Review
The
barrier-belief
approach
in
the
counselling
of
physical
activity
Adrie
J.
Bouma
a,*
,
Paul
van
Wilgen
b,c,
Arie
Dijkstra
daHanzeUniversityofAppliedSciencesGroningen,InstituteofSportsStudies,Groningen,TheNetherlands bTranscare,TransdisciplinairyPainmanagementCenter,Groningen,TheNetherlands
cPaininMotionStudyGroup,DepartmentofPhysiotherapyandRehabilitationSciences,FacultyofPhysicalEducation&Physiotherapy,FreeUniversityof
Brussels,Brussels,Belgium
d
DepartmentofPsychology,FacultyofBehavioral-andSocialSciences,GroteKruisstraat2/1,9712TS,UniversityofGroningen,Groningen,TheNetherlands
Contents
1. Introduction... 000
2. Thetheoreticalbackground ... 000
2.1. BarriersinhibitPA... 000
2.2. Barrier-beliefsandgoals ... 000
2.3. Attributions,self-efficacyandnegativeoutcomeexpectations... 000
2.3.1. Attributions... 000
2.3.2. Self-efficacyexpectations... 000
2.3.3. Negativeoutcomeexpectations... 000
2.4. Relatingdifferentbarrier-beliefs... 000
2.5. Functionsofbarrierbeliefs... 000
2.6. Changeabilityofbarrier-beliefs... 000
3. Thebarrier-beliefscounselling... 000
3.1. Generalprinciplesofthecounselling... 000
3.2. Designingaction... 000
3.2.1. Installingminimalmotivation... 000
ARTICLE INFO
Articlehistory: Received16June2014
Receivedinrevisedform26September2014 Accepted6October2014 Keywords: Barriers Beliefs Physicalactivity Behavioralchange Relapse Maintenance Counseling Lifestyle Socialcognitive Strategies ABSTRACT
Objective:TounderstandinactivityandrelapsefromPA,andtodeveloptheory-basedbehaviourchange
strategiestostimulateandsupportmaintenanceofPA.
Methods:We conductedaliteraturesearch toexplorebarriersto PA.Socialcognitive theoriesand
empiricalevidencewereevaluatedandguidedtheprocessdevelopingatheoreticalframeworkand
counsellingstrategies.
Results:AtheoreticalframeworkispresentedtounderstandwhypeopledonotengageinPAandoften
relapseoncetheystartedPA.AdistinctionismadebetweenthreerelatedtypesofBBs.InPAcounselling
thesethreebeliefsareaddressedusingfourdifferentBBbehaviourchangestrategies.
Conclusion:BBcounsellingaimstodevelopanindividualpatternofPAforthelongtermthatisadapted
tothe(oftenlimited)motivationoftheclient,therebypreventingtheoccurrenceofBBs.Theclientwill
learntocopewithfactorsthatmayinhibitPAinthefuture.
Practiceimplications: TheBBsapproachcomposesawayofcounsellingaroundthecentralconstructof
barrier-beliefstostimulateengagementinPAindependently,inthelongterm.
ß 2014ElsevierIrelandLtd.Allrightsreserved.
* Correspondingauthorat:HanzeUniversityofAppliedSciencesGroningen,InstituteofSportsStudies,Zernikeplein17,9766ASGroningen,TheNetherlands. Tel.:+31642301818;fax:+31505955555.
E-mailaddresses:a.j.bouma@pl.hanze.nl(A.J.Bouma),c.p.vanwilgen@online.nl(P.vanWilgen),arie.dijkstra@rug.nl(A.Dijkstra).
ContentslistsavailableatScienceDirect
Patient
Education
and
Counseling
j ou rna l hom e pa ge :ww w. e l s e v i e r. c om/ l o ca t e / pa t e duc ou
http://dx.doi.org/10.1016/j.pec.2014.10.003
3.2.2. Formulatingspecificgoalsandgoalrelatedbeliefs... 000
3.2.3. Investigationofbarrier-beliefs... 000
3.3. TheBBbehaviourchangestrategies ... 000
3.3.1. Changingmeans ... 000
3.3.2. ChangegoalstochangeBBs... 000
3.3.3. Restructuring/changingBBs ... 000
3.3.4. AcceptingtheinvestmentsdemandedbyBBs... 000
4. Discussionandconclusion... 000
References... 000
1. Introduction
Physicalinactivityisaworldwidegrowingproblemwithone outoffiveadultsbeingphysicallyinactive[1].Physicalinactivityis ariskfactorforchronicdiseasessuchasdiabetesand cardiovas-cular diseases, overweight and several cancers [2]. Regular physical activity (PA) is positively associated with fitness and healthrelatedbenefitsandrelatedtoanestimated30%reduction in risk for all-cause mortality among adults [3]. Engaging in regular,moderate-intensityPAisimportantforthepromotionof
physical and mental well-being [4], and the prevention and
managementofmanychronicdiseases[5–7].Inaddition,stopping ormarkedly reducing PA canresult in a significant reversalof initialhealthimprovements[8,9].Thus,toimprovephysicaland mentalhealthandtopreventillness,itisimportantthatpeople engageinPAonaregularbasis.However,despitethewell-known benefitsof PAand theavailabilityofeffectivePA interventions, manypeopledonotengageinsufficientPA.Forexample,around theworldpercentagesofphysicalinactivityvaryfrom20%upto 70%indifferentcountries,withabout40%intheUnitedStatesof America,andover60%intheUnitedKingdom[10].
