by Jim Broadbear, Ph.D., CWP, NBC-HWC & Barbara Broadbear, Ph.D., MPH
Abstract: The heart of wellness work is helping people adopt and sustain healthy behaviors. Wellness professionals benefit from developing a deep understanding of this biopsychosocial process. The Stages of Change from the Transtheoretical Model offer psychological insights into behavior change and with this article, additional neurobiological insights are considered. Mindset and neurobiological profiles are presented for the contemplation, preparation, and action stages. Perspectives of what it feels like to be in each stage and implicaitons for wellness practice are presented.
The heart of wellness work is helping people adopt and sustain healthy behaviors. This work is deeply dependent on insights into volitional behavior change which is a biopsychosocial process. It involves a cascade of physical and psychological changes happening within the context of a person’s life.
Psychologically, the Transtheoretical Model (TTM) provides a conceptually rich and evidence-informed way to relate to people’s experiences and organize efforts through the stages and processes of change. Stages are defined by characteristic mindsets meaning, for example, a person in the action stage thinks and feels differently about a behavior than when she was in the preparation or contemplation stages. The processes of change are tailored to different stage mindsets and help people shift their patterns of thoughts, beliefs, and expectations toward the next stage.
Similarly, from a physical perspective, stages are associated with underlying neurobiological characteristics. As complex as the psychology of behavior change is, the neurobiology is wildly more so. The focus here is limited to considering the roles of cortisol in stress regulation and dopamine and serotonin in the reward system.
Pulling together these elements of behavior change, we present three profiles for the stages of change based on mindset and neurobiology. The contemplation, preparation, and action stages are the focus because this is where the difficult work of behavior change happens for clients and where wellness professionals can have their greatest impact. In addition to the profiles, we completed an activity to gather qualitative insights into the stages with our students who are undergraduate majors in health promotion. They were asked to write about the thoughts, feelings, and sensations they associate with being in each stage. A compilation of these descriptors is presented as what “They said” for each of the profiles. Implications for wellness practice are also presented. Two cautionary notes:
- This is very Therefore, the profiles are admittedly simplified and debatable. We limit the underlying neurobiology of behavior change to considering cortisol, dopamine, and serotonin. Psychologically, the focus is on a defining characteristic of each stage that frames the behavior change experience.
- We are not suggesting that a person in a particular stage for a particular wellness behavior is always experiencing the mindset and neurobiology described. One’s whole life is not consumed by behavior change. Rather, when a person is considering the behavior and attempting to do something about it, characteristics of the profile may emerge.
With those limitations in mind, here are the six terms to understand that form the basis of the profiles:
Contemplation: “…the (Transtheoretical Model Stage of Change, i.e., ‘stage’) in which people are intending to take action in the next six months. They are more aware of the pros of changing but are also acutely aware of the cons. This weighting between the costs and benefits of changing can produce profound ambivalence (emphasis added) that can cause people to remain in this stage for long periods of time” (Prochaska & Prochaska, 2017, p. 306). In this stage, people are often stuck between wanting to change their behavior and not wanting or feeling capable of making the effort to change.
Preparation: “…the stage in which people are intending to take action (emphasis added) in the immediate future, usually measured as the next month” (Prochaska & Prochaska, 2017, p. 306-7). In this planning stage, people seek resources and are receptive to being recruited into wellness programs.
Action: “…the stage in which people have made specific overt modifications in their lifestyles within the past six months” (Prochaska & Prochaska, 2017, p. 307). People in this stage are committed to performing behaviors (emphasis added) sufficient to optimize wellness and reduce risks for disease.
Cortisol: A steroid hormone synthesized from cholesterol in the adrenal gland. The hypothalamus-pituitary-adrenal (HPA) axis regulates production and secretion of cortisol. Cortisol has many functions related to stress regulation, metabolism, inflammation, and immunity (Thau, Gandhi, & Sharma, 2022). Think – energy metabolism, fight, flight or freeze response.
Dopamine: a multi-function neurotransmitter that is primarily produced from the amino acid tyrosine and stored in the brain. It also acts as a hormone produced in the adrenal glands and a neuromodulator affecting the function of other neurotransmitters (Berke, 2018). Dopamine is involved in numerous processes including mood, learning, stress response, and reward systems. Its reward system function is primarily pleasure sensations and motivating the satisfaction of hunger and sex drives. Think – short-term pleasure and gratification of cravings.
Serotonin: a multi-function neurotransmitter that is primarily produced and stored in the gut (Shine, et. al., 2022). It has hormonal functions regulating digestion, mood, sleep, and wound healing. Serotonin is produced in the body by the essential amino acid tryptophan so consuming foods such as eggs, salmon, oats, and nuts supports serotonin levels (Jonnakuty & Gragnoli, 2008). Its role in the reward system is primarily satisfaction, happiness, focus, and calmness. Think–goal satisfaction and delayed gratification.
Contemplation
Mindset: Ambivalent
Neurobiology: Elevated cortisol; Suppressed dopamine and serotonin
During a workshop we conducted recently, a client described what it felt like to be in the contemplation stage and said, “It just feels like…” What followed was not more words but a sigh, with her shoulders sagging and head tipping slightly to the side. The nonverbal response was the embodiment of feeling stuck in a pattern of behavior. For various individualistic reasons, when unhealthy behavior and its associated negative outcomes are either not uncomfortable enough and/or motivation for a healthier option is lacking, behavior persists.
So it is with ambivalence, a defining characteristic of the mindset of contemplation. The teeter-tottering between ‘should I or shouldn’t I’ and ‘can I or can I not’ can last for years. Ambivalence is fueled by awareness of a problem coupled with a vague understanding of what to do about it (Ryan & Deci, 2017). When ambivalent, a person experiences a lack of clarity about the nature of the problem. Viable solutions seem beyond reach. The mindset of ambivalence emerges and is reinforced by two broad thought patterns – unable and unworthy. Perceived inability takes many forms and can often include perceived lack of time. Other resource issues such as availability and access play a role as do more externalized locus of control, knowledge deficits, and poorly developed skills.
An ambivalent mindset can also be fed by feelings of inadequacy. Accepting unhealthy as normal, feeling incapable of changing, low motivation, lack of confidence, and also enjoying sensations associated with unhealthy behavior are among the influences shaping ambivalence (Ryan & Deci, 2017). When people feel that pursuing more optimal wellness is not worth it, they have essentially adopted beliefs aligned with low expectations. Feelings of self-doubt, anxiety, shame, and inadequacy can emerge.
The ambivalent mindset of contemplation is stressful which contributes to elevated cortisol (de Vries, et. al., 2017). Recurrently thinking about the behavior, even ruminating on it, but not doing anything about it, evokes the stress response. Ambivalence is also associated with a lack of pleasure and satisfaction. Feeling stuck and viewing a wellness goal as daunting and possibly beyond reach means little to no reward consistent with inhibited dopamine and serotonin.
When students were asked about the contemplative stage,
They said:
…a weight on my chest, stressed to decide, there isn’t clarity or any sort of resolution, would take a lot of effort, wishy washy, indecisive, frustrated, confused, mad at myself for not having the confidence to move forward, stressed about making the change, worried, knowing I should, questioning, stressed due to feelings of guilt, being held back by the cons and my own thoughts, unclear if pros outweigh cons, feeling unsure of my abilities, lack confidence when I can’t attain something right then and there, fighting myself over why I haven’t already been doing it and then forgive myself as I remember all the cons, fear of failing, stalling, some days committed and other days not, everything else stands in the way, I know there are certain things I cannot have and that would be hard
How wellness professionals can respond: Go really big and really small with wellness visioning and Motivational Interviewing.
The key to successfully moving beyond contemplation is resolving ambivalence. One of the most powerful evidence-informed practices to address the mindset of ambivalence is Motivational Interviewing (MI) (Miller & Rollnick, 2013). Delivered by a wellness professional with training and experience, MI helps people focus on removing internal interference that makes behavior change seem unattainable and stasis appealing. While quality training and years of experience are obviously helpful to increase the likelihood of impact, foundational strategies from MI, specifically developing discrepancies and importance, confidence, and readiness ‘rulers,’ are not complicated and are relatively easy to implement. We have seen this in health and wellness coaching education as students who learn the skills rapidly and effectively use them in coaching conversations. The strategies help clients go granular in their thinking by brainstorming numerous potential benefits of healthy behavior and disadvantages of the status quo.
We help clients go big through wellness visioning. Visioning work gives people the opportunity to gain clarity and perspective (Jack, et. al., 2013). The strategy engages imagination and creative thinking by articulating more optimal ways of being which makes wellness seem more attainable. In our experience, using the dimensions of wellness is very useful in visioning work. Prompt clients to describe more optimal physical, intellectual, emotional, social, spiritual, and occupational wellness. Written or oral visioning work helps clients resolve ambivalence by adding clarity and through the social interaction of expressing it.
Preparation
Mindset: Intentional
Neurobiology: Elevated cortisol; Fluctuating dopamine and serotonin
What is it like to prepare for a big trip? When it is months away, we can take time to comparison shop for good deals on flights and places to stay. We can explore the options the location offers and anticipate, with building excitement, all that we will see, do, eat, and enjoy. As the departure nears a very different experience can emerge. We may have to get extra work done before leaving, pack for kids, arrange care for our pet, worry about weather disrupting travel, and so on. It can make us wonder if taking this trip was a good idea to begin with.
The co-mingling of excitement and anxiety are characteristic of the preparation stage as the buildup to action progresses. A challenge during preparation is the absence of actual behaviors. This is consistent with increased levels of cortisol and a reward system in flux (de Vries et. al., 2022; Fancourt et. al., 2021; Katsu & Baker, 2021). Anticipation drives the urge to behave, yet without actual performance, rewards are not experienced in connection with the behavior.
The preparation stage involves moving from a mindset of vague ideas to clear intention (Prochaska & Prochaska, 2017). Once the ambivalence of contemplation is resolved, a path forward is implied, though typically a wide variety of options exist. Clarifying goals, task sequencing, identifying needed resources, connecting with social support, selecting ways to track progress, identifying benchmarks for success…all of these planning elements enhance the likelihood of success – of turning intention into sustainable behavior.
During the preparation stage, the focus is cultivating intentionality that is likely to be turned into behavior. Competing patterns of behavior include moving too quickly into action and overplanning – i.e., rushing and ruminating. Both compromise success and are stressful. Effective preparation imposes order by choosing a way forward that is sufficient to limit second-guessing and heighten readiness. Similar to the trip example above, once you actually reserve a flight and place to stay, all of the other possibilities fall away. The focus becomes embracing the choice that was made. Clear, precise, and concise plans help people manage stress and direct focus and energy toward self-determined goals. Help people prepare efficiently and then get on with it.
When students were asked about the preparation stage,
They said:
…I feel nervous and excited at the same time, need time in this stage because I can be spontaneous, I struggle because my expectations exceed reality, I LOVE planning so I’m excited, have the ability to control my urges, stressed trying to plan time into my day, feel more motivated and excited, more of a purpose, having the goal makes me feel more energized, excitement around planning and seeing new routine come to life, questioning if I’ve prepared enough, make lots of plans and experiments, it feels good to prepare and there is some pressure to perform, knowing the behavior is coming up tends to make me motivated, nervous to show others, figuring out the most efficient and effective way, still confused but have more clarity, ready, procuring accessories brings a sense of happiness because I love to shop and pick things out
How wellness professionals can respond: Narrowed choice, efficient plans, behavioral experiments.
Intentionality needs direction and too many options is a threat to finding it. Winnowing possibilities makes an actionable way forward more evident. Clear intention looks at the mountaintop that is the wellness vision and says, “I’m taking that way to the top.” In her book The Art of Choosing (2011), Sheena Iyengar explained that choosing is enhanced by cutting down on possibilities, cultivating confidence with advice from trusted others, categorizing options into groups, and conditioning ourselves for success by making small choices and following through on them.
It is like the cereal aisle. There are dozens of options, but if the only category you will choose from is whole grain, high fiber, no sugar, and cold, none of the other options matter and choice is drastically narrowed. Add (increasingly with inflation) price point and taste preference to this nutritional choice and you may be left with a very clear choice (Yeah Shredded Wheat-n-Bran!)
Curiosity and self-compassion are also helpful to creating clear intention and mitigating stress (Ewert, Vater, & Schröder-Abé, 2021; Schutte & Malouff, 2020). This is where we believe behavioral experiments during preparation are very useful. An experiment is a low stakes venture and is designed for learning. It taps into the growth mindset and has the goal of generating evidence about what works and what does not. Experiments allow people to try a goal-directed behavior rather than just think about it which can relieve stress and start to condition the reward system. For example, each day for the next two weeks, replace one soda with water and see how it goes. This is low stakes, short-term, and merely designed to see how it goes. A spirit of curiosity and self-compassion are useful. With many people, it takes a long time for unhealthy behavior to create suffering and it takes time to get out of that pattern.
Action
Mindset: Committed
Neurobiology: Regulated cortisol; Conditioned dopamine and serotonin
The action stage involves repeated performance of wellness behaviors with a high degree of fidelity to optimize evidence-informed practices such as consuming no more than 30g of sugar/day or accumulating at least 150 minutes/week of exercise.
The hallmarks of contemplation and preparation are resolving ambivalence and clear intention. A defining mindset of action is commitment represented by a shift in change talk from “I may” to “I will” (Cancer Prevention Research Center, 1998; Prochaska & Prochaska, 2017). When a person truly arrives in the action stage, they are convicted to act on their “I will.”
Action is about the day-in, day-out grind of commitment to behavior change. Therein lies an important distinction. A more fully formed commitment has to face the twists and turns, and likely bumps and bruises, of action. It is in the doing that commitment and intention become rooted.
Performing a wellness behavior provides the opportunity for functional commitment (Overton & MacVicar, 2008). During the action stage, wellness behaviors are incorporated into lifestyle with all the attending cognitive negotiations and lifestyle navigations. Preparation meets reality. The importance of this cannot be understated. What happens in contemplation and preparation are essential to successful behavior change but performing wellness behaviors is where new identity forms. Behavior transforms underlying affect, perceptions, thoughts, emotions, and physiology. With a mindset of functional commitment, progression through the action stage transforms cortisol, dopamine, and serotonin. The stress response associated with unhealthy behavior is mitigated and the reward system becomes conditioned to new sensations.
When students were asked about the action stage,
They said:
…less stress and more at ease as I am no longer in a state of anticipation, feel accomplished, growth, assurance, seeing changes, proud of one self, stay on track by finding ways to make it happen, begin to look forward to it, regulate stress as I manage the habit, go time, partner to keep improving, have my moments of weakness but I’ve been consistent, I can put my mind to it and get the behavior done, feelings of relief, consistent pleasurable feeling after completing my target behavior, less anxiety about possible future health issues, mental clarity, feeling accomplished for the day, behavior and routine feel comfortable and safe, sense of pride, feel more accomplished, in a better mood each day
How wellness professionals can respond: Habit design, supportive others, tracking change
Consistent and sustainable wellness behaviors are woven into a person’s lifestyle. They take on functional qualities of other normal daily activities. We don’t have to riddle our way through the routine. We simply perform. It is like hand washing pans after a meal, we run the water, add soap, grab the sponge, and get on with it. Help people in the action stage make it familiar, normal, typical, common, and habitual. Creative environmental design really matters and the design elements to prioritize include repeated attempts, supportive others, and tracking change.
Habituating a wellness behavior is dependent on repeated performance. The only way is through. Help clients find ways to perform the behavior multiple times. Breaking it down to small increments can be helpful. For some behaviors that is obvious. A person cannot or will not consume all the water needed in a day at one time. For other behaviors, more creativity is needed. “No time” for exercise? Break physical activity into six small chunks. Committed to healthy eating? Eat a serving of vegetables with every meal and one snack. Need to de-stress? Practice mindfulness four times a day, two minutes each. Repeat, repeat, repeat.
Functional commitment means it works in the context of a person’s life, so the support of others is key. This is a deeply and well-established reality (Connell, et. al., 2019). It may be that a person’s family, friends, and co-workers only provide occasional verbal support. After all, they have their own problems and priorities. Support does not have to be substantial, but if it is absent or disapproving, behavior change is more stressful. The act of making wellness goals known to others is valuable in itself. Help clients enlist others in their wellness journey.
In this era of smartwatches and tracking devices, health-related data are readily available. For good and bad, devices interplay with neurobiology. However, measuring progress needs to be individualized. Some people are quantitative-oriented and love the data generated by their devices while others enjoy journaling or simply talking about progress. Whatever the approach, measuring progress provides self-accountability and the opportunity to reflect on gains (Connell, et. al., 2019). Those before and after images in weight loss commercials are there for a reason. Perhaps dramatic visible transformation will happen over time but much of what changes is more subtle or hidden. Helping clients track the nuances can contribute to real changes that are happening right now.
In conclusion, it is helpful for wellness professionals to think beyond theoretical concepts and more about the lived mindset and neurobiological reality of behavior change. That is what the mindset/neurobiology profiles offer. This has the potential to enhance the resonance and relevance of wellness services and improve the behavior change experience for our clients.
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