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Affective and Cognitive Resistance
to Health Behaviors

Dr. Leon James
Department of Psychology
University of Hawaii

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See Interview Notes for Flossing Movie with Gary Roma

ABSTRACT
A content analysis method is described that identifies types of resistance or opposition felt or thought by an individual receiving health information or instructions. The discourse analysis technique is applicable to any health issue, with single cases or groups, in spontaneous oral exchanges or in prompted written responses. Verbalizations are viewed as inner speech acts, which are socialized affective and cognitive responses to health and lifestyle issues. A classification scheme is suggested which can help health professionals keep better track of the causes of non-adherence and provides specific interventions which may counteract or modify inner negative speech acts. To illustrate the language analysis technique, data are given with specific examples for each of the speech act categories.
Introduction
Noncompliance to health instructions often implies some degree of client resistance to change. This resistance is undoubtedly both cognitive and affective. Health professionals can gain a better understanding of their clients' resistance by examining the content of theirverbal reactions. This paper presents a method for categorizing statements made by clients when prompted to state their view on some health issue or procedure. The presence of affective resistance is revealed by unwillingness to receive information, holding on to misconceptions, or avoiding contact. Cognitive resistance is inferred from faulty explanations or the elaboration of negative fantasies. The ability to assess client resistance to change is becoming an important issue in health care.

RESISTANCE TO CHANGE

Psychotherapists deal with client resistance as a dynamic component of growth and change. "Tactical resistances" are defined as "psychic operations and behaviors" that serve to avoid information about the self; "strategic resistances" are regressive behaviors by which a person seeks "fulfillment of childhood choices or fantasies" (Dewald, 1982, p.490). Therapists view resistance as the client's attempt to defend against acknowledging a particular drive or impulse. It is "a reaction that enables an individual to avoid frustration and anxiety, and to rely on established, repetitive modes of gaining satisfaction" (Blatt & Erlich, 1982, p.72). Viewed in this light, resistance to compliance to health care instructions is an expression of a relationship problem between client and health care professional. The skill of the latter in helping the client become aware of the presence of these resistances might be an important aspect of the health care process.

Resistive behaviors noted by therapists include the following: withholding information; attempting to thwart the therapist; denying cooperation; avoiding to collaborate; having to be forced to repeat; not wanting to recognize responsibility for one's actions; rejecting new information; avoiding inner pain from confronting facts or facing the consequences of one's actions; forgetting details. The forms of intra-psychic resistance in health care need to be examined. Though clients may want relief from symptoms, they do not want to give up anything and oppose whatever threatens the continuation of one's style of life.

HEALTH INSTRUCTIONS

It is now recognized that patient nonadherence or noncompliance has emerged as a major problem for health professionals (Morisky, 1986). Nonconformance to treatmentplans threatens to decelerate the progress achieved in illness control. According to a recent review of the literature on noncompliance behavior the challenge that faces health professionals is to "provide relevant information, feedback, and explanations that will maximize the impact and personalization of an unexpected and unwelcome message" (Hollis, Connor, and Matarazzo, 1982, p.474). Health information is often an unwelcome message which triggers a basic antagonism between service provider and client. The health message may be unwanted because it can arouse unpleasant sensations of dissonance and fear. Health may be perceived as a demand to change lifestyle habits and can threaten to remove cherished delights and comfortable surrounds. Yet health information may contain many promises of relief from discomfort, of vitality, and of long life. Thus there could be a two-fold reaction to the health provider's message or instruction. One is "the teachable moment," when the message triggers a desire to change one's lifestyle habits (Hollis, Connor, and Matarazzo, 1982, p.475). The other may be the arousal of intra-psychic defense mechanisms such as avoidance, rationalization, and denial.

Health professionals today have come to look upon the majority of society as "people at risk." Cultural lifestyles and economic conditions reinforce negative health behavior, poor physical and mental health conditionsmay be generationally transmitted within entire populationsor communities. Because of the complexity of interrelationships among the social forces which contributeto decline in health, we need to examine noncompliant behavior in sufficient psychological depth to highlight itsaffective and cognitive reaches within each individual's unique behavioral style. As argued by Hollis, Connor, and Matarazzo (1982), "personalizing" health instructions may overcome the resistance to health information that lies deep within an individual's unique behavioral style. This paper presents a rationale for identifying varieties of intra-psychic resistance to health information.