In addition, when people start engaging in PA, they often relapsetoinactivity,evenwhentheytakepartinPAinterventions [11]: Results of systematic reviewsand meta-analysesof long-termeffectsindicatethatamajorityofindividualsrelapsetoaless activeortoan inactivestatus when interventionsupportis no longer provided[12–15]. However, only sustainedPA canhave relevant effects on health and the prevention of illness. For a sustainablebehaviouralchange,Greaves’review[20]suggeststhat futureinterventionsshouldaddbehaviourmaintenancestrategies. Thesestrategiesshouldtargetthemostinfluentialdeterminantsof PAmaintenance[17–21].
Inconclusion,PAinterventionscanleadtohigherlevelsofPA,
which is related to several beneficial physical outcomes.
However,manypeopledonotengageinsufficientlevelsofPA
anddonot usethese interventions, andwhentheydo usePA
interventions,theyoften relapse.Therefore, thereisa needfor understandinginactivity andrelapse from PA,and for
theory-based behaviour change strategies to stimulate and support
maintenanceofPA.
2. Thetheoreticalbackground
2.1. BarriersinhibitPA
InresearchonPA,thegeneraltermbarrierisoftenusedtorefer toverydifferentfactorsthatholdpeoplefrominitiatingPAorthat causerelapsefromPA.Insummary,thesestudiesmentionbarriers suchas,lackoftime,highfinancialcosts,healthcomplaints,lackof safety, lack of facilities, bad weather, no transport, no family assistanceorchildcaresupport[22–30].Inthesestudiesbarriers areoftenseenasmoreorlessfixedfactorsthatinhibitPA,anditis generallyagreedthatfocusingonbarriersisimportanttocounter relapse[31–42].
From a psychologicalperspective, an importantquestion is:
‘How do these barriers influence PA?’ Our answer is that the
mental representations of these barriers are central. These
representationsbecomemanifestinpeople’sbeliefs abouttheir reality. In psychological theories, the most important beliefs related to barriers are attributions, self-efficacy, and negative outcome expectancies [43,44]. In the present theorizing, these threetypesofbeliefsarecalledbarrier-beliefs.
In this article we will,firstly, presenta cognitivetheoryon
motivation and relapse, and explain how the three types of
barriers-beliefsplaytheirrole.Thecoreassumptionis,inlinewith generalcognitive-behaviourtherapy,thatbarrier-beliefsareactual causesof inactivity orrelapse. Secondly, inthis article we will present a set of cognitive and behavioural strategies that are developedtodealwiththesebarrier-beliefsinordertomotivatePA andpreventrelapse.Thesecounsellingstrategiescanbeappliedin theprocessof(re)startingtoengageinphysicalexercise,aswellas insupportingmaintenanceofphysicalexercise.
2.2. Barrier-beliefsandgoals
Barrier-beliefs(BBs)regarding PAare thoughtsor verbalized experiencesorestimatesofapersonaboutwhatiskeepinghimor herfromstartingormaintainingPA.BBsareaclusterofbeliefsthat allrefertopeople’sperceptionofthemoreorlessspecificorconcrete factors thatstand inthe wayofengaging inor maintainingPA. Importantly,the startingpointisthatpeoplehaveatleastsome knowledgeonthebenefitsofPA:BBscandevelopwhenpeoplefeel theyshouldsetaPAgoal,whentheyaresettingaPAgoal,whenthey havesetaPAgoal,orwhentheyareworkingonaPAgoal.BBsare related to goals in the opposite direction; they obstruct the achievementofgoalsbypreventingordisturbingthegoalrelated behaviour.AlthoughBBsregardingPAmayhavedifferentsources– fromhearingfromothers,throughmassmedia,orbasedontheown experience–theyhaveincommonthattheyinhibitPA.
