How to help your patients make healthier choices
A primer on behavior-change theories and tactics
Most clinicians starting wellness-focused practices are dedicated to helping their patients live healthier lives to prevent or even reverse disease. Similarly, most patients are signing up for a holistic combination of: 1) allopathic medicine (e.g., prescribed pharmaceuticals, surgeries), 2) complementary and alternative medicine (e.g., acupuncture, herbal medicine), and 3) lifestyle medicine (e.g., modifying behavior such as exercise, nutrition, and sleep).
The last branch, lifestyle medicine, is unique in that it requires the highest degree of investment from the patient. It depends largely on the patient’s willingness and ability to change their behavior. However, clinicians can play a significant role by both providing evidence-based tools for behavior change and being a source of accountability and support.
At Otto, we believe a personalized approach, building on the patient-clinician relationship and helping patients establish self-efficacy, is the key to sustained behavior change. We recommend clinicians leverage 1) their relationship with a patient, 2) their knowledge of evidence-based approaches to behavior change and health, and 3) their understanding of a patient’s particular situation to collaborate with patients on developing, implementing, and iterating on effective plans for behavior change.
Below, we summarize some of the key literature and perspectives on how to best support patients on their behavior change journey.
Science of behavior change: key theories
We’ll start with a few theoretical concepts to establish a foundation, and then move on to the tactical implications. If you prefer to go straight to the tactical, scroll to the next section with an orange header.
The key theories come primarily from the worlds of psychology and behavioral economics. These are several of the most popular theories, with links to videos that provide examples and explain them in further detail:
Classical conditioning (Pavlov): Behaviors are learned through associations between stimuli and responses.
Operant conditioning (Skinner): Behaviors are shaped by rewards and punishments.
Social learning theory (Bandura): Behaviors are learned through observing others and imitating their actions.
Cognitive dissonance theory (Festinger): Individuals experience discomfort when holding conflicting cognitions, leading to motivation to reduce the dissonance.
Self-efficacy theory (Bandura): Belief in one's ability to succeed in specific situations influences behavior.
Theory of planned behavior (Ajzen): Behavior is driven by intentions, which are influenced by attitudes, subjective norms, and perceived behavioral control.
Self-determination theory (Deci and Ryan): Human motivation is driven by the need for autonomy, competence, and relatedness.
Expectancy theory (Vroom): Behavior is motivated by expected outcomes.
Ecological systems theory (Bronfenbrenner): Behavior is influenced by multiple levels of environmental systems.
Nudge theory (Thaler and Sunstein): Small changes in the environment significantly influence behavior.
Cognitive theory (Beck): Dysfunctional thinking patterns are the root cause of emotional distress and maladaptive behaviors.
Science of behavior change: tactics
Several tactics have been established based on these core theories, and rigorously tested using the scientific method. Although there is no single intervention or approach that has 100% effectiveness, it’s important to have a set of evidence-based tools in your toolkit.
Here are 40 tactics that have compelling literature to support them:
1. Set SMART goals
Description: Specific, measurable, achievable, relevant, and time-bound goals are more likely to lead to successful habit formation.
Example: Lose 1 pound per week for the next 12 weeks by exercising 30 minutes daily and eating 1,500 calories a day.
Supporting literature: Locke & Latham, 2002
2. Reduce friction
Description: Making it easier to perform a habit by removing obstacles increases the likelihood of adherence.
Example: Prepare healthy meals in advance to avoid the hassle of cooking when hungry.
Supporting literature: Fogg, 2009
3. Commitment devices
Description: Creating self-imposed barriers or penalties for not performing a habit can improve adherence.
Example: Pay for a month of fitness classes upfront to ensure attendance.
Supporting literature: Rogers et al., 2014
4. Intrinsic rewards & identity-based habits
Description: Connecting habits to core values and identity can increase internal motivation and long-term adherence.
Example: Reward yourself with an activity you love (e.g., watching your favorite show) after a workout, and identify as 'someone who prioritizes health.'
Supporting literature: Deci & Ryan, 2000; Clear, 2018
5. Start small & build tiny habits
Description: Starting with small, manageable changes can help build momentum and reduce resistance.
Example: Start with 5-minute daily walks and gradually increase duration.
Supporting literature: BJ Fogg, 2009
6. Implementation intentions
Description: Formulating "if-then" plans can improve the likelihood of following through on intentions.
Example: Plan: 'If I feel hungry between meals, I'll drink water first.'
Supporting literature: Gollwitzer & Sheeran, 2006
7. Social support
Description: Engaging in social networks that encourage and support habit changes can enhance motivation and persistence.
Example: Join a weight loss support group to share progress and challenges.
Supporting literature: Berkman & Glass, 2000
8. Behavioral substitution & habit reversal
Description: Replacing unwanted behaviors with healthier alternatives can effectively facilitate habit change.
Example: Replace snacking with a 5-minute walk whenever you feel stressed.
Supporting literature: Marlatt & Gordon, 1985; Miltenberger, 1997
9. Mindfulness
Description: Mindfulness practices can reduce stress and improve self-regulation, aiding habit formation.
Example: Practice mindful eating by savoring each bite and avoiding distractions.
Supporting literature: Kabat-Zinn, 1990
10. Reflective practice
Description: Periodically reviewing progress and adjusting strategies can help maintain and refine habits. Reflect on your experiences and learn from setbacks to improve future adherence to the habit.
Example: Keep a journal to reflect on what worked and what didn’t each week.
Supporting literature: Baumeister & Heatherton, 1996; Schön, 1983; Baumeister, 1996
11. Education
Description: Staying informed about the benefits and techniques related to a habit can boost motivation and adherence.
Example: Learn about nutrition to make informed choices about portion sizes and food quality.
Supporting literature: Schwarzer, 2008
12. Routine establishment
Description: Creating consistent routines helps automate habits, making them more resilient to disruption.
Example: Create a morning routine that includes exercise, meal prep, or planning healthy meals.
Supporting literature: Wood & Neal, 2007
13. Behavioral contracts
Description: Written agreements outlining commitment to habits and consequences for non-adherence can improve accountability and success rates.
Example: Sign a commitment contract with a friend to stick to your weight loss plan.
Supporting literature: Mahoney, Thoresen, & Freeman, 1971
14. Behavioral triggers & cue-control
Description: Use specific cues to prompt the desired behavior (e.g., placing running shoes by the bed to trigger morning exercise). Modify or eliminate cues that lead to undesired habits while introducing cues that promote desired behaviors.
Example: Place workout clothes near your bed as a cue to exercise each morning.
Supporting literature: Duhigg, 2012; Wood & Neal, 2007
15. Precommitment
Description: Commit to a behavior in advance to reduce temptation and increase the likelihood of follow-through.
Example: Arrange meals for the week ahead so you have no unhealthy choices available.
Supporting literature: Ariely & Wertenbroch, 2002
16. Social influence & social proof
Description: Leverage peer pressure by surrounding yourself with people who exhibit the desired behavior. Emulating successful individuals can provide motivation and practical strategies for habit formation.
Example: Post your weight loss achievements on social media to gain support and stay accountable.
Supporting literature: Christakis & Fowler, 2007; Cialdini, 2009; Bandura, 1986
17. Self-talk
Description: Use positive self-talk to reinforce commitment and resilience in maintaining the habit.
Example: Use positive self-talk like 'I am capable of reaching my goal.'
Supporting literature: Hardy, Hall, and Hardy, 2005
18. Goal gradient hypothesis
Description: Increase motivation by breaking long-term goals into smaller milestones to create a sense of achievement and momentum.
Example: Increase workout intensity as you near your goal, feeling more motivated to finish.