AFFECTIVE AND COGNITIVE VERBALIZATIONS

Problem solving behavior is a primary use of language or inner speech. We talk to ourselves in order to make sense of our surrounds. Exposure to new information entails a reaction to it. This reaction is dual, includingan affective component relating to motivations and attitudes, and a cognitive component relating to beliefs and perceptions. Both components have been considered behaviorally by prior investigators (Ajzen and Fishbein, 1980; Schlesinger, 1982). In a review of the literature onhealth compliance behavior, Heiby and Carlson (1986) organized the many factors into four basic interacting components. Inspection of their model shows the importanceof both affective components ("intentions" and "attitudes") and cognitive components ("beliefs" and "perceptions") in determining adequate adherence levels tomedical recommendations.

The analysis of verbalizations as an index to affective states and cognitive operations has a long tradition in functional and behavioral psychology (Skinner,1957; Pool, 1959; Auld and Murray, 1955; Mahl, 1959; Gottschalk & Viney, 1986). The field of applied psycho-linguistics encompasses clinical applications (Rieber, 1980). Ericsson and Simon (1985) describe methods for diagramming thought sequences reconstructed from tape recordings of verbalized thoughts made during problem solving tasks. The control function of verbalizations has long been of interest (Vygotsky, 1965), and can be recog-nized in the expanding work on "self-regulatory sentences" for behavior self-modification (Meichenbaum, 1977; Ellis, 19xx; Watson and Tharp, 1985). The method of content analysis described here has been successfully used in two other areas, tape recordings made while driving a car (Jakobovits, 1987), and while doing library research (Jakobovits and Nahl-Jakobovits, 1987).

A behavioral view of the discourse produced by an individual identifies units that can be considered as responses to affective states (feelings) and cognitive operations (thoughts). Searle (1969) and Austin (1965) have initiated analytical methods for investigating the units of "speech acts" in oral and written discourse. Labov and Fanshel (1977) chart the course of psychotherapy through speech act analysis of transcripts produced during the successful treatment of a bulemic patient. A speech act can be defined as a normative verbal response to a common social stimulus. For example, a question is posed through some appropriate stimulus such as asking for some-thing, or making a quizzical gesture, and some response is given, such as an answer, a shrug, or the act of ignoring it. Asking, answering, ignoring, denying, or being suspicious are common speech acts in everyday language exchanges. Investigators analyzing speech acts use common sense categories since there are no standard methods of analysis.

CONTENT ANALYSIS OF INNER SPEECH ACTS

The method described in this paper assumes that providing health information within a health care or instructional situation constitutes a social and psychological condition in which the individual spontaneously produces inner speech acts as a response to the personal implications of the message. For example, a person may look at a weight chart in a magazine article andthink, "Oh, no, according to this I am classified as obese!They're exaggerating. Where do they take these figures from!" This sequence of language responses (either out loud or mentally) constitutes a social speech act, that is,an interactional exchange between the originator (or source) of the information and the recipient of the message. Within this transaction both affective (motivational) responses and cognitive (rational) responses can be detected. In this example, the response, "Oh, no," may be considered a symptom of negative affect, perhaps rejection or threat, and the response "Where do they take these figures from," is a symptom denial, suspicion, or distrust. The response, "They're exaggerating," indicates that the individual has reinterpreted or reclassified the information so as to allow its rejection.

The analysis of inner speech acts thus involves the categorization of verbal and gestural units in a fashion similar to the coding system used by social psychologists to study interpersonal exchanges (Bales, 1970). This approach requires the development of some agreed upon taxonomy or classification system. The method proposed here involves two general assumptions that are widely accepted in contemporary psychology. First, that all behavior may be classified into three domains: affective, cognitive, and sensorimotor. Second, that all behavior is acquired by development or habit through stages which, broadly speaking, may be divided into beginning (or superficial), intermediate, and mature (or internalized). For example, Kelman (1958) describes three levels of conforming behavior differing in maturity or depth of acquisition. The lowest is mere obedience to authority andrequires external monitoring to maintain it. The second level is conformity by identification and depends on the individual seeing the compliant behavior as relevant to self and peer group. The third and most mature level depends on internalizing the new behavior and incorporatingit into one's motivational system. At this stage, the new behavior is done from one's own initiative and in the absence of external monitoring.