2.3. Attributions,self-efficacyandnegativeoutcomeexpectations BBs manifest in one of three types; as attributions of PA-inhibiting causes, as self-efficacy expectations with regard to engaginginPA,andasnegativeoutcomeexpectationsofPA. 2.3.1. Attributions
Attributions are beliefs about the causes of behaviours,
includingone’sownPAbehaviour[45,46].Peoplespontaneously develop attributions for different reasons but one reasons is
problem solving [47]: When people notice that their goal
accomplishmentsareinhibited,theystartseeking forthecause oftheinhibition.IntheframeworkofPA,people’sattributionsare theirdiagnosisaboutwhatisholdingthemfromengaginginPA. The concept of perceived barriers actually refers to people’s attributionstonotengageinPAorrelapsefromPA[48]. Attribu-tionsmaybebasedonundeniablefacts(e.g.,‘Icannotwalkbecause mylegisbroken’),oninterpretationsofexperiencesorobservation
(e.g.,‘IstoppedjoggingbecauseImayoverburdenmyfoot’),oron seeminglyfarfetchedinferences(e.g.,‘Idonotexerciseanymore becauseitspoilsthefixedandlimitednumberofheartbeatsIhave inmylife’).However,oncetheyhavedevelopedtheymaygovern behaviour; they are ‘true’for theperson as representationsof realityand,thus,asabasisofthebehaviour.Therefore,attributions
as BBs regarding PA are important manifestations of the
psychologicalcausesofwhatinhibitspeopletoengageinPA.In counsellingpeople,attributionsofinhibitingcausesareastarting pointforthediagnosisandtreatmentofinhibitedPA.
2.3.2. Self-efficacyexpectations
Self-efficacy expectations can alsobe regarded as BBs. Self-efficacy is concerned with people’s beliefs in their ability to performaspecificactionthatisrequiredtoattainanexpectedand
desired outcome of the behaviour [49]. In the framework of
barriers,self-efficacyexpectationsreferto‘beingableto accom-plishthetaskofovercomingaspecificbarrier’,forexample,‘being abletoengagein30minoutdoorexercisedespitethebadweather’. Highself-efficacyexpectationswillneutralizetheinhibitingeffects ofthebarriers(thebadweather).Highself-efficacyexpectations motivatepeopletoinvestintheirbehaviourbecauseitwillpayoff:
They perceive the desired outcomes as within their reach.
Perceivedbehavioural controlis a similarconstruct[50] but in itstheory moreexplicitly based on underlyingbeliefs on one’s controloveratask.Empiricaldatashowthatself-efficacyisrelated tobarrierstoPA[32–38,50],andtoPAmaintenance[42,51].
Self-efficacyexpectationswithregardtoovercomingaspecific barriercanbebasedonvarioussources[44]:Comparingtoother people’saccomplishments(e.g.,‘whenhecannotdoit,Icertainly cannot’),interpretationofphysicalsensations(e.g.,‘myincreased heartrateduringPAisasignofillness,Ihavetobecareful’),social influence (e.g., ‘maybe he is right and I cannot do this’), and enactivelearning(e.g.,‘IcannotdothisbecauseIfailedbefore’).
Thus, different types of knowledge can support self-efficacy
expectations, for example – as related to the above sources –
knowledgeabout how others do, and how the body works. In
conclusion,incounsellingpeople,lowself-efficacyexpectationsas BBsareanotherstartingpointforthediagnosisandtreatmentof inhibitedPA.
2.3.3. Negativeoutcomeexpectations
Negativeoutcomeexpectationscanalsobeconceptualizedas BBs.Negative outcomeexpectationsconsistof beliefsaboutthe occurrenceofaversiveorotherwiseundesiredeffectsofaspecific behaviour[44].Theyarethecognitivederivateofpunishmentin operantconditioning.The PA-inhibiting expected‘punishments’ maybediverse:Theymaybesocial(e.g.,expectednegativesocial reactions),physical(e.g.,expectedaversivephysicalsensationsor damage)ormonetary(i.e.,expectedfinancialcosts).
Negative outcome expectations are oftenbased on negative experiencesrelated tobeingphysicallyactive (e.g.,‘Ifeelmore tiredinsteadoffeelingbetter’or‘mykneehurtsasaconsequence ofthiswalkingintervention’).Thesenegativeexperiencestranslate intoexpectationonwhatwillfollowwhenonekeepsonengaging inPA,oronwhatwillhappennexttimesomeonewillengageinPA. Expectationsofnegativeoutcomeshavebeenshowntoberelated to relapse and maintenance in PA [43]. The type of negative outcomespeoplearesensitivetovariesamongpeopleandmaybe
based on knowledge or individual history. For example, some
peoplemayespeciallydislikeaversivephysicalsensationsbecause they are inclined to catastrophize, while others are especially
sensitive to negative social reactions on the basis of past
experiences. In conclusion, in counselling people, negative
outcomeexpectationsas BBsareanother startingpoint for the diagnosisandtreatmentofinhibitedPA.
