A cognitive-behavioral approach for promoting exercise behavior: the disconnected values model.

Anshel, Mark H.

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Attempts at encouraging exercise behavior have been extensive in recent years. However, the use of effective interventions in promoting exercise behavior for use by sport psychology consultants has been relatively ignored in the extant applied sport and exercise psychology literature. In addition, interventions have been only moderately successful in promoting and maintaining exercise behavior (discussed later). The purpose of this article is to propose a cognitive-behavioral intervention, The Disconnected Values Model (DVM), that encourages the development of an exercise habit that may be used by sport psychology consultants in both sport (e.g., sport injury rehabilitation; physical training; game preparation) and exercise settings such as joining and adhering to exercise programs.

Brief Overview of the Problem

The consequences of an overweight and inactive society include widespread serious deterioration of health and quality of life. For example, past studies indicate that 63% of U.S. men and women are overweight, and about 33-37% are classified as obese. Approximately 60-70% of adults who begin an exercise program will quit within 6-9 months, despite the common belief (82%) that exercise is beneficial to good health (Marcus, King, Bock, Borrelli, & Clark, 1998). A sedentary lifestyle and lack of sufficient physical activity results in deterioration in health also has long-term consequences. In her keynote address at the 2004 Society of Behavioral Medicine Conference in Baltimore, Dr. Risa J. Lavizzo-Mourey, President and Chief Executive Officer of the Robert Wood Johnson Foundation, indicated for the first time in U.S. history, children today will live a shorter, lower quality of life than their parents. She reported that since 1980, overweight children ages 6 to 11, and adolescents has doubled and tripled, respectively. The combination of obesity and a sedentary lifestyle, leading to the widespread onset of types 1 and 2 diabetes and hypertension, are the likely culprits (Nestle & Jacobson, 2000). As Nestle and Jacobson contend, it is one thing to know the causes of obesity (i.e., poor eating habits, lack of physical activity), but quite another to motivate individuals to change these entrenched, unhealthy habits.

The problem of nonadherence in maintaining healthy habits is not new in the health psychology literature. For example, Sackett (1976) found that scheduled appointments for treatment are missed 20 to 50% of the time, and that about 50% of patients are remiss in taking their medications as prescribed by their physician. After six months, other health-related behaviors, such as smoking cessation, dietary restrictions and weight control strategies have an adherence rate of less than 50%.

Justification of a New Intervention Model

The attempt to justify the current exercise intervention model necessarily includes examining limitations of previous research in this area--both early and more recent studies. While existing theories and models have provided a coherent framework with which to provide explanations, descriptions and predictions of exercise behavior, their application for increasing exercise behavior have been met with only equivocal success (see Lox, Martin & Petruzzello, 2010). These limitations lend credence to the need for providing new approaches in promoting exercise behavior.

Limitations of Intervention Research

Critiques of previous exercise promotion interventions are not new, and have been shown to be less than effective and fraught with conceptual and methodological limitations. For instance, in two early reviews, Baranowski, Anderson, and Carmack (1998) concluded that the amount of outcome variance explained in studies testing the efficacy of exercise interventions has rarely been above 30%. Along these lines, in a meta-analysis of 127 studies and 14 dissertations to determine the effectiveness of interventions to enhance exercise adherence in a healthy population, Dishman and Buckworth (1997) reported that only about 20% of the studies included a follow-up to the intervention. Typically, they found increased physical activity or fitness associated with the interventions diminished with time after the end of the intervention.

In their review of limitations of the extant exercise intervention literature, Buckworth and Dishman (2002) lament the absence of a theoretical framework or model to examine the efficacy of an intervention intended to promote exercise participation and adherence. In addition, they found that "interventions are typically not tested to see whether they change the variables they are designed to change, or whether the target variables are actually responsible for changes in the outcome variable" (p. 252). In addition, Dishman (1991) and, more recently, Prochaska, Spring, and Nigg (2008), assert that the majority of early exercise intervention research has relied on one-dimensional techniques and a small sample size of highly selected participants (e.g., clinical populations, individuals already engaged in a specific program). Most studies, for example, have tested the effectiveness of specific cognitive (e.g., positive self-talk, imagery, cognitive appraisal) and behavioral strategies (e.g., goal setting, listening to music, social support), rather than a coherent intervention program.

Another reason that may explain the paucity of exercise intervention effectiveness is that strategies and programs have often been imposed on the individual, followed by a lack of social support during the intervention (Lox et al., 2010). Researchers have not controlled for the exerciser's motives, rationale and personal commitment to begin and maintain an exercise program, although more current interventions such as motivational interviewing (Rollnick, Miller, & Butler, 2008) have shown promise in fostering exercise adherence.

An additional limitation of existing exercise intervention research is the assumption that the person desires a change in behavior (Marcus & Stanton, 1993). Goals for behavior change have been traditionally imposed on the individual by the researcher or clinician rather than self-determined by the exerciser. Along these lines, participants' lack personal involvement in voluntarily choosing and committing to the type and schedule of exercise involvement--a strategy referred to as perceived choice (Markland, 1999) or what Ajzen (1985) calls perceived behavioral control. In typical exercise adherence studies, exercisers are required to attend group sessions at specific times, often performing predetermined exercise routines. Absent from these studies has been the option to exercise alternatives such as participants choosing to exercise alone, self-selection of the exercise venue, and selecting exercise times and routines, each of which contradicts the perceived choice option and impairing, not facilitating, exercise adherence during and after the intervention period.

In addition, previous intervention research has focused on outcomes (e.g., changes in attitude toward exercise and level of exercise adherence) rather than the mechanisms and processes by which changes occur in exercise-related attitudes and behavior. Not addressed in these studies are the processes (i.e., mechanisms) by which improvements in exercise behavior occur. For instance, in one relatively recent study, Anshel and Kang (2007) found that the combination of educational materials, personal coaching and social support significantly improved exercise adherence.

Taken together, it is apparent that the effectiveness of exercise interventions on improving fitness and creating healthier lifestyle changes is equivocal. Lox et al. (2010) concluded from their review of exercise intervention studies that "further research is needed to determine the long-term effectiveness of these types of interventions and their utility in real-world settings" (p. 170). Glasgow, Klesges, Dzewaltowski, Bull, and Estabrooks (2004) have concluded from their related literature review, "it is well documented that the results of most behavioral and health promotion studies have not been translated into practice" (p. 3).

Attempts to Overcome Current Limitations: Toward Justifying the Current Model

New attempts are needed to help overcome the limitations of previous exercise interventions. For example, one such approach consists of making exercise an integral part of one's daily routine (Loehr & Schwartz, 2003; Oldridge, 2001). Oldridge suggests "keeping the regimen straightforward, providing clear instructions and periodic checks, promoting good communication with the patient, and reinforcing their accomplishments" (p. 322). He contends that adherence strategies are seldom effective on their own.

Another approach to changing exercise behavior is to help the client to examine the "costs" and "consequences" of maintaining a sedentary lifestyle and other unhealthy behaviors. This area has been explored in the sport psychology literature.

The Drugs in Sport Deterrence Model (DSDM; Strelan & Boeckmann, 2003) is an example. This model posits that an athlete's decision to ingest banned drugs is facilitated by helping the competitor acknowledge the benefits and costs of this unhealthy behavior. There are benefits to every negative habit, such as drug-taking, or the athlete would not sustain the drug use. In addition, unless the benefits of the negative habit are recognized, determining their costs is given less credibility. The "benefits" of not exercising include time to do other things, avoiding physical discomfort, costs of exercise apparel, exercise equipment, a fitness club membership, and feelings of anxiety, embarrassment, or self-consciousness when exercising in the presence of others. Just a few of the costs of not exercising include poorer health, weight gain, heightened stress, negative mood states, poor physique and attractiveness, and poorer quality of life. Ostensibly, the athlete's perceptions of the benefits and costs of drug taking as inherently undesirable, illegal or even immoral will inhibit future drug use. The DSDM, however, is a conceptual model that describes the factors that underlie drug-taking behavior: it is not an intervention model. Still, factors borrowed from the DSDM can be used to describe exercise behavior in which a person determines the benefits and costs of exercising and maintaining an active lifestyle as opposed to not exercising and remaining sedentary.

Perhaps the most commonly neglected research area related to behavior change is the contrast between a person's values and beliefs about the importance of good health in contrast to their lack of exercise or not living an active lifestyle (Dunn, Andersen, & Jakicic, 1998). The inconsistency between values such as health, family, faith, and performance excellence, and a sedentary lifestyle forms an essential source of incentive to change exercise habits. As Ockene (2001) correctly concludes, "... change is a process, not a one-time event, and we can't expect people to make changes at a level for which they're not ready. Our interventions need to be directed to where the individual is" (p. 45). Values, then, form a relevant component of the present model.

The Importance of Values For Exercise Interventions

Values are core beliefs that guide behavior, provide impetus for motivating behavior and provide standards against which we assess behavior (Rokeach, 1973). Values are highly relevant to establishing a person's individuality and help our understanding of behavior. For example, as Rokeach contends, a person who values health will tend to develop daily rituals and long-term habits that enhance health and general well being. Hogan and Mookherjee (1981) describe values as "one of the most distinguishing characteristics motivating human beings; the likely effects of values on human behavior, beliefs, and attitudes are indisputable" (p. 29).

Segar, Eccles, and Richardson (2011) examined the relationship between superordinate-level goals and the core values of 226 middle-aged women exercisers, ranging in age from 40-60 years. They found a significant discrepancy between their goals and values. Specifically, "despite equally valuing Healthy-Aging, Quality-of-Life, and Current Health goals, participants with Quality of Life goals reported participating in more exercise than those with Current-Health and Healthy-Aging goals" (p. 94). They concluded that exercise goals related to health and healthy aging were associated with less exercise than those related to enhancing daily quality of life, despite being equally valued. Thus, an exercise intervention is needed that promotes a consistency between our values and our behavior patterns, in this case, health and exercise, respectively.

Crace and Hardy (1997) developed an eight-step values-based intervention to enhance sports team building that has implications for the current (DVM) model. Briefly, their model consists of: (a) helping athletes understand the importance of individual differences for enhanced performance (i.e., differences in team member personality are viewed as normal); (b) assessing individual differences on the athletes' own goals and values; (c) understanding the interactions between values and life roles (i.e., values are identified within each life role), (d) identifying and understanding the primary team values (i.e., values shared by team members), (e) identifying ways in which values can enhance or inhibit team cohesion (e.g., the athlete's value of responsibility can improve commitment to team success, but also can result in being overwhelmed by the lack of responsibility from selected teammates, resulting in mental fatigue and guilt), (f) developing an action plan to improve compatibility of the athletes' and the team's values with the ultimate purpose of improving attainment of team values, (g) performing similar athlete and team strategies with the team's coaches, and finally, (h) scheduling follow-up meetings with the athletes and coaches to discuss the effectiveness of the team building program.

The strength of this model is the recognition that a person's values guide their behavior, and that sharing values with others has a strong affect on the commitment to sacrifice personal, self-serving needs for the benefit of others, and in this case, the team. One important implication of their model in an exercise setting is that a person's values may or may not be compatible with the values of family members or an employer. Crace and Hardy (1997) recognize the need, however, to enhance the values among these parties to help the person reach optimal performance. However, there are several components of this model that limit its effectiveness in promoting exercise behavior, not the least of which is to detect discord between the individual's values and the negative habit of lack of exercise. This is particularly relevant when addressing several values such as health, energy, happiness, family and faith, which are fundamental tenets of a high quality of life.

Values are more central determinants of behavior than are interests and attitudes, the latter of which are more situational and derived from a core set of values (Super, 1995). Thus, a plethora of interests and attitudes are derived from a relatively reduced number of values. In addition, interests, attitudes and needs are transitory and once satiated, may not influence behavior. Values, on the other hand, are almost always firmly entrenched and stable, and therefore transcend situations and guide behavior over a long period of time.

While there is a paucity of research on the influence of values on exercise behavior, it is likely that values predict behavior (Brown & Crace, 1996; Hogan & Mookherjee, 1981). For example, it can be surmised that individuals who place health as an important value are more likely to maintain healthy habits than individuals who do not consider health among their most important values. Too often, however, this is not true. Instead, persons who consider health as a relevant value often maintain an unhealthy lifestyle (e.g., poor nutrition, lack of exercise, poor sleep, high stress). Take, for instance, the smoker who acknowledges they "should" quit, or the obese individual who admits he or she needs to lose weight. For these individuals there is an inconsistency, or disconnect, between their values and their actions. One possible explanation of this behavior pattern may be the issue of immediate versus distant payoffs.

Conceptual Foundations of the DVM

The DVM is anchored by concepts related to other cognitive-behavioral frameworks that have successfully demonstrated health behavior change. These include cognitive dissonance theory (Festinger, 1957), motivational interviewing (Miller & Rollnick, 2002), and acceptance and commitment therapy (Ossman, Wilson, Storaasli, and McNeill, 2006). A brief overview and relevance to the present model of each follows.

Cognitive Dissonance Theory

Festinger's (1957) cognitive dissonance theory posits that individuals naturally seek consistency among their cognitions (i.e., beliefs, personal views, emotions, values). An inconsistency between the person's attitudes (i.e., cognitions) and behaviors results in a state of dissonance, and is followed by the attempt to change attitude in order to accommodate these actions. The most important factors that influence this drive for attitude change are the number of dissonant beliefs and the importance a person attaches to each belief. For example, beliefs about the importance of exercise is ostensibly dissonant from leading a sedentary lifestyle, not engaging in regular exercise, and being overweight or obese. Dissonance may be minimized or eliminated by one of three strategies: (a) reducing the importance of the conflicting beliefs, (b) acquiring new beliefs that change the balance, or (c) removing the conflicting attitude or behavior.

While cognitive dissonance theory provides a valid conceptual foundation for the current model, the DVM goes beyond the recognition of dissonance between values, short-term costs, and long-term consequences of their unhealthy habit(s) by including a self-regulation action plan that carries out cognitive-behavior strategies to replace the negative habit with more desirable, healthier routines. Changes in health behavior are more likely if new habits are scheduled and ritualized (Gollwitzer, 1999; Loehr & Schwartz, 2003). The absence of self-regulation action plans, according to Lox et al. (2010), has been a weakness in previous exercise adherence programs and studies.

Motivational Interviewing (MI)

The focus of MI is to increase a person's intrinsic motivation (i.e., their sense of satisfaction, perceived competence, and achievement) for changing their health behavior (Miller & Rollnick, 2002). This is accomplished by collaborating with the client to initiate and adhere to behavior change, to explore reasons in favor of and against changes in unhealthy behaviors, and to help the client take responsibility for initiating and maintaining behavior change. The client determines how and when change will occur.

Rather than relying on teaching new mental skills, reshaping thought and emotions, or reexamining the past MI focuses on the person's concerns and perspectives. Specifically, MI addresses specific changes in behavior that are most desirable and realistic, while at the same time addressing possible barriers to change. The primary goal of MI is to increase the person's motivation to initiate short-term and long-term behavior change by resolving issues that create ambivalence and resistance. Application of MI techniques has resulted in changes in dietary habits (Resnicow, Jackson, Wang, Dudley, & Baranowski, 2001) and in promoting healthy habits (Resnicow, Dilorio, Soet, Borrelli, Hecht, & Ernst, 2002). Relatively few studies using MI intervention techniques, however, have examined changes in exercise habits.

Acceptance and Commitment Therapy (ACT)

ACT is a form of psychotherapy that addresses a person's normal tendency to promote and distort unpleasant emotions, which lead to engaging in inappropriate behaviors for the intention of avoiding or reducing those unpleasant emotions (Ossman, Wilson, Storaasli, & McNeill, 2006). The goal of ACT is not to change or control undesirable personal and private thoughts or emotions, but rather to develop effective behaviors of "proper" daily living. Clients assess their previous attempts at resolving the problem, and to determine the success or failure of these attempts, and see thoughts as only thoughts, not as truths with no attempt to get rid of "bad" thoughts. ACT helps clients conclude that accepting their unpleasant emotions leads to a reduction in their intensity or frequency, with acceptance as a strategy designed to reduce or eliminate the emotions.

Both ACT and the current model (DVM) help clients acknowledge "the truth" about their negative (undesirable) habits and their costs and consequences. The client's goal is not the absence of the negative habit, but effective movement toward meeting specific goals or desirable outcomes. In addition, ACT and the DVM help clients to clarify their values, and to commit to behaviors that are consistent with these values. Finally, ACT and the DVM both require an action plan to experience the benefits of the more desirable habit (e.g., engaging in regular exercise), but without addressing and trying to extinguish all undesirable thoughts or actions. Instead of complete avoidance of the negative habit, the ACT action plan, similar to the DVM, helps keep the client focus on incorporating new routines.

The Disconnected Values Model (DVM)

As indicated earlier, the process of behavior change is a challenging because habits and routines (e.g., lack of regular exercise) are firmly entrenched in the person's lifestyle. These habits may or may not be consistent with their values. Attempting to increase exercise behavior is particularly difficult because it is accompanied by an array of long-held feelings and attitudes that may reflect previous negative experiences (e.g., the physical education teacher who used exercise as a form of discipline, burnout from too much physical training as a former athlete, injury from previous exercise attempts). Further, vigorous exercise requires effort and some degree of physical discomfort in order to obtain the well-known benefits. Expenses can be costly for purchasing exercise clothing, particularly proper footwear, and memberships in fitness clubs or other facilities that promote various forms of physical activity (e.g., recreation centers, Boys or Girls Clubs) create further challenges to increasing an active lifestyle. An effective intervention is needed that overcomes these barriers and improves the frequency and intensity of exercise participation and long-term adherence that may be used by personal trainers, sport or exercise psychology consultants, and mental health professionals.

The DVM is predicated on two postulates that define self-motivated behavior and have strong implications toward promoting exercise behavior, which is often missing from existing exercise intervention research.

Postulate one. Self-motivated behavior reflects a person's deepest values and beliefs about his or her passion. Developing a sense of purpose creates the desire to become fully engaged in activities that really matter in meeting personal goals and future aspirations.

Postulate two. The primary motivators of normal human behavior are: (a) to identify a deeply held set of values, (b) to live life consistent with these values, and (c) to consistently hold ourselves accountable to them. Ostensibly, an individual whose values include, for example, health, family, faith and performance excellence should be self-motivated to exercise because it is consistent with these values. A deeper sense of purpose consists of shifting one's attention from fulfilling one's own needs and desires to serving and meeting the needs of others. Exercisers who value family, for instance, realize that they will have more energy and lead a higher quality of life in meeting the needs of family members. Perhaps, then, the self-motivated drive to develop an exercise habit rests, at least in part, on recognizing the inconsistency between one's negative habits (i.e., lack of regular exercise) and their values and then to institute a new, positive habit of exercise that is strongly connected to one's values. The DVM is illustrated in Figure 1.

The DVM is based on the interaction between a "personal coach" or sport/exercise psychology consultant and the client. The interaction reflects receiving information (e.g., facing the truth about who you are and how you live), self-reflection (e.g., acknowledging the costs and long-term consequences of living a sedentary lifestyle), determining personal goals (e.g., knowing what I want or need), and identifying strategies needed to reach those goals (e.g., generating an action plan that replaces negative habits with positive routines).

The DVM includes a component virtually heretofore ignored by researchers--providing intervention content that includes a sense of purpose, that is "the energy derived from connecting to deeply held values and a purpose beyond one's self-interest" (Loehr & Schwartz, 2003, p. 131). The authors contend that self-destructive behaviors, also called negative habits (e.g., poor nutrition, lack of exercise, poor sleep) reflect a "lack of ... firm beliefs and compelling values (that are) easily buffeted by the prevailing winds. If we lack a strong sense of purpose (i.e., what really matters to us; our passion) we cannot hold our ground when we are challenged by life's inevitable storms" (p. 133). Thus, previous interventions have consisted of selected cognitive (e.g., mental imagery, positive self-talk) and behavioral strategies (e.g., goal setting, social support) while ignoring the antecedent thoughts, emotions, and values that each participant brings to the exercise venue. As discussed later, taking into account a person's values and beliefs forms a foundation on which future intervention research is needed. Finally, rather than using pre-determined cognitive and behavioral strategies to enact behavior change, the model's last stage consists of an "action plan" that includes one or more strategies.

[FIGURE 1 OMITTED]

Negative Habits

The DVM begins by acknowledging that each of us has habits that can be categorized as unhealthy, negative or undesirable. These are operationally defined as thoughts, emotions or tasks we experience regularly that are acknowledged by the person as not healthy or in the person's best interests, yet remain under our control. Despite our ability to prevent or stop these negative habits, we maintain them. Not exercising and poor nutrition, for example, form negative habits that need changing.

The primary reason individuals engage in negative habits is because the perceived benefits of maintaining the habit outweigh its costs and long-term consequences (Hall & Fong, 2007). Hall and Fong's temporal self-regulation theory posits that human behavior is a function of the universal tendency toward greater responsivity to immediate contingencies (e.g., eating less healthy "fast food" due to fulfilling short-term needs) and the tendency toward behavior in accordance with the cost-benefit tradeoff over time (e.g., our actions reflect competing motives between short-term benefits versus long-term costs). The benefits of exercise are perceived as irrelevant in the short-term and experienced in the distant future as compared to the perceived short-term benefits of not exercising and the relative unimportance of long-term costs. Hall and Fong contend that unhealthy, or undesirable (negative) habits do not exist without benefits. Thus, a negative habit will begin and persist under two conditions: (a) the habit's benefits outweigh its costs, and (b) benefits are experienced in the short-term, while costs and consequences are likely to be experienced in the distant future or long-term. Cultures who prioritize immediate gratification as opposed to delayed gratification nurture the decision to engage in meeting short-term needs.

Performance Barriers

Performance barriers are operationally defined as a persistent thought, emotion or action that compromises and creates obstacles to high quality performance (Dunn et al., 1998). Whether these barriers can be actual (e.g., injury, anger) or perceived (e.g., time restraints, discomfort, anxiety), they are always controllable and thus, changeable. For instance, the emotional barrier of anxiety (i.e., worry) can be controlled by addressing the source(s) of concern and developing adaptation strategies that overcome these maladaptive thoughts. A person who is uncomfortable and self-conscious about exercising among younger, fitter, thinner individuals at a fitness facility can focus on their exercise regimen, while ignoring others in the room. A person who has time restraints can develop time management strategies and social support by significant others to allow for exercise time.

Performance barriers in the DVM have a root cause--negative habits. These behavioral tendencies, or habits, are labeled "negative" because: (a) it is generally acknowledged that they have a deleterious effect on some aspect of the person's quality of life, and (b) that continued expression of the negative habits is directly linked to problems and limitations in work performance. For example, lack of exercise, an unhealthy "physical" habit, may lead to low energy and premature mental fatigue. Persistent anxiety, an unhealthy "emotional" habit, may lead to poor (slow, inaccurate) decision-making. The negative physical habit of poor work/life balance results in poor relationships with family. One function of the model is to help clients detect their negative habits and how these habits lead to undesirable performance--physically, mentally and emotionally--in various aspects of their life, not only health. The primary goal at this stage is that after negative habits have been associated with limitations to physical performance the process begins in self-examining the reasons of maintaining negative habits such as lack of exercise.

Perceived Benefits of "Negative" (Unhealthy) Habits

The model posits that there are perceived benefits to each of our unhealthy habits, such as lack of exercise or other forms of physical activity, or else the unhealthy habit would not continue. It is important to recognize the term "perceived" in this context because a person who repeatedly and habitually engages in unhealthy, self-destructive behavior patterns is able to justify their actions, either rationally (e.g., to quickly satisfy hunger; too busy, not enough time to exercise) or irrationally (e.g., "I am obese, but my doctor tells me I am healthy and just fine"). Perception, then, is in the eye of the beholder and reflects the individual's sense of reality; perception does not necessarily represent the reality of medical test data or the opinion of the person's medical practitioner. As discussed earlier, the "benefits" of not exercising, for example, include more time to do other things, not experiencing the discomfort of physical exertion and expenses related to purchasing fitness club memberships and exercise clothing.

Costs and Long-term Consequences of Negative (Unhealthy) Habits

The concept of a cost-benefit tradeoff is a balance sheet, often referred to in corporate settings as the cost-benefit ratio. In addition to the benefits of not exercising or engaging in other forms of regular physical activity, there are short-term costs and long-term consequences. A few costs of a sedentary lifestyle include poor cardiovascular and strength fitness, weight gain, higher stress and anxiety, reduced physical energy, lower mental (cognitive) functioning, and less satisfactory sleep. The long-term "consequences" of not exercising include poorer physical and mental health, depression, greater likelihood of diseases such as diabetes, certain types of cancer and cardiovascular disease, reduced quality of life, and shorter lifespan (Long & van Stavel, 1995; Stathopoulou, Powers, Berry, Jasper, Smits, & Otto, 2006).

The client is asked a very important question that has high self-motivation value; whether the client finds these costs acceptable. If the client concludes that the costs of a particular negative, unhealthy habit are acceptable, then the negative habit (e.g., not exercising and maintaining a sedentary lifestyle) will likely continue. If, however, the costs are greater than the benefits of maintaining the unhealthy habit, and the person concludes that these costs are unacceptable then a change in behavior is far more likely. The process of behavior change is not complete, however, according to the DVM. Missing is the ignition point that links the costs of inactivity to the person's deepest values and beliefs. Table 1 provides examples of perceived costs and benefits of selected negative habits.

Determining One's Deepest Values and Beliefs

The values of most individuals would likely include, in no particular order, health, faith, character, family, happiness, honesty, knowledge, commitment, integrity, concern for others, and performance excellence. Our values are often influenced by our culture, gender, geographic location, religion, and life experiences. Behavior change is more likely to be permanent when the client concludes that life satisfaction is linked to behaving in a way that is consistent with one's deepest values.

Establishing a Disconnect

To help clients detect an inconsistency between their values and their negative (self-destructive) habits, sport psychology consultants might ask their clients a few or all of the following questions: "To what extent are your values consistent with your actions? If you value your health, do you have habits that are not good for you, and therefore, inconsistent with your values? What about your family? Do you value your spouse, children, or parents? If you lead a sedentary lifestyle and are not involved in a program of exercise, yet one of your deepest values is to maintain good health, to what extent is your value inconsistent with your behavior? Can you detect a 'disconnect' between your beliefs about good health and your unhealthy behavioral patterns?"

Acceptability of the Disconnect

If clients acknowledge that the negative habit of not engaging in exercise is inconsistent with their deepest values and beliefs about what is really important to them, the follow-up question must be to ascertain if this is acceptable. For example, the consultant asks the client, "Given the disconnect between your negative habit of not engaging in regular exercise and the costs and long-term consequences of this disconnect, is this acceptable to you? Is this ok?" If the client acknowledges the costs and long-term consequences of the disconnect and concludes the disconnect is acceptable, the client's negative habits will not change. If the disconnect is unacceptable, however, then the client may be ready to engage in an action plan that replaces the negative habit with one or more positive, healthier routines.

Developing a Self-Regulation Action Plan

The person's decision to initiate an exercise program, ostensibly because disconnects between their negative habits, including lack of exercise, and their deepest values and beliefs is followed by developing a detailed self-regulation action plan. Action planning "entails forming concrete plans that specify when, where, and how a person will translate exercise intentions into action" (Lox et al., 2010; p. 153). The plan consists of determining the details of developing a habit of regular exercise during the week. Specifics include type of exercise, exercise location(s), days of the week and times of day exercise will occur, exercise testing to establish a baseline of fitness and health indicators, and availability of social support (e.g., exercising with others, working with a personal trainer), all of which is encouraged. Specificity of timing and precision of behavior dramatically increases the probability of successfully carrying out a self-controlled action plan (Loehr & Schwartz, 2003). The self-regulation action plan serves the primary purpose of creating a more immediate payoff and providing clients with a sense of achievement and other immediate payoffs that have higher motivation value than using more distant goals (Segar, Eccles, & Richardson, 2011).

Specifically, the action plan consists primarily of three factors that will markedly enhance the individual's permanent commitment to including the new, healthier habit (e.g., regular exercise): (a) a specific time within a 24-hour period for exercise engagement; (b) a set of routines that support the exercise habit (e.g., selected thoughts and behaviors prior to, during and following the exercise session, exercising with a friend and promoting other forms of social support, minimizing distractions that will interfere with exercise plans), and (c) linking these specific times and routines to the individual's deepest values and beliefs about what is really important in order to remove the existing disconnect.

Existing Empirical Support for the D VM

The DVM has received empirical support in the extant research literature. Anshel, Brinthaupt and Kang (2010) and Anshel and Kang (2007) applied the model over a 10-week period with university faculty and staff. Both studies concerned improving exercise habits, as measured by a series of fitness tests and changes in dietary habits based on the results of a lipids profile blood test. The collective results indicated significantly improved cardiovascular and strength fitness scores, as well as reduced "bad" cholesterol and triglycerides. In addition, exercise adherence rates were well beyond most related studies, at approximately 70-76% for both aerobic and strength training. The Anshel et al. (2010) study included a measure of mental well-being. The researchers found significant gains in selected dimensions of mental health among participants.

Two case studies were conducted with a sedentary obese middle-aged male (Anshel, 2008) and a middle-aged male with strong religious convictions and whose core values included faith (Anshel, 2010). In both case studies, the participants were asked to indicate three unhealthy habits from a list of 20 undesirable habits, including lack of exercise and poor nutrition. Then they listed the reasons for engaging in each negative habit, which formed the habit's benefits, each followed by the costs and long-term consequences. It was important that the participant acknowledged that each of these behavior patterns was in fact, unhealthy and undesirable, otherwise he would find no reason to acknowledge their costs and seek to replace them with healthy routines. If lack of exercise was perceived as desirable, for instance, there would be no perceived need to replace this unhealthy habit with a more active lifestyle. Then the participants were asked to indicate up to five core values, that is, their most important beliefs about what really matters to them in living a high quality of life. The second client (Anshel, 2010) who was a person of deep religious convictions placed faith at the top of his list of values.

The next step was particularly important; clients were asked to identify an inconsistency, or disconnect between their negative habits and values. The person of faith indicated that his obesity and unhealthy lifestyle was inconsistent with his value of faith, given the plethora of scripture that pontificates the virtues of maintaining a healthy lifestyle. Other disconnects between values and the undesirable habit of not exercising, poor eating habits, and the resultant obesity included family, health, and character. Both clients detected at least one disconnect between their values and behavior patterns. The clients were then asked if given the costs and consequences of each unhealthy habit they found the disconnect acceptable and something they could live with the rest of their life. Participants in both case studies acknowledged the disconnect between at least one value and a behavior pattern deemed undesirable or unhealthy, and indicated a strong willingness to change. When asked how committed they were to follow an action plan to remove the disconnect, on a scale of 1 (not at all committed) to 10 (extremely committed), they both indicated "10." An action plan was then constructed by the performance coach who worked with a fitness coach and a registered dietician to follow through on changing exercise and dietary habits.

Results of both case studies demonstrated marked changes in fitness scores for upper and lower body strength, sub-max VO2 exercise testing on a treadmill, and percent body fat. Changes in nutrition were obtained by self-report on following the dietician's recommendations. Post-study debriefing indicated the clients' failure to acknowledge their self-destructive lifestyle, misalignment with their deepest values, the lack of energy that results from their current (unhealthy) lifestyle, and the importance of considering the needs of others "who matter' (i.e., family members, the Lord, work colleagues) in making significant changes in replacing their unhealthy habits. While the results of these case studies do not provide conclusive evidence of the model's efficacy, the participants did provide narratives, reported in the study, that reflected their strong commitment to health behavior change based on acknowledging their self-described "failure" to maintain healthier habits that are consistent with their values.

Efficacy of the DVM was examined in another (group) study by Anshel and Kang (2008). The researchers examined the model's efficacy in changing the unhealthy habits of 57 male and female police officers using an action research method. Action research is a reputable research method when situational conditions do not lend themselves to multiple group experimental designs, such as frequent interactions among study participants or the required use of programs or treatments that are publically advertised throughout the immediate environment, such as educational settings or, in this case, law enforcement. Action research consists of developing and implementing a plan of action, to observe the effects of action in the current context, and reflect on those effects as a basis for further planning and subsequent action (Mills, 2003).

The Anshel and Kang (2008) study began with a two-hour seminar that started the intervention covered each stage of the DVM, the officers indicated their lifestyle was generally sedentary and were unfit (i.e., they were not exercising nor engaging in regular vigorous physical activity), overweight, eating "fast food" at least once per day, suffered from poor sleep, chronic stress, and often experienced low physical energy. The officer's engaged in a 10-week action plan that consisted of fitness and nutrition coaching, in addition to meeting their performance coach--the seminar leader--on at least one occasion for an hour to review their overall action plan and to insert new routines that would improve adherence to exercise and dietary changes. They were given the option to meet individually for a second hour as follow-up, and 60% of the group opted for the second meeting. The results of the study indicated significantly improved scores (p 3<.01) on sub-max VO2 (cardio) and strength (upper and lower limb) fitness tests, lipids profile (i.e., cholesterol) scores, and reduced percent body fat.

To ensure that outcomes are a function of the treatment, action research includes several forms of validation including evaluative, outcome and process validity. Each of these was evident in the Anshel and Kang (2008) study and in more recent similar studies conducted on a university campus (Anshel, Brinthaupt, & Kang, 2010; