By Simon Matthews, FASLM, MHlthSc, DipIBLM, MAPS, PCC, NBC-HWC, CPHWC
Firstly, thanks to Gary Sforzo for distilling and illuminating some key elements of this paper. And thanks also to my co-authors! This was a true trans-disciplinary effort in which the whole became greater than the sum of the parts and the specific contributions of each part of the system merged into that whole.
I’d love to explore a little more deeply one specific part of the behavioral change puzzle – sustaining change. Gary has named “permissive flexibility,” in particular as a likely contributor to sustained change. I want to explain why and how that might be the case, and also suggest a useful working idea for how we might think about “sustainable” in clinical practice.
Let’s start with a useful idea of sustainable and I think this will draw us towards understanding why the principle of permissive flexibility has value. As we explored in the paper, there is no universal definition of sustainable. If a person is able to maintain a change into the medium or long term, or some other defined period of time, we could call that sustainable. If the manner of supporting change in the healthcare system leads to cost reductions, or improvements in vocational satisfaction for the agents of behavioral change (physicians, dietitians, EPs and so on), we could also call that sustainable. The concept you use to define sustainability will affect the metrics used to assess it. So, is there a “best” candidate? I think there is.
The healthcare system has multiple actors including the patient, physicians, allied health clinicians, healthcare organizations, government policy actors, economic policy actors and more. However, the system is (or should be!) designed to serve the needs of the patient, and not vice versa! Therefore, the most useful idea of sustainable in healthcare, in my opinion, is one which is focused on patient needs and patient priorities. In effect – sustainable needs to be understood in whatever way supports the patient to engage meaningfully and vitally in their own life, and their family, community and national life. If we separate this idea from the patient, we risk setting an arbitrary (and likely external, system focused) standard of “sustainable” and losing the focus on patient priorities.
Given that, how might we go about supporting sustainable change? The notion of permissive flexibility encourages us to work with the client to create pathways for change that allow for variability. It also means recognising that different physical and psychological environments are likely to cue different behaviors in the client. This concept was made clear by the German American psychologist Kurt Lewin (1890 – 1947) who developed the field theory of behavior, leading to the famous formula B= ∫(P,E) – behavior is a function of the person and their environment. Therefore, if we focus behavioral change efforts only on asking someone to do a behavior differently, we’re ignoring the critical influence of variable psychological and physical environments.
If we instead approach this by inviting the client to be curious about those environments and to question how they come to behave differently in different environments, we’re starting to move towards the idea of third order change in which the coach is supporting the client to become their own “diagnostician”, their own decision maker and their own expert in implementing particular strategies at particular times. This third order of change idea has been explored deeply by Donella Meadows (1941-2001) in her paper Leverage Points – Places to intervene in a system. She shows very clearly that intervening at the “parameter” level of a system rarely leads to long term behavioral change. In health care an example of this type of intervention could be instructing or encouraging a person to eat 6 servings of vegetables rather than 2, or exercise for 30 minutes daily rather than 10, or sleep for 7.5 hours per day rather than 5. The patient may briefly change behavior but because nothing else has changed in the values, beliefs, attitudes, fears, hopes, dreams and capacities of the person, the new behavior will likely extinguish quickly.
Meadows argues powerfully that the most effective leverage point for change is the “power to transcend paradigms”. This calls us all to remain flexible; to realise that there is no one correct or best way of approaching change and difference; to recognise that every situation will provide facilitators and inhibitors of change.
In health behavior change contexts we can harness this power through inquiry, listening and reflection to support the patient to understand their own capacity to consider themselves in new and different ways. Examples of the types of inquiry that might prompt this type of self-reflection could be:
How did you come to form that view of yourself?
When have you noticed that this perspective has not helped you?
What other ways might there be of considering this?
What else could be different when this changes?
What will it mean to you, to be able to adapt in this way?
What can you do to develop more trust in your own plans?
What benefits could arise from changing your approaches at different times?
How could disruptions to your routine and plans help you?
What could be the best outcome of experiencing a failure?
Third order changes are not easy to implement – the entire system must adapt, rather than simply performing one limited behavior differently; however, intervention at this level also provides the most likely pathway to sustainable and constantly evolving behavioral change.
Further reading
Lewin, K. (1951). Field Theory in Social Science. New York: Harper
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