2.4. Relatingdifferentbarrier-beliefs
Thethreewell-definedBBs,attributionsofinhibitingcauses,low self-efficacyexpectations,andnegativeoutcomeexpectations,can be understood as different mental representations concerning barriersthatarecloselyrelated(seeFig.1).Forexample,onebarrier apersonforwardstoexplainhisorherrelapsefromPAmaybealack of time. First of all, this explanation implies an attribution of inhibition:Aperceptionofthecauseofacertaineventorbehaviour, inthiscase,stoppingPA.Secondly,handlingtimeconstraintsmaybe conceptualizedasatask,forwhichacertainlevelofself-efficacyis neededtobeaccomplished.Forexample,timemanagementskills maybeusedtohandletimeconstraints.Thirdly,timeasabarrier may imply that engaging in PA despite the time constraints is expectedtohavenegativeoutcomes:Itmaybethatapersonexpects thatengaginginPAwillbeatthecostoffotherpersonalgoals.Thus, attributions are end-conclusions; they explain explicitly what causesapersontonotengageinPAorwhatcausedrelapse.They alwaysrefertoataskthatcannot(easily)beovercome(self-efficacy expectations) or toa negative experienceor outcome(negative outcomeexpectations).ThethreetypesofBBsarerelated,buteach providetheirowninformationonthepsychologicalrepresentations ofthefactorsthatinhibitapersonengageinPA.
2.5. Functionsofbarrierbeliefs
IndividualsdevelopBBsforareason:BBsconcernadiagnosisof whyagoalisormightnotbeaccomplished.Intheevolutionary
framework of survival and goal-setting this is an essential
function: People have limited resources and, therefore, it is
important to decide to abandon a goal in time to not waist
resources.Thus,BBshaveafunctioninresourceallocation. WhenapersonhasdecidedtoinvestinthebehaviourofPAto reachdesiredoutcomes,thisbehaviourwillbeonlymaintainedas longasthepersonestimatesthatitpaysoff.Payingoffreferstothe balancebetweenthecostsandthebenefits.Thecosts,here,referto theinvestmentcostsofengaginginadifficulttask (self-efficacy-related)orcopingwithanaversiveexperience(negativeoutcome expectations-related). Whenthisbalanceisnegative–thecosts outweighthebenefits–peoplemaygiveup.Inthecontroltheory, abandoningagoalorgivingupiscalledgoal-disengagementandis anessentialaspectofeffectiveself-regulation[52].
BesidesBBsfunctionsinresourceallocation,theycanalsobeused by individuals tolegitimize goalabandonment. When a person abandonsagoaldespiteknowledgeofthenegativeconsequencesof this(e.g.,increasedriskforCHDbecauseoflowPA),apsychological stateisactivatedthatisconceptualizedasaself-discrepancy[53], cognitivedissonance[54]oraself-threat[55].Thisisanaversive psychologicalstatethatneedstobedealtwith.Onewaytoloweritis by psychologically constructing self-serving ‘valid reasons’ to abandonthegoal:BBsarguethattheinvestmentbalanceisnegative
and,therefore,itissensibleandlegitimizedtoabandonthegoal,for example,‘I cannot do this’or ‘I don’t likethis’. Withregard to attributionsthisfunctioniscalledtheself-servingbias[56]. 2.6. Changeabilityofbarrier-beliefs
IntheaboveperspectiveoninhibitedPA,changingBBsinPA shouldbecentral. However, notall BBscanbe easilychanged. Firstly,BBsmayberelatedspecificallytohowpeopletrytoreach theirgoal. Forexample,engaging inPA on Fridayeveningmay bringnegativeoutcomesthatmayinhibitapersontoengageinPA. ItmaybethatengaginginPAonFridaymorningoronSaturday leadstolessnegativeoutcomes.Thus,creativesolutionsmayhelp tochangeBBs.Secondly,BBsmayrefertobarriersthatcannotbe
changed. For example, when there is a tornado, self-efficacy
expectationwithregardtothetaskof‘joggingdespitethetornado’ maybelowbutitisnotreasonabletoexpectthatpeoplechange theirself-efficacywithregardtothistask.Inthiscase,itmightbe bettertochangethegoal(tomaketheBBirrelevant).Thirdly,BBs maybehighlychangeableanddependonknowledge.Forexample, apersonmaystopengaginginPAbecauseofthenegativeoutcome expectations-related belief that certain physical sensations are earlysignsoftissuedamage.However,thisBBmaynotbevalidand itmaybechangedbyknowledgeonhow,forexample,jointswork. Fourthly,wemustrealizethatsometimesgoalscannotbechanged andBBscannotbechanged.Inthatcasebarriersmightbeaccepted. Thesefouraspectsrelatedtothe(lackof)changeabilityofBBs arethecore ofthe counselling methodusing fourdifferentBB changestrategiespresentedbelow.
