The wellness process for healthy living: a mental tool for facilitating progress through the stages of change.

Introduction

The U.S. media are filled with advice about how to make personal health-promoting behavior changes. How to exercise: choice of sports, schedules, techniques, and equipment. How to lose weight: diets, food choices, and advice on shopping, cooking, and how to eat. How to quit smoking, how to drink wisely, and so on. There is also a great deal of information available on the consequences of unhealthy lifestyles. Yet Americans continue to engage frequently in unhealthy behaviors and the rates are increasing. It is apparent that if most people are to achieve success, advice on techniques, schedules, diets, and the "how-to's" of behavior modification, and information on "what is good for you and what is not" are not sufficient.

Over many years I've observed people who have successfully changed their behaviors. In every case, a significant amount of mental work was necessary before the how-to's were undertaken. I've also observed that this mental work follows a particular pattern. Yet in most of the health-promoting advice that is offered, very little attention is paid to that essential mental process. The ideas in this article were born out of approximately 20 years of observation, anecdotal interviewing, and personal experience (1). Further research, using epidemiological science and statistical methods, is certainly indicated. Since such research is very complex, difficult to carry out, and expensive, for now this result of descriptive research will hopefully be of use.

After we look at some definitions of health and wellness, we'll consider the well-known and well-accepted paradigm of personal behavior change called the Stages of Change (2-5). Finally, we'll consider my concept of the Wellness Process for Healthy Living (WPHL). It is a practical, organized approach to the mental work that appears to be necessary for achieving success. In practice, its use can be very helpful in assisting patients in proceeding from the second of the Stages of Change, Contemplation, through the fifth, Maintenance (Table II).

Some Definitions of Health and Wellness

Health can be defined as a state of being that can be measured at any given point in time: anything from height and weight, through the results of a physical exam, to an examination of the levels of various components of the blood, to "how do you feel today," to an evaluation of how well one is functioning in one's work, play, family life, community, and nation. Health can also be defined in terms of health-promoting behaviors that a person may engage in. In personal health promotion, a "Basic Ten" can be recognized (Table I).

In contrast to health, a state of being, wellness is a process of being. It can be described as a journey that is lifelong if one makes it so, a central element that it shares with the Taoist religion. Wellness is a pathway along which one can proceed during one's lifetime, to achieve and maintain a healthy state of being in the broadest sense, as is maximally feasible for each person at each phase of his or her life. It is also a process that provides a guide to living a healthy life, as well as a life that is both happy and productive--well beyond the usual parameters of health.

My good friend known as the "Dean of Wellness," Donald Ardell, PhD, of Tampa, Florida, has been writing definitions of the term "wellness" for 30 years or so. He is always coming up with some new insight on the subject. A recent definition of his is:</p> <pre> Wellness is a philosophy. It's also a lifestyle. It could as well be characterized as a mindset. [It is] a positive approach, not just for health but for a high quality of life. Wellness is first and foremost a choice to assume responsibility for the quality of your life. Wellness is a choice that will increase the chances that you will be fit, committed to personal responsibility, and as healthy as your genetics, environment, and good fortune permit. With a wellness lifestyle, you won't be normal (i.e., overweight, under-fit, stressed, and easily fooled). You will, more likely than not, be emotionally intelligent, a critical thinker, open to and alert for discoveries that add meaning and purpose in life. With a wellness lifestyle, you'll also value fun, play, tolerance, and the common decencies (6). </pre> <p>Wellness is a particular path that one can choose to follow that will enable the maximization of positive outcomes for whatever part of life one chooses to apply it to. It is a road that has many milestones but no end point, other than the one that death brings. Thus broadly, in my view, the goal of wellness is to enable us to pursue:</p> <pre> A way of life and living in which one is always exploring, searching, finding new questions and discovering new answers, along the three primary dimensions of living: the physical, the mental, and the social; a way of life designed to enable each of us to achieve, in each of the dimensions, our maximum potential that is realistically and rationally feasible for us at any given time in our lives (1). </pre> <p>How does wellness, a process of being, relate to health, a state of being? How do we use the wellness concept to make healthy choices, to help us to function at higher levels, and make that "conscious commitment" to making changes in our personal health status? Wellness, as Dr. Ardell shows, can help us function more effectively and happily at a variety of levels. Being on the wellness pathway through life becomes part of health, of being healthy, at any given time. The WPHL is a tool for implementing the wellness concept, for making it real for ourselves and our patients. For engaging in personal health-promoting behavior change, for example, it organizes, focuses, and directs the mental work that experience and observation have shown is necessary if attempts to move through the Stages of Change are to be successful.

The Stages of Change

In talking with patients about making health-related personal behavior changes, many practitioners find the widely used model of the psychological change process underlying it to be very useful. Its original developers, Drs. Prochaska and DiClemente, named it the Transtheoretical Model (2, 3). It is often referred to as the Stages of Change model (4, 5). The six Stages of Change are shown in Table II.

In Pre-contemplation the person does not yet understand that he/she has a problem and/or that he/she could do something about it, or both. Thus, either contentedly or uncontendedly they accept their present state of being. In Contemplation a measure of self-awareness makes its appearance. The person recognizes that a behavior such as leading a sedentary lifestyle constitutes a health-related problem. It is the ability to begin seeing oneself as a person who will in the future behave differently than at present that distinguishes those who will be able to proceed to the next stage from those who will not.

In Preparation, the person undertakes serious planning to engage in behavior change within a set period of time, say one month. There is a conscious choice to engage in a new set of behaviors; the belief that positive change is possible has been established. The person is now into the formal or informal design process for a program with which they can achieve the desired behavior change. In Action the person moves to implement his or her chosen program. In Maintenance the person will either permanently incorporate the new behavior into his/her life, completely relapse into their old behavior, or on occasion lapse into the old pattern followed by a quick return to the positive behavior, perhaps more than once. In Termination the person has permanently incorporated the lifestyle change into their behavior. Lapse may occasionally occur but complete relapse does not. A term that in my view better describes what is meant by "Termination" is Permanent Maintenance.

The Wellness Process for Healthy Living

Proceeding from Pre-contemplation through Contemplation into Preparation (or Active Planning) and then onto Action is a complex process for most people. In one form or another there is a five-step mental process in play as one makes one's way along the Stage route. Introducing it to patients can be very helpful for them and can make your job easier as well, for it reduces some fairly complex concepts into a set of mental actions that are easy to understand.

There are five steps in the WPHL (1). They embody in practical terms the common denominators of how individuals actually go about successfully changing their behaviors. They describe the thought process that can be of significant assistance to the person navigating their way along the Stages of Change paradigm. It is in essence the application of the classic health-services program planning model (8) to personal health-promoting behavior change. It is an attempt to systematize the wellness approach to and for healthy living. The objective is to help the person produce for themselves a healthy, happy, productive state of being at any given time, in the context of what is reasonably and rationally possible and feasible for them at that time.

The five steps of the WPHL are: 1.) Assessment, 2.) Defining success, 3.) Goal setting, 4.) Establishing priorities, and 5.) Mobilizing motivation. They provide a single common mental pathway for preparing to successfully make health promoting behavior change. It is necessary, of course, to decide to try to make a change, before change can be made. That is, before the person can begin to implement the WPHL for themselves, they do have to somehow move from Pre-contemplation to Contemplation. However, given that decision, experience has shown that most people who have been successful have followed the pathway in one form or another.

1. Assessment has two components, assessment by oneself and assessment by others, usually health professionals. Self-assessment is asking oneself questions like: Where am I now in my life? How did I get here? What do I like about myself? What do I not like? What would I like to change, if anything, and why? What is going on in my life that would facilitate behavior change? Inhibit it? Health-professional assessment can range from the simple, as in a health-risk appraisal by questionnaire, to the complex, such as laboratory testing.

2. Defining success is about establishing how one knows when they "get there." To work for any given individual, that desired outcome must be something that is realistically achievable. For example, running a four-minute mile (or even a five- or six-minute one) is beyond the realm of possibility for most people, no matter how hard they train. To set that as a goal, then, would be entirely unrealistic and in fact inhibiting, not facilitating, of positive behavior change. Success must also be set in the context of what else is going on in one's life at the time. Success should be defined such that the person is not setting themselves up for failure. Defining success productively also includes giving oneself permission to fail, assuming that one really did try. There is always a "next time."

3. Goal setting is the central element of the WPHL. All else is commentary. Goal setting asks questions like: Where do I want to be? Why do I want to get there? For whom would I be making the change, others, or myself? What do I expect to get out of the change, should I achieve it? What do I think I can reasonably expect to accomplish? What are the "give-ups," and do I want to commit to them? Arriving at satisfactory answers to these questions is absolutely key. Doing so provides the focus and the concentration one must have in order to have the best chance of success in the chosen endeavor.

4. Establishing priorities among possible health-promoting behaviors, and between these behaviors and the rest of one's life, is the next step. Given more than one goal, what is the ranking of each? Which is the most important to achieve, which the least? What about priorities between the new goals and other important things in other parts of the patient's life, like relationships with family and friends? In the case of athletics, how might other leisure activities weigh in, or employment? If the person needs to juggle these various aspects, it will be very helpful to do some thinking about that and yes, set priorities.

5. Mobilizing motivation. Motivation is a process, not an endpoint. It links a thought, feeling, or emotion to an action. Because it is a process, no person can give it to another person. Nor can it be found packaged in a pill or a machine. When people are unmotivated, it does not mean that they lack the "right stuff." It simply means that the motivational process for the desired change hasn't been mobilized. Only through the process of mobilizing motivation do people make lasting change.

Mobilizing motivation is a complex process with ten steps of its own. The first four are the WPHL. The full set is presented in Table III. Briefly, "Taking control of your life: running your life instead of letting it run you," is self-explanatory but a difficult challenge for many of us to meet. "Recognizing that gradual change leads to permanent changes" is another way of saying that proceeding slowly and easily along the wellness pathway most often wins the race to health. "Exploring your limits, while recognizing your limitations" mean injecting realism into your program: playing to your strengths while at the same time dealing with your weaknesses realistically. "Dealing with the fear of failure" again means just what it says. The necessity of dealing with the "fear of success" may come as a surprise but this is a documented problem for certain people, especially in the realm of weight loss. Finally, giving oneself permission to fail can be, for many, marvelously liberating and actually help them significantly in navigating the pathway to success.

This is a model for engaging in the mental work that appears to be necessary for most people undertaking health-promoting behavior change, in order to increase the chances of achieving success. The model has been developed from observation, anecdotal interviews, and experience. It has not been tested experimentally. However, it is a logical approach to the problem and also appears to have no negative side effects. It is proposed as an engine that can be of significant assistance to those in need of organizing their thinking and actions as they move through the Stages of Change to improved health. It is the application of the classical program-planning model to getting on and staying on the wellness pathway--for life.

REFERENCES

(1.) Jonas S. Talking About Health and Wellness with Patients: Integrating Health Promotion and Disease Prevention into Your Practice. New York: Springer Publishing Co., 2000.

(2.) Prochaska JO, Clemente BH. Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy Theory, Research, and Practice 1982; 19:276-288.

(3.) Prochaska, JO, Velicer WF. The transtheoretical model of behavior change. American J of Hlth Prom 1997; 12:38-48.

(4.) Ardell DB. What is wellness? Ardell Wellness Report, 69th Edition, Winter 2005, p. 1.

(5.) Jonas S. Getting ready to exercise. In: ACSM Fitness Book. Thompson W (principal author). Champaign, IL: Human Kinetics, 2003, Chapter 3.

(6.) Hilleboe, HE, et al. Approaches to national health planning. Public Health Papers, # 46. Geneva, Switzerland: World Health Organization, 1972.

RELATED ARTICLE: Table I

The "Basic Ten" of Personal Health Promotion

1. Exercising regularly

2. Managing one's weight

3. Eating a healthy diet

4. Not using tobacco products, or, on a non-prescription basis, the prescription psychoactive drugs 

5. Safe use of the other non-prescription mood-altering drugs, including ethyl alcohol 

6. Managing one's internal and external stressors effectively.

7. Using safe sexual practices

8. Protecting one's personal safety in the home, in the automobile, and at the workplace

9. Maintaining one's immune status at an effective level

10. Undergoing periodic health-risk/wellness-status appraisal

RELATED ARTICLE: Table II

The Stages of Change

1. Pre-contemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

6. Termination

RELATED ARTICLE: Table III

Mobilizing Motivation

1. Assessment

2. Defining success

3. Setting goals

4. Establishing priorities

5. Taking control of your life: running your life instead of letting it run you

6. Recognizing that gradual change leads to permanent changes

7. Exploring your limits, while recognizing your limitations

8. Dealing with the fear of failure

9. Dealing with the fear of success

10. Giving yourself permission to fail

by Steven Jonas, MD, MPH, MS, FNYAS