Leaders must reflect (i.e., model) the lifestyle they advocate, otherwise their integrity is compromised, and they will less likely be able to influence health behavior change. While the effects of modeling healthy lifestyle choices by religious leaders on health behavior change of institution members is apparently lacking, parental modeling has been shown to strongly influence smoking habits and alcohol intake of their children. Altman and Jackson (1998) reviewed research on adolescent tobacco use and concluded that parental models are most effective in changing the attitudes and behaviors of their children when they model actual non-use of tobacco products. In addition, the authors also contend that parental behaviors include ‘‘modeling of the consequences of use, and modeling of avoiding use, as when a parent requests a non-smoking section in restaurants… and setting household rules that prohibit indoor smoking, and setting clear expectations about the negative consequences of trying smoking’’ (p. 320).
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Modeling on proper tobacco use has implications for religious leaders in promoting healthy habits among institution members. If their medical conditions allow, then leaders, themselves, should exercise regularly, maintain the proper weight, initiate group memberships at a local fitness facility, or alternatively, provide exercise programs (e.g., strength training, walking, jogging) at the institution, host guest speakers on health-related topics, and offer low fat food choices at institution social functions. In addition, the leader’s family should also engage in healthy behaviors and be included in institution programs. To use a cliche´, leaders have to ‘‘walk the walk, not just talk the talk.’’ The religious leader is uniquely qualified to apply the DVM. Few individuals possess more respect, credibility, and integrity in fulfilling the spiritual life of religious institution members, individuals whose unhealthy habits are not immune to disease, long-term disability, and reduced energy, all of which reduces his or her capability to serve God. The ability to promote the concept of free will in living a life consistent with one’s values is consistent with the sacred scriptures of the world’s religions. It is the primary mission of religious leaders to help others—and themselves—to lead a high quality of life, both physically and spiritually, and to reveal their devotion to God. ‘‘God works within us to will his holy spirit and the free will to have the desire to create balance in our life—and the will to act on that desire’’ (Philippians 2:13). Addressing the future of health behavior change, Glasgow et al. (2004) have concluded ‘‘If we are serious about evidence-based behavioral medicine and about closing the gap between research findings and application of these findings in applied settings, we cannot continue ‘business as usual’’’(p. 11). New, creative approaches to changing health behavior, including exercise, are needed. The DVM is one strategic approach to address possible ways to change behavior and prevent what is becoming a dangerous health crisis in the US and elsewhere.
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