Behavior Change and Cognitive Interventions

Behavior Change and Cognitive Interventions

Gail W. Stuart

The goal of all nursing interventions is to help patients change in ways that promote their health and adaptive functioning. To do this, nurses must believe that change is possible and that new perspectives, behaviors, and experiences are open to evaluation and change.

Promoting health and adapting to illness often means that individuals, families, and communities must give up current behaviors and learn new ones. These changes can be related to any aspect of one’s life, including exercise, eating habits, medication adherence, use of drugs, self-defeating thoughts, denial of problems, or unresolved interpersonal issues. Behavior change is the most powerful aspect of health care.

Research has shown that cognitive behavioral interventions are effective in reducing symptoms and relapse rates with or without medication in a wide range of clinical problems, particularly depression, anxiety, eating disorders, personality disorders, and schizophrenia (Dobson, 2010; Ledley et al, 2010). They can be used in any treatment setting and have much to contribute to nursing practice.


Behavior is any observable, recordable, and measurable act, movement, or response. A behavior is what is observednot the conclusion, inferences, or interpretations drawn from the observation. For example, hyperactivity is not a behavior but is a conclusion drawn from observing a set of behaviors. Hyperactivity cannot be measured. What can be measured is the number of times a child gets out of one’s seat, interrupts a conversation, drops a book, or completes required homework assignments. Thus treatment for the child should focus not on hyperactivity but on the specific behaviors that interfere with the child’s adjustment to school, home, or the community.

A clear definition of a behavior minimizes subjective interpretations. It is measurable, not subject to interpretation, and states what the person does. Other examples of inferences rather than behaviors are the labeling of patients as uncooperative, aggressive, difficult, noncompliant, or hostile. These adjectives globally describe a person but do not reflect the specific behavior that led to such conclusions.

Behavior Change Strategies

Behavior change strategies apply learning theories to problems of living with the aim of helping people overcome difficulties in everyday life. These difficulties often occur along with most medical or psychiatric conditions.

Nurses can use the following principles to guide their behavior change interventions:

• All change is self-change. Patients are the active participants and primary agents of change. Nurses and other health care providers are the coaches, not the doers.

• Self-efficacy is critical. Patients need to feel that they are in control of their own lives and accept responsibility for their efforts. All patients have strengths.

• Knowledge does not equal change. Education is only one part of the change process. Patients need to transfer what they know into the actions they take.

• A therapeutic alliance helps patients initiate and maintain change. The responsive and action dimensions of the nurse-patient relationship (Chapter 2) are critical ingredients for change.

• Hope is essential. All effective interventions are based on the positive and hopeful expectations that life can be better (Stuart, 2010).

Behavior change strategies can be applied to school, work, home, family, and leisure activities. In these situations treatment strategies help people achieve personal growth by expanding their coping skills. Behavior change strategies can be used by nurses with any background and in any health care setting to promote healthy coping responses and to change maladaptive behavior.

Readiness to Change

The only reason people change their behavior is because they want to do so. Readiness to change is tied to a person’s motivation or what is referred to as motivational readiness. A central element in increasing motivation and eventual behavioral change is to take into account the person’s readiness to change. Behavior change occurs in stages over time (Prochaska et al, 1992; Center for Substance Abuse Treatment, 2008).

The first stage of change is precontemplation. In this stage people do not think that they have a problem; thus they are not likely to seek help or participate in treatment. In working with these patients the goal is to listen to the patient and create a climate in which the patient may consider, explore, or see value in the benefits of changing.

The second stage of change is contemplation. This is characterized by the notion of “yes, but.” Often patients recognize that a change is needed, but they are unsure and indecisive about whether it is worth the time, effort, and energy to achieve it. They are ambivalent about what they might have to give up if they make a change. In working with these patients, the goal is to create a supportive environment in which the patient can consider changing without feeling pressured to do so. If patients are pushed to change in this phase, they are likely to actively resist.

The third stage of change is preparation. At this time the patient has made a decision to change and is assessing how that decision feels. Patients can be helped to select realistic treatment goals and different ways to reach those goals. They need to be actively involved in designing their own strategies for change.