Supporting literature: Hull, 1932
19. Behavioral flexibility
Description: Allow for flexibility in how and when the habit is performed to reduce pressure and increase sustainability (e.g., allowing varied types of physical activities).
Example: If an unexpected event arises, swap your usual workout for a shorter home workout.
Supporting literature: Lally et al., 2010
20. Practice deliberate rest
Description: Ensure adequate rest and recovery to prevent burnout and maintain motivation.
Example: Take breaks and avoid burnout to maintain a sustainable weight loss journey.
Supporting literature: Ericcson et al., 1993
21. Immediate implementation
Description: Act on new habits immediately to reduce procrastination and inertia.
Example: Start a new habit (e.g., walking after dinner) immediately after deciding to lose weight.
Supporting literature: Aarts, Paulussen, & Schaalma, 1997
22. Cognitive behavioral therapy
Description: Use CBT techniques to identify and change unhelpful thought patterns that hinder habit formation.
Example: Challenge distorted thinking patterns by recognizing and correcting self-defeating thoughts.
Supporting literature: Beck, 2011
23. Automated processes
Description: Automate parts of the habit formation process using technology.
Example: Use meal planning apps to automate grocery lists and healthy meal prep.
Supporting literature: Payne, Moxley, & MacDonald, 2015
24. Gratitude practice
Description: Regularly practicing gratitude can support positive habit formation by fostering a positive mindset.
Example: Express gratitude for the progress you've made and your body's capabilities.
Supporting literature: Emmons & McCullough, 2003
25. Gamification
Description: Use game-like elements (points, badges) to make habit formation more engaging and motivating.
Example: Track progress with a points system, leveling up as you reach goals.
Supporting literature: Hamari, Koivisto, & Sarsa, 2014
26. Self-compassion
Description: Practice self-compassion to manage setbacks and maintain motivation by treating oneself with kindness and understanding.
Example: Be kind to yourself after setbacks, focusing on your efforts instead of failures.
Supporting literature: Neff, 2003
27. Peer comparison
Description: Comparing your progress with peers to create a sense of competition and motivation.
Example: Compare your progress to others with similar goals to motivate further efforts.
Supporting literature: Festinger, 1954
28. Loss aversion
Description: People are more motivated to avoid losses than to achieve gains. Structuring incentives to highlight potential losses if habits are not maintained can be effective.
Example: Log prepaid sessions at a gym, so skipping feels like losing money.
Supporting literature: Kahneman & Tversky, 1979
29. Hyperbolic discounting
Description: People tend to prefer smaller, immediate rewards over larger, future rewards. Structuring habit formation to provide immediate, small rewards can help sustain motivation.
Example: Plan for indulgences by incorporating them in moderation, to prevent feeling deprived.
Supporting literature: Laibson, 1997; O'Donoghue & Rabin, 1999
30. Default options
Description: Making the desired behavior the default choice can lead to higher adherence rates. People are more likely to stick with pre-set options.
Example: Use smaller plates as the default option to control portion sizes.
Supporting literature: Johnson & Goldstein, 2003
31. Mental accounting
Description: Segregating funds or time for specific purposes can help in managing resources better and staying committed to habits.
Example: Categorize calories spent on healthy vs unhealthy food to budget daily intake.
Supporting literature: Thaler, 1999
32. Scarcity and urgency
Description: Creating a sense of scarcity or urgency can motivate action.
Example: Sign up for a limited-time fitness challenge, creating urgency to commit.
Supporting literature: Cialdini, 2009
33. Endowment effect
Description: Valuing something more highly simply because you own it (i.e., creating a sense of ownership over the habit).
Example: Use a special water bottle that you value to encourage hydration habits.
Supporting literature: Thaler, 1980
34. Salience
Description: Making key aspects of a habit more prominent and noticeable increases the likelihood of attention and action.
Example: Display your progress chart where you see it daily, keeping it top of mind.
Supporting literature: Tversky & Kahneman, 1974
35. Temporal landmarks
Description: Utilizing significant dates or events (like New Year’s, birthdays, or the start of a new month) as opportunities for fresh starts and new habits.
Example: Start a diet on the first of the month for a fresh beginning.
Supporting literature: Dai, Milkman, & Riis, 2014
36. Surprise rewards
Description: Intermittently rewarding the behavior with unexpected incentives can maintain engagement and motivation.
Example: Surprise yourself with a small non-food reward when reaching a mini-goal.
Supporting literature: Skinner, 1953
37. Hedonic adaptation
Description: Understanding that people adapt to both positive and negative changes. Rotating or varying habits can keep them fresh and engaging.
Example: Accept that initial excitement will fade, so focus on maintaining your habits.
Supporting literature: Brickman & Campbell, 1971
38. Effort justification
Description: People value outcomes more if they have put effort into achieving them. Highlighting the effort put into habit formation can increase its perceived value.
Example: Recall how hard you’ve worked so far to justify sticking to the plan.
Supporting literature: Aronson & Mills, 1959
39. Anticipated regret
Description: Encouraging people to consider how they would feel if they do not follow through with a habit can motivate them to stick with it.
Example: Visualize feeling disappointed if you don’t follow through on your workout.
Supporting literature: Zeelenberg, 1999
40. Future self-continuity
Description: Strengthening the connection between the present self and future self to enhance long-term planning and adherence to habits (e.g., writing a letter to your future self).
Example: Write letters to your future self about the importance of your goals.
Supporting literature: Hershfield, 2011
The power of motivational interviewing
Whew, all done! That’s a long list. Here’s one last tool that might help to cut through the noise and figure out which tactic might work for a specific patient: motivational interviewing.
Motivational interviewing is an approach designed by clinical psychologists William R. Miller and Stephen Rollnick for clinicians to help individuals find their own motivation and develop a personalized concrete plan of action to implement the change.
The key elements of motivational interviewing are:
Partnership: Work collaboratively and avoid the “expert” role
Autonomy: Respect the patient’s ability to make their own decision. Accept that change is up to the patient and they have control over their actions
Compassion: Keep the patient’s best interests in mind
Evocation: The best ideas come from the patient. The clinician’s goal is to draw out the patient’s intrinsic motivations, personal goals, and solutions
The approach leverages four key techniques, known as OARS:
Open-ended questions: To encourage the client to talk about their thoughts and feelings in detail
Affirmations: Positive statements to recognize the client’s strengths and efforts
Reflective listening: Mirroring back what the client says to show understanding and encourage deeper exploration
Summarizing: Pulling together key points from the conversation to reinforce
The stages of motivational listening are:
Engaging: Building a trusting relationship
Focusing: Narrowing the conversation to areas where the patient is considering change
Evoking: Drawing out the patient’s motivations for change
Change talk: A client’s own statements that favor change, including the desire to change, ability to change, specific reasons for change, need for a change, commitment to change, willingness to change, and steps to change
Planning: Developing a concrete plan of action to implement the change
Action planning: Creating a detailed plan that outlines the steps the patient will take
Identifying resources and support: Social support, tools, and information that the patient might need and how to access them
Strengthening commitment: Encouraging the patient to verbalize their commitment to the plan
Identifying barriers and coping strategies: Discussing potential obstacles and strategies to overcome them
Monitoring and reviewing: Setting up a system for the patient to track their progress and reflect on their achievements and setbacks
Adjusting the plan: Being flexible and making changes based on the client’s experiences and feedback
For more information, here is a 1-hour video explanation by the founder and a 5-minute demo applying motivational interviewing to a patient consultation focused on weight loss.
You got this!
We hope this primer on behavior change theories and tactics has gotten the juices flowing for you.
We’d love to hear about how you apply these tools to your daily practice. Please reach out to us with any questions, ideas, or stories!