3. Thebarrier-beliefscounselling
Inbarrier-beliefscounsellingPAisstimulatedbyaddressingthe BBs.Thenovelty of this counselling liesin thevarious waysit addressesBBstolowertheirPAinhibitingeffect.Thesewayscanbe conceptualizedasbehaviourchangestrategies[56].Thebehaviour changestrategiescompriseclustersandsequencesofactionsofthe counsellor(questions,decisions,etc.)withthegoalto:(1)design meansto reach the goal; (2) change goals to change BBs; (3) restructure/changeBBs,and(4)accepttheinvestmentsandcosts demandedbyBBs.Thesefourbehaviourchangestrategiesmustbe embeddedinabroadercounsellingprocess.
3.1. Generalprinciplesofthecounselling
Thegoalofphysicalactivitycounsellingistoguide clientsto engage in PA on the long term; independently of professional support.ToengageinPAonthelongterm,intrinsicmotivationis essential[57].AccordingtoMagnanetal.(2013)intrinsicmotivation ispartlydeterminedbypeople’saffectiveresponsesduringPA[58]: Theyfoundthatactivepeopleoftenexperienceagreaterdegreeof positiveaffectiveresponsesthaninactivepeople,andadecreasein negativeaffectiveresponsestowardsPA[58].Inaddition,affective responsesseemtoberelatedtothefrequencyandintensityofPA [59]:Higherfrequencyandintensityisrelatedtoexperiencinga ‘flow’offeelinggoodandenjoyment.Thus,tostimulateintrinsic
motivation it is important to work towards positive hedonic
responsesduringPA.Wearguethattheonlywaytodevelopthis motivationisbyenactivelearning:TheownexperiencethatPAleads topersonallyrelevantoutcomesmayleadtoa robustlongterm motivation.Inaddition,toengageinPAonthelongtermandtobuild intrinsicmotivation,PAinhibitingfactorsshouldbesmall,thus,BBs shouldbeabsentorweak.TobeabletoindependentlyengageinPA on the long term, clients should beskilled in self-management concerningPA[60];theyshouldbeabletoapplytheBBsbehaviour changestrategiestotheirownsituation.
Apatient-centredapproachisapplied,meaningthatwedonot followgeneralrecommendationsonthe levelofPAbutfocuson individuallydesiredlevelsofPA.Thestartingpointofthecounselling is that benefits for physical and mental health can already be achieved if clients engage in PA less than international recom-mended30minperday[61–67].Besidessporting,manytypesand levels of PA can help to satisfypersonal goals, for example in transportationanddailydomesticactivities(lunchwalks,cyclingto work,gardening,takingstairs),orhouseholdorgardeningactivities,
alone or with others. Below we will describe the different
subsequentstepsandcounselloractionsinthecounsellingprocess. In thisphase the counsellordevelops a preliminaryinsightinto potentialbarriersthroughidentificationofBBs.Wewillnotgointo theseaspectsofcounsellingandonlymentiontheminsum: Personalintroduction.
Explanationofaimsofthecounselling andagreementsofthe sessions.
PAdiagnosis,extensiveinventoryof: ohealthandbehaviourmeasurements; ocurrentlifestylerelatedtoPA; olongtermgoals;
omotivationtoengageinPA;
oattitudes,levelofself-efficacyandexpectationstowardsPA. 3.2. Designingaction
Afterthediagnosticinformationisgathered,aplanforclient action can be designed. MostBBs are related tospecific goals. Therefore,theclient’sPAgoalsmustbeexplored.
3.2.1. Installingminimalmotivation
To formulate PA goals, clients must have at least some
motivationtoengageinPA.Thatis,peoplesetgoalsonthebasis oftheirmotivationtoachievecertainvaluedoutcomes, suchas, lookinggood,losingweight,orloweringtheriskforaheartdisease. Importantly,inthepresentcounsellingapproach,asarguedabove, theclient’smotivationtoengageinPAisnotboostedtosethigh goals. Instead, the client’s spontaneous intrinsic motivation is
explored and only when clients miss knowledge on the basic
positiveeffectsofPA(e.g.,loweringriskforchronicillnesses)they are provided withpotentially motivating information. As men-tioned above,we believe that thetruemotivation that will be sufficientlypowerfulonthelongterm,isthemotivationbasedon theownexperiencewithPA.
3.2.2. Formulatingspecificgoalsandgoalrelatedbeliefs
Theclient’soverallgoalsmustbeinvestigated,usingquestions suchas:‘Whatwouldyouliketoachievethroughthiscounselling, Whatdoyoudreamof,Whatwouldyouchangeifyoucouldmake
a wish?, What would you like to achieve in 1 month?’. The
answerstothesequestionswillhelptheclienttoformulateoneor morespecificPAgoalsthatcanbeunambiguouslyevaluated,for
instance ‘walk 30min every day’, ‘run the marathon within
6months’,‘gotoworkonmybikeatleast3timesaweek’,‘to continuemyrunningforthe10yearstocome’,‘tokeepwalkingin
the evening for 4 times a week for at least 10min’. In a
hierarchicalperspectiveongoalstructures[68],thesepersonal PAgoalsarebasedonvalues,andtheysetthedirectionofthe moreconcretePAintentions,suchas‘TomorrowIwillgotomy workbybike’.