By putting together domain of behavior and level of internalization, we construct a matrix as in Table 1. For the sake of simplicity, this paper addresses itself to two of the three behavioral domains. The 6 intersections are definable in terms of the marginals. For example, the third (deepest) level of resistance in the cognitive domainis zone "-C3" or Cognitive Opposition. This type of resistance manifests behaviorally as dogmatic reasoning, negative fantasies, and the like. Or, consider zone "-A1,"which is affective resistance at the first level, or Affective Ignorance. This type of resistance is behaviorally shown as "disinterest" or "overcautiousness" (non-adaptiveness). This type of schematic matrix can be used to classify inner speech acts that are produced by individuals as verbal reactions to receiving new health care information. It should be noted that each zone marks a general type of psychological mechanism as defined by theintersecting marginals. The specific title for each zone may vary to reflect the focus of the investigator. This makes the classification scheme versatile and adaptable to varying health care settings.

By categorizing spontaneous verbal reactions of individuals to health information or instructions, we obtain an objective indication of the nature of their affect, the content of their cognitions, and the level of internalization of their response. In this sense, the analysis of speech acts, which occur in spontaneous verbalizations aroused by health information, is a source of data for studying the dynamic nature of noncompliance and resistance. A speech act analysis was done of written reactions ofstudents to information on colonic hydrotherapy given in class during a lecture on health psychology. Student responses were individually categorized and assigned a zoneaccording to Table 1. Theoretically, the matrix may be viewed as a display of an individual's dynamic profile indexing the degree or intensity of activity present withineach of the six zones of behavior. The scheme is 'dynamic,' in that each zone is defined by the intersectionof the marginal definitions for domains and levels. Users of the scheme can therefore adapt the labeling of each zoneto their own health issue. Such adaptations may be seen inJakobovits (1987), in the area of improving driving behavior, and Jakobovits and Nahl-Jakobovits (1987), in thearea of overcoming maladjustment in library user behavior.

Research is needed to explore the reliability of the categorizations. The results presented here are given for illustrative purposes by way of explaining the theory.

Level 1 Resistance. This is a relatively external form of resistance to information and has been labeled "ignorance." Affective ignorance (box "-A1") manifests itself behaviorally as showing disinterest or acting overcautiously (non-adaptively). For example, one student's reaction to the colonic irrigation information was the following inner speech act: "This treatment is not for me. It is not vastly known. I've never heard of it." This indicates the person's felt resistance which appears as disinterest or the attempt to distance oneself from the topic. Another individual manifests this type of affect with the statement, "I'm satisfied with my present health, thank you." Cognitive ignorance (box "-C1") is a speech act characterized by inadequate knowledge or superficial reasoning. An example is, "I don't think it's likely that I would have it done because for one thing I don't have time, and because I think it's kind of gross." Or, "It doesn't seem to be extremely important to maintain health."

Level 2 Resistance. This is labeled "misconception." It is a more internalized form of resistance than mere ignorance. Affective misconception is embedded in speech acts that indicate fear or suspicion in its many varieties (box "-A2"). For example, "I wouldn't trust anyone withouta license to probe within me. It could be dangerous." Or, "The experience would seem to be a very stressful and shameful one." Cognitive misconception is embedded in a biased focus or in unrealistic, uninformed expectations (box "-C2"). For example, "I might do it if it was prescribed by a doctor and it wouldn't cost anything and itwouldn't hurt at all. But I don't think I would." Or, "There must be a reason why this is not used by doctors or hospitals. Besides, it's disgusting and must be extremely painful."

Level 3 Resistance. This is the most internalized form and is labeled "opposition" to health information. Affective opposition (box "-A3") takes the form of rejection and avoidance. For example, "I'd rather die of colon cancer because I can't stand pain and bad smells." Or, "Only crazy people would do such a disgusting thing or people who get off on that sort of thing." Cognitive opposition (box "-C3") takes the form of dogmatic reasoningand negative fantasies or dramatizations. For example, "I wouldn't go to someone to get this sort of therapy because I feel I won't ever need it. It's embarrassing to bend over and let a doctor or (please!) a nurse see your kaka. It might smell bad." Or, "Not a chance. I can't stand needles or long tubes going in any part of my body. And ifI see the black stuff coming out I'll probably barf."

Note that speech acts do not overlap with sentence boundaries. Individuals differed with respect to the amount they wrote and how they expressed themselves. More than one speech act may occur in a long response. For example, the following response was categorized as three speech acts: "It is artificial, unnatural, and probably dangerous. (-A2) I'm perfectly healthy. If I needed it, mydoctor would have told me. (-C1) Anyway, why do something that sounds utterly uncomfortable. (-C3)" The total numberof negative speech acts obtained by an individual or group is a measure of the intensity of resistive behavior. The distribution of negative speech acts within the boxes of the matrix is an indication of the locus of resistance, or its dynamic quality.