The fourth stage of change is action. Patients now have a firm commitment to change and have identified a plan for the future. They should be offered emotional support and help in evaluating and modifying their plan of action to be successful.

The fifth stage of change is maintenance. Change continues, and focus is placed on what the patient needs to do to maintain or consolidate gains. Anticipating potential threats for relapse and developing prevention plans are essential. Any relapses should be seen as part of the change process and not as failure.

The sixth and final stage is termination. It is based on the notion that one will not engage in the old behavior under any circumstances. As such, it may be more of an ideal than an achievable stage. Most people stay in the stage of maintenance where they are aware of possible threats to their desired change and monitor what they need to do to keep the change in place.

Patients are more likely to engage in behavior change when their provider assesses their readiness for change and tailors their interventions accordingly. Table 27-1 summarizes these stages of change. Figure 27-1 shows the stages of change model applied to substance use disorders.

TABLE 27-1


Precontemplation Not currently considering change: “ignorance is bliss” Raise doubt
Increase awareness of the problem
Validate lack of readiness
Clarify: decision is patient’s
Encourage reevaluation of current behavior
Encourage self-exploration, not action
Explain and personalize the risk
Contemplation Ambivalent about change: “sitting on the fence”
Not considering change within the next month
Tip the balance to consider making a change Validate lack of readiness
Clarify: decision is patient’s
Encourage evaluation of pros and cons of behavior change
Identify and promote new, positive outcome expectations
Preparation Some experience with change and is trying to change: “testing the waters”
Planning to act within 1 month
Help patient determine the best course of action Identify and assist in problem solving about obstacles
Help patient identify social support
Verify that patient has underlying skills for behavior change
Encourage small initial steps
Action Practicing new behavior for 3-6 months Help the patient take steps to change Focus on restructuring cues and social support
Bolster self-efficacy for dealing with obstacles
Combat feelings of loss, and reiterate long-term benefits
Maintenance Continued commitment to sustaining new behavior
After 6 months to 5 years
Help prevent relapse Plan for follow-up support
Reinforce internal and external rewards
Identify prevention strategies to avoid relapse
Termination     Support change and adaptive coping strategies


Motivational Interviewing

Motivation to change comes from within the individual. Without the desire or motivation to change, a person will not change one’s behavior. Motivational interviewing is a patient-centered, directive counseling method for enhancing a person’s internal motivation to change by identifying, exploring, and resolving ambivalence (Rollnick et al, 2008).

Everyone has ambivalence about changing, and there are always advantages and disadvantages to making a change. A person is motivated to change when one’s values and goals conflict with one’s current behavior and when the benefits of change outweigh the benefits of staying the same.

AmbivalenceDiscrepancyBehavior Change


Most people are aware of their unhealthy behaviors. Clinicians seeing these behaviors point them out and advise change; however, too often patients’ natural responses are to defend themselves and resist any suggestion of change.

The four key elements of motivational interviewing are as follows:

1. Express empathy. Acceptance of the patient facilitates change. Ambivalence is normal, and the use of reflective listening expresses understanding.

2. Identify the discrepancy. Ask the patient about the pros and cons of changing. Change is motivated by perceived discrepancy between present behaviors and important goals and values.

3. Roll with resistance. Avoid arguing about change. Offer new perspectives, but remember that the patient is the primary resource to identifying problems and finding solutions. It is helpful to emphasize personal choice and control.

4. Support self-efficacy. Belief in the possibility of change and hope in the future are important motivators. The patient is responsible for choosing and carrying out change; however, the clinician’s belief in the patient’s ability to change can become a self-fulfilling prophecy.

Motivational Interventions

A number of interventions can be used to enhance a patient’s motivation to change. The use of open-ended questions can help to identify the patient’s agenda. Affirming, hopeful, and reinforcing statements can emphasize that change is possible. One can also focus on the disadvantages of the way things are and the advantages of change.

The nurse can ask simple questions about how important the change is to the patient and how confident the patient is about making the change based on a scale of 1 to 10 (10 being the highest) to help to gain a sense of where the patient is in the stages of change. In working with patients, nurses must be sensitive to issues of mutuality, which means not prescribing solutions to the patient as the passive recipient of care. It also means not labeling problems or placing blame, both of which are likely to decrease the motivation to change.

Critical aspects of effective motivational interventions include the FRAMES approach and decisional balance exercises. FRAMES stands for the following basic elements of motivational counseling:

Decisional balance exercises are specific ways that the clinician can assist the patient to explore the pros and cons of old and new behaviors for the purpose of tipping the scales toward a decision for positive change. The items are identified by the patient with gentle help from the clinician and then written in a grid. This is shown in Figure 27-2 for a patient who has an alcohol use problem. The four blocks of the grid add a new twist to the traditional two-column “pros and cons” list.

One advantage of the four-block grid is recognition that there are positive elements about the old behavior that must be acknowledged. For example, if drinking helps the patient relax, part of recovery may include finding other ways to relax without alcohol. Even more important than the number of items in each block is the weight of each item. For example, the negative impact on the family may more than outweigh the social pleasures of drinking.

The clinician then summarizes the list of concerns and presents them to the patient in a way that expresses empathy, develops discrepancy, and weighs the balance toward change. The objective is to meet the patients where they are in their thinking, walk with them through the process and help them commit to making needed changes in their lives.

The nurse should be proactive and summarize the patient’s perception of the problem, areas of ambivalence, and desire to change. Asking the key question, “What is the next step?” is critical. Setting goals, listing all possible options, supporting the patient’s decision to engage in a plan of action, and reinforcing success in achieving it are essential nursing interventions.

Cognitive Strategies

Cognition is the act or process of knowing. Cognitive strategies are based on the thinking that it is not the events themselves that cause anxiety and maladaptive responses but rather people’s expectations, appraisals, and interpretations of these events. They suggest that maladaptive behaviors can be altered by dealing directly with a person’s thoughts and beliefs (Beck, 1976, 1995).

Specifically, maladaptive responses can arise from cognitive distortions. These distortions include errors of logic, mistakes in reasoning, or individualized views of the world that do not reflect reality. The distortions may be either positive or negative.

For example, someone may consistently view life in an unrealistically positive way and thus take dangerous chances, such as denying health problems and claiming to be “too young and healthy for a heart attack.” Cognitive distortions also may be negative, such as those expressed by a person who interprets all unfortunate life situations as proof of a complete lack of self-worth. Common cognitive distortions are listed in Table 27-2.

TABLE 27-2


Overgeneralization Draws conclusions about a wide variety of things on the basis of a single event A student who has failed an examination thinks, “I’ll never pass any of my other exams this term, and I’ll flunk out of school.”
Personalization Relates external events to oneself when it is not justified “My boss said our company’s productivity was down this year, but I know he was really talking about me.”
Dichotomous thinking Thinking in extremes—that things are either all good or all bad “If my husband leaves me I might as well be dead.”
Catastrophizing Thinking the worst about people and events “I’d better not apply for that promotion at work because I won’t get it and then I’ll feel terrible.”
Selective abstraction Focusing on details but not on other relevant information A wife believes her husband doesn’t love her because he works late, but she ignores his affection, the gifts he brings her, and the special vacation they are planning together.
Arbitrary inference Drawing a negative conclusion without supporting evidence A young woman concludes “my friend no longer likes me” because she did not receive a birthday card.
Mind reading Believing that one knows the thoughts of another without validation “They probably think I’m fat and lazy.”
Magnification/minimization Exaggerating or trivializing the importance of events “I’ve burned the dinner, which goes to show just how incompetent I am.”
Perfectionism Needing to do everything perfectly to feel good about oneself “I’ll be a failure if I don’t get an A on all my exams.”
Externalization of self-worth Determining one’s value based on the approval of others “I have to look nice all the time or my friends won’t want to have me around.”

Feb 25, 2017 | Posted by in NURSING | Comments Off on Behavior Change and Cognitive Interventions
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