3.2.3. Investigationofbarrier-beliefs
Thegoal-scaleratingsareusedtosupportthediagnosisofBBs. Bytalkingabouttheratingsthecounsellorhastheopportunityto observethespontaneouslygeneratedBBsbytheclientinreaction
toPAgoalsingeneralorspecifiedgoals:attributionsofinhibition, lowself-efficacyexpectations,andnegativeoutcomeexpectations. Inaddition,BBsmaybeexploredexplicitly,forexamplebyasking ‘Whatkeepsyoufromachievingyourgoal?’or‘Whatmadeyou stop?’.TosupporttheexplorationofBBsandidentifythecoreBBs, BBsalsocanberatedontheirstrength(seeFig.2).Theinformation ongoalsandBBssetthestageforapplyingtheBBbehaviourchange strategies(Fig.3).
3.3. TheBBbehaviourchangestrategies
With the above information on the client’s psychological
representations of barriers, the four main behaviour change
strategies canbe applied.When doing soit is importantto be aware of the functionsof the BBs: Are they developed in the functionofdecidingabouteffortinvestmentoraretheyinfunction ofprotectingtheselfandlegitimizingnotengaginginPA?Only
when BBs have the investment function the below behaviour
change strategies should be applied. When BBs have the
‘legitimizing’ function theyshouldfirst beused to identifythe motivationalconflictthatbringsupthisneed.However,mostlyitis notimmediatelycleartowhatextentBBsareakindofexcusesto
not engage in PA. Applying the below BB behaviour change
strategiesmayrevealmoreabouttheindividual’suseofBBs. 3.3.1. Changingmeans
Thisfirstbehaviourchangestrategythatcanbeappliedandis basedonBBs–andthatisalreadyusedinhealthcounselling–is designing ways to reach the goal [69–72]. Forexample, a BB regardingthegoalto‘lose2kilogramsofbodilyweightinfour weeksbyexercising5timesaweekfor10min’maybe‘thiscosts too much time’. Anaction planto reach the goal could be: ‘I changemyeveningroutinesothatIhavemoretimetoexercise’. Inthis behaviourchange strategy thegoal is not changedbut differenthandlingstrategies,measuresormeansareappliedto make the goal-directedbehaviour more feasible.Thus, clients
have to find solutions and take actions – set priorities,
reschedule, askotherpeople,useother clothing,etc. –tostick totheirgoal.
OnepotentialdrawbackofthisBBbehaviourchangestrategyis thatitstillmaycost(extra)investments.Aslongasthemotivation isstrongthiswaymaysufficebutwhenmotivationdeclines,the investmentsmaybecometoohigh.However,itisalsopossibleto changethemeanstoreachagoalinsuchawaythatlesseffortis
1. Whatkeepsyoufromachievingyourgoal? ………
2. Whatistheexactbarrier-belief
………..
3. Howstrongthisbarrier-beliefkeepsyoufromyourgoal?
Notstrongatall 1 2 3 4 5 6 7 8 9 10 Verystrong
Fig.2.RatingscaleofBBs.
Checkself-confidence
Highmotivation
Changingmeansstrategy: -Supporttosticktothegoal -Changestrategiestoreachthegoal Problemsconcerningperformingstrategies
Goalsettingstrategy:
-Supporttochangethegoalintoagoal withno/smallBBs
Investmentproblemsinreachingthegoal InhibitingcognitionstowardsPA
Restructuringstrategy: -Supporttosticktothegoal -CognitivelychangeBBs
Acceptingstrategy:
-Supporttotaketheinvestmentsand costsinordertoreachingthegoal AversiveexperienceswithalmostallPA InvestigateBBs
Lowself-confidence Highself-confidence
Continuetheprocess
Checkmotivation
Lowmotivation
Coachtoindependently maintainPA Formulatespecificgoals adgoalrelatedBBs
Installaminimal motivation Start
needed.Forexample,regardingtheabovesituation,itmaybemore efficienttoreschedulePAtowardstheeveningthanatdaytime. 3.3.2. ChangegoalstochangeBBs.
Tolowertheinvestmentsradically,thePAgoalmaybechanged. Theabovegoalmaybechangedinto‘exercising3timesaweekfor 10min’or‘exercising5timesaweekfor5min’,ora completely differentPAgoalmaybeset,suchas‘takeabrisk10minlunch-walk everyday’or‘takethestairsinsteadoftheelevator’.Avarietyof creative alternatives can be discussed, and with each feasible alternativeBBsmustbechecked.Thisgoal-settingapproachleadsto aPAgoalwithnoorwithonlysmallbarriers.Althoughthelowset goalmayhaverelativelyweakeffectsonhealth,ourpremiseisthatit isbettertostartsmallandgrowwhenintrinsicmotivationdevelops, thantostarthighwithincreasedriskfordisappointmentandrelapse. 3.3.3. Restructuring/changingBBs
WhenBBscannotbechangedbyhandlingthemdifferentlyand bygoal-setting,theymustbechangecognitively.Thatis,BBsmay bebasedonerroneousknowledgebasedondifferentsources.For example,BBsmaybe‘Ifeelthatpeopleridiculemewhentheysee mejogging’or‘IthinkitisnousetotrytoengageinPAregularly again,Ialreadyfailedsomanytimes’.ThefirstBBprimarilyrefers toanaversiveoutcome,whilethesecondBBprimarilyisrelatedto lowself-efficacy.BothBBsareinterpretationsofwhatpeoplehave observedorhaveexperienced.Thecorequestionhereis‘Isittrue?’. Asincognitivetherapyingeneralthesebeliefsmaybechallenged inaSocraticdialogue[73];e.g.,‘canyoutellmehowyoucameto thisconclusion?’),orwithexperiments(‘letusseewhathappens when you do this’). Often erroneous beliefs related to cardio-vascularormotoricfunctioningmayworkasBBs.Forexample,a patientwithosteoarthritismay avoidPA becauseof theillness belief:‘WhenIexperiencepaininmyrightkneeduringPA,this signalsa damagingprocess’.Education mayprovidetheclients withthefactualknowledgeontheevidenceofpositiveeffectsofPA in osteoarthritis, thereby changing the BB. Thus, clients are supportedtosticktotheirgoalbutchangetheirperspectiveon theinhibitingfactorstheywerebotheredby.
3.3.4. AcceptingtheinvestmentsdemandedbyBBs
Sometimeshandlingcannotfurtherbeimproved,goalscannot befurtheradapted,andBBscannotberestructured.Forexample, whenaclientexperiencespainasabarrierwith(almost)every physicalmovement,or a clientfinds evensmall experiencesof physicaleffortsaversive,theinhibitingfactorsmaybeaccepted. Acceptancemeansthattheinvestmentsandcoststhatcomewith reachingagoalarenotavoidedbuttaken[74].Justasrentingacar hasitscostsandwedonotexpectittobefree,reachingaPAgoal maybenotexpectedtobeforfreeeither.Goodacceptancedoesnot removethefactorthatmightinhibitPAbutitlowersorcompletely removestheinhibitingpowerofthefactor[75,76].
Several strategies can be used to enhance acceptance. For example, by discussing the positive and negative sides of PA, relevantfactorsmaygain orlosevalue.ConsidertheBB: ‘Ifeel uncomfortableridingmybikeinmyneighbourhood,itlookssilly’.
This BB reveals a negative outcome. However, this negative
outcomemaybecontrastedwiththealternativesofnotridingthe bikeorridingthebikeelsewhere.Theoutcomesrelatedtothese
options may change the relative value of the BB, which is a
mechanismofacceptance.TheBB:‘Theexercisealwayscostsmea lotofefforts’mightbeacknowledgedbutplacedintheframework of‘nothingisforfree,exceptthesun’.Inthiswaytheeffortsneeded
to exercise do not become lower but they feel less unjust.
MindfulnessexercisesmayhelpclientstonottakeBBstoseriously [76].Forexample,when duringPAa personisdwellingon the thought‘Thisiscrazy,thatIneedsomuchtimetoengageinPA’,the personmightlearntojustobservethebeliefwithsomedistance and‘letitgo’.Inthatwaythepersonmaybelessbotheredbythe BB(Table1).
4. Discussionandconclusion
The presented barrier-belief approach to counselling PA is basedon contemporarytheoreticalmodelsofbehaviourandon empiricalevidence.Thetheoreticalbackgroundissocial-cognitive andtheappliedbehaviourchangestrategiesthattargetBBsare already used in different change perspectives and therapies. However,in thebarrier-beliefapproachtheseprovenbehaviour changestrategies–changemeansreachgoals,set(different)goals, restructurebeliefs,induceacceptance–areallappliedtotargetthe coreofproblemswithinitiatingandmaintainingPA.Using
well-known theories and strategies, the barrier-beliefs approach
composes a wayof counselling aroundthecentralconstruct of barrier-beliefs.
ThestrongfocusofourapproachonBBsdoesnotmeanthatthe
approach is narrow. The BBs comprise the most important
psychological factors that have been shown to be related to
startingandmaintainingPA:perceivedbarriers(attributions), self-efficacyexpectationsandnegativeoutcomeexpectations[43,44]. Inaddition,inthecounsellingmethodthefourbehaviourchange strategies are applied in the context of general counselling methods, suchas,developing rapport, makingagreements,and providing assignments. In addition, within the four strategies commonelementsincounselling,suchasprovidingknowledgeon factsandonskills,areapplied.Thus,thepresentBBcounselling makesuseofmuchexistingknowledgeandskillsbutappliesthem withthefocusonBBs.
Typically, our approach does not try to boost people’s
motivationtoengageinPA.Whenthemotivationisverystrong, allkindsandlevelsofbarrierscanbeovercome.However,formost peopleitisnotpossibletoalwaysstaythathighlymotivated.This meansthatweascounsellorsacceptthatclientsmaynothavevery
Table 1
VariousBBslinkedtoexamplesofthecorrespondingcounsellingstrategies.
Barrier-belief Examplesofcounsellingstrategies Changingmeans:
‘‘Ihavenotimetorunfive timesaweek’’ ‘Sticktoyourgoalbuttrytobemoreflexibleinwhenyourun’ ChanginggoalstochangeBBs:
‘‘Ifeelpainwhenrunning5timesaweek’’ ‘Changeyourgoalfromrunning5timesto3 times,orengageinadifferentactivity’ RestructuringBBs:
‘‘IfeelpainwhenIamrunningandIthink thisisharmfulformybody’’
‘Letusfindoutwhetheryourexpectationaboutharmcanbetrue’ AcceptingtheinvestmentdemandedbyBBs:
‘‘Ihavenotime(anymore)toengagein whateverphysicalactivities’’
strongmotivationsand,therefore,willonlyengageinPAonthe longtermwhentheyexperiencefewinhibitionstodo so.Some
clients, however, may be trapped in a cycle of low energy/
motivationtoengageinPAthatiscausedbyalowlevelofPA,and viceversa.TheymayhavenomotivationatalltoengageinPA.In theseclientsthefirstgoalistoinduceaminimalmotivationby guidingpositiveexperiencesofminimallevelsofcarefullytailored
exercise with personal coaching. To start the process, even
extrinsicincentives maybe used togenerate experiences with PAthateventuallyshouldleadtointrinsicmotivation.Oncethe clientdevelopsintrinsicmotivation,furtherPAgoalsmaybeset takingintoaccountBBs.
The BB approach may not only be used to counsel
individuals;its principles may beadapted to fit,for example, aschooleducationalprogrammeformat.Oneprinciplewouldbe toadjustthemeansandgoalsconcerningPAtowhatstudents findfeasible.DetectedBBsmayguidethedesignofmeansand goals,possiblyforsubgroupsofstudentsinclasses.Inaddition, studentmaybeeducatedaboutself-managementbylearningto setgoals,detectBBs,andhandleBBsusing(oneof)thefourBB strategies.
AlthoughtheBBcounsellingin this articleis shapedaround face-to-facecontact, it shouldalso bepossibleto applytheBB
approach through another channel, for example, through the
Internet, presented in a Smartphone application (app). Guided questioningon PAgoals andonBBsispossible,withindividual feedbackonaccomplishmentsbutalsoonthepowerofBBs,and educational texts as well as videos might be applied. Unique featuresofsuchanapparethatpeoplecanuseitwheneverthey want,thepotentialreachofappsishigh(ascomparedtoindividual counselling),andthatoftenpeoplehavetheirSmartphonewithin theirreachconstantly,evenduringPA.Researchwillhavetoshow whethertheinvolvementoftheindividualwithanappissufficient toleadtoactualbehaviourchange.
The barrier-belief approach is evidence based in the sense
that most elements it is comprised of are based on theories
or empirical evidence. Of course it is important to test the
barrier-belief approach as a full counselling method for PA
empirically. To start with, the four BB behaviour change
strategies might be tested and compared experimentally.
Anotheraspecttypicalofthepresentapproachisthesequence of theapplication of thefour BB behaviourchange strategies. Althoughitseemslogicaltostartwithnotchangingthegoalbut changethemeanstoreachthegoal,andonlywhenthisdoesnot workchangethegoal,itmaybethatitisevenlyeffectivetostart withacceptanceofBBs.Attheleast,thepresentpackageoffour
BB behaviour change strategies embedded in a broader
counsellingprocedureshouldbetestedagainstacontrolgroup toproveitseffectiveness.
Anotheraspectthatneedsfurtherstudyisthedurationofthe applicationoftheBB-counsellingprogramme.Ideally,the coun-sellingis finishedwhen theclient is abletodetect BBsand to handle barriers independently of the counsellor. However, in practice the duration of counselling will depend on financial constraintsandprofessionalculture.Forsomeclientsacontinuing care-modelmaybemoreappropriate.
WehopethattheperspectiveofBBsincombinationwiththe fourBBbehaviourchangestrategiesinPAcounsellingwillinspire practiceaswellasresearch.Intheend,thebroadavailabilityof effectiveevidencebasedinterventionsforPAmaycontributeto further increasing health, preventing illness, and supporting qualityoflifeofpeople.
Conflictofinterest
Theauthorsdeclarethatthereisnoconflictofinterest.
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