VARIETIES OF INNER SPEECH ACTS

Further development of the model is needed to specify the psychological dynamics of positive speech acts and how these emerge transformed from the initial negative ones. As well, further work is needed to explore the sub-varieties of speech acts within each zone in Table 1. On the basis of limited data several sub-varieties emerged thus far in each of the six zones:

1. Zone -A1: Affective Ignorance.

a. Feeling dissociation or disinterest.

b. Maintaining excessive or unusual cautiousness.

c. Unwilling to become involved.

2. Zone -A2: Affective Misconception.

a. Simple, unaccounted rejection.

b. Maintaining a negative attitude.

c. Being fearful or anxious.

d. Feeling embarrassment or shame at the idea.

e. Maintaining disbelief (being hard to convince)

f. Experiencing weakened resolve (agreeing and appearing to comply, then not doing so).

g. Feeling suspicion or a lack of trust.

3. Zone -A3: Affective Opposition.

a. Absolute refusal or avoidance under any circumstance.

b. Confirmed opposition or prejudice.

c. Condemnation of the practice or discrimination

d. Ridiculing, mocking, showing disdain or scorn.

4. Zone -C1: Cognitive Ignorance.

a. Engaging in superficial reasoning, making excuses, or non-sequiturs.

b. Deciding against it on the basis of inadequate knowledge.

5. Zone -C2: Cognitive Misconception.

a. Thinking of contradictory arguments.

b. Focusing on expectations that are unrealistic or unlikely.

c. Holding unsupported or unexamined negative assumptions.

d. Biased and selective consideration of facts.

6. Zone -C3: Cognitive Opposition.

a. Setting up impossible or unrealistic preconditions.

b. Making up inhibitory dramatizations or fantasies.

c. Engaging in dogmatic reasoning or closed-mindedness.

APPLICATIONS

In a review of the literature on behavioral strategiesfor reducing noncompliance, Ley (1986) calls for research into the conditions under which an increase in patients' understanding produces greater compliance. Cochran (1986) found that noncompliance is a predictable outcome when attitudes and beliefs are present which inhibit intentions to comply with a prescribed regimen. He argues that since compliance behavior can be influenced, it becomes a prof-essional responsibility of providers to treat noncompliance. The model or taxonomic scheme described in this paper is a potentially useful approach to assess the behavioral domain and level of resistance of a client. Statements from an individual can be obtained in either oral interviews, written questionnaires, diary logs, or self-reports. Health professionals would be able to note the type of resistance (affective and cognitive) and its level or depth.

Social psychologists have reported that self-focused attention increases self-awareness (Wicklund and Frey, 1980). Gatchel and Baum (1983) list a person's health theories as one of the significant determinants of compliance. Patients can be asked about their health theories, either in spontaneous oral exchanges or in writing. The content of the responses provides an index ofthe affective and cognitive speech acts generated by the patient's health theory or belief. The health professionalcan use the matrix in Table 1 to assess the area of patientresistance with a view to planning interventions designed to counteract fallacious elements in a patient's health beliefs. Affective and cognitive interventions can be ini-tiated to fit the level of the resistance, such as providing reassurance for overcautiousness (box "-A1"), giving detailed information or rationales to counteract faulty reasoning ("-C1"), developing trust with suspicious reactions ("-A2"), providing explanations to shift a biasedfocus ("-C2"), or hope to influence rejection ("-A3"), and expertise to overcome dogmatic beliefs ("-C3").

Once identified, resistance to health information or instruc- tions can be counteracted in verbal exchanges with the client, either individually or in a group. Negative speech acts can be transformed by means of exposure to positive speech act models of other clients or of health professionals. This kind of transformation can be seen in the following statement made by a student after a lecture on colonic hydrotherapy: "When I first heard about it, my first reaction was gross! I didn't have enough information to validate these feelings. However, after learning the facts, I was surprised to find myself a little more open to this health technique. My first re-action was no ways, because it was something new to me and scared me." This statement is evidence for the presence oflevel 2 affective resistance ("-A2" "My first reaction was gross!") and its transformation into a positive speech act, ("I was surprised to find myself a little more open" ("+A2"). A similar change is evident in another student's response, "I personally do not feel comfortable about it yet, but if it grows in popularity, I might try it." Case History Applications. The domain by level matrixin Table 1 can be used to assess the type of resistance experienced by an individual during self-change attempts. This application will be illustrated with data gathered by a female college student involved in a field project on diet change. For six weeks she kept tape recorded diary notes on her thoughts and feelings about food. A typical paragraph may be quoted from her transcription:

"Lunch -- Went to eat with my girl friend D. We decided to eat at the campus cafeteria. I wrote down what I ate: hamburger and fries, ketchup, mustard, some lettuce, and a medium diet coke. It was a very big lunch and I felt sleepy after. Decided I would go jogging, but Ididn't. I felt very bad because I was on my vegetarian diet -- I made a resolution not to break my diet again. Dinner -- I am eating stuffing. It is out of a box. I realize that this is not a balanced diet at all but I really enjoy stuffing! At least it doesn't contain any meat! Want something to drink. Can't decide whether I should drink Coke, or diet Coke or water. That would be the best for me, but I need something to keep awake. --- Had a coke!"

The typed (double spaced) diary notes amounted to 9 pages for the first three weeks and 8 for the last three weeks. At the end of the first three weeks the student decided to try to improve her diet by eating balanced mealsand staying away from meat as much as possible. In a situation like this, the researcher or health professional may have an interest in examining the content of her notes before and after the commitment to change diet. This situation is analogous to a baseline-intervention paradigm common in behavior modification studies. In the present case, the analysis consists in marking all her statements as positive or negative relative to the commitment to improve her diet, then categorizing the negative statementsusing the domain by level matrix in Table 1.

Table 1

Types of Inner Speech Acts for Assessing

Affective And Cognitive Resistance to Change

          AFFECTIVE RESISTANCE              COGNITIVE RESISTANCE              
          Rejecting or dogmatic reasoning   Misconception (Level 3)           
          and opposition (Level 3)                                            
          Avoiding negative fantasies       Disinterested or superficial      
          (Level 2)                         reasoning (Level 2)               
          Suspicious or biased focus and    Ignorance and overcautious or     
          unrealistic expectations (Level   inadequate knowledge (Level 1)    
          1)                                                                  

In the baseline period, the person produced 35 negative speech acts and 17 positive; in the intervention period, there were 10 negative and 51 positive speech acts.This pattern indicates that the intervention was accompanied by a decrease in thoughts and feelings of resistance to better food behavior, and an increase in statements that support the commitment (Chi Square=36, df=1, p<.01). The categorization of negative statements yielded 14 affective and 21 cognitive speech acts during the baseline period, and during the intervention period there were 4 affective and 6 cognitive speech acts. Clearly, there was a decrease in both affective and cognitive resistance accompanying the diet change commitment (Chi Square=16, df=1, p<.01).

It may be useful to present the sub-categories generated by these data. It will be noted that they are different in specific content than those generated by the colonic data presented above, but in general content they belong to the same major category. In other words, the domain by level matrix remains fixed as to its psychologi-cal mechanism in each zone, but adapts its specific contentto each health area.

1. Zone -A1: Affective Ignorance.

a. showing vulnerability to externally induced desire to eat (e.g., "But, as soon as we see commercials for pizza or anything, it's like let's go out and eat something. So I think that's one of the problems."

b. showing vulnerability to snack foods that are available (e.g., "I tend to eat it cause it's quick and easy to get to because it's in our room.")

c. wanting to eat without being hungry (e.g., "Ate the poptart earlier and I don't really know if I'm hungry enough to eat something right now. Oh, well, I guess I'll eat anyway."

2. Zone -A2: Affective Misconception.

a. automatic eating or showing fear of being hungry (e.g., "Ate some leftover chicken. Cold from the refrigerator. It was just something to put in my stomach.") or, "Rushed to Kapiolani Hospital to do volunteering. Was still wondering whether I should have eaten something more substantial for breakfast."

3. Zone -A3: Affective Opposition.

a. having a compulsion to clean the plate (e.g., "Breakfast consisted of 1 1/2 cherry pop-tarts -- I didn't really enjoy the taste but I ate it anyway. Later Ithought how dumb I was to continue eating food I didn't like."

b. disregarding a diet rule or making an exception (e.g., "Whenever I cook for them, I tend to eat more! I had a lot of sour cream with my soft taco -- it was heavenly. Again I felt guilty though about eating such a rich meal."

c. imagining still being hungry though feeling stuffed (e.g., "Had a sandwich and a diet coke. Still felthungry even though I was stuffed. I guess I waited too long to eat.")

d. making light of transgressions or scorning them (e.g., "Snacked on some Maui Potato Chips with J. andate two soft tacos when I came home. Left overs from last night. Still used a lot of sour cream, ha, ha!")

e. feeling resentment of restrictions (e.g., "I had a bagel and a salad for dinner tonight. As I look at my dinner and compare it to what my roommates are eating across the table from me, I do admit that have a slight amount of resentment towards my diet.")

4. Zone -C1: Cognitive Ignorance.

a. self-serving reasoning or rationalizing a bad practise (e.g., "All that white rice and greasy corned beef! Felt guilty! But I thought that when I'm going to eat something that's not good for me, I might as well enjoyit, or what's the use of eating it in the first place!")

b. inadequate planning leading to bad food behavior (e.g., "I'm rushing to the office. I'll grab something to eat from the wagon outside Gartley."

c. justifying a harmful practise on account of convenience (e.g., "Made myself a dinner of macaroni and cheese. I realize that this has a lot of preservatives because it comes out of a box, but it's just so convenient.").

5. Zone -C2: Cognitive Misconception.

a. engaging in erroneous reasoning or drawing a false conclusion (e.g., "Although I ate a lot, the servingswere small so I don't really feel that stuffed.")

b. believing that good taste and richness are necessarily related (e.g., "I really enjoy the salad bar here because it has potato salad and pasta salad! Fattening!")

6. Zone -C3: Cognitive Opposition.

a. being obsessed with food thoughts (e.g., "Was still wondering whether I should have eaten something more sub-stantial for breakfast. The more I thought of this, the more hungry I got!! I think too much about food!!!")

b. confirming the idea that one is bound by a compulsion (e.g., "Now I have a piece of coconut cake in front of me. Don't really know if I want to eat it or not,it's just sort of sitting here. But most likely I know I'll eat this later.")

c. confirming a cherished false idea or excuse (e.g., "I realize how bad it is for me to keep eating out, but I'm just so lazy to make something wonderful for me toeat.")

d. magnifying the importance or salience of hunger pangs (e.g., "My stomach is making strange noises. I'm trying to act nonchalant but I still feel rather weird.")

e. elaborating speculations or untestable hypotheses about one's obsessive behavior (e.g., "Why do I always feel guilty when I eat -- is it something from my childhood the way I was raised, because I'm an only child. Nah, I really wonder why!")

f. overdramatizing an ordinary food situation (e.g., "Snack - terrible, I feel like eating again. Decided to snack.")

g. pretending others are responsible for one's food behavior (e.g., "I'm eating some chips at the proddingof my roommate and her boyfriend!")

h. confirming one's intention of breaking the diet (e.g., "The ice cream was so delicious. So sweet. I didn't realize how long it has been since I had eaten any- thing really sweet. Oh oh, I feel cravings coming on in the future.")

Morisky (1986) reviews the literature on strategies for promoting compliance behaviors and discusses three broad approaches: family member involvement, provider-patient interaction, and written instructions and self-monitoring. Involving family members tends to improve adherence behavior by providing the patient with social support and reinforcement. A similar effect is achieved through group meetings with other patients. Improving provider-patient interaction reduces the common barriers toadequate adherence such as miscommunication, lack of understanding of recommendations, and confusion about dosages or procedures. Self-monitoring training improves the patient's record-keeping skills, allows an objective view of self and provides more effective techniques for self-management, self-regulation, and self-reinforcement.

These three approaches correspond to the three domainsof behavior as assumed in this paper. Providing social support (through family members or other groups) probably influences the patient's affective skills by making available more models of adaptive speech acts that mediate adherence behavior. Improving provider-patient interactionhas a beneficial effect on cognitive skills by increasing the patient's knowledge base and ameliorating decision making sequences. Self-monitoring training develops the patient's specific sensorimotor skills by improving the accuracy of self-observation and objective record-keeping of one's own behavior. The analysis of people's inner speech acts as they attempt to deal with health problems, can give health care professionals and researchers a closer and more objective look at the proximal causes of inadequate adherence to instructions and treatment plans. Patient education and guidance can become more effective by targeting indivi-dualized interventions that weaken habits of thinking that counteract health information, and to strengthen inner responses that are congruent with the philosophy and attitudes of the health care worker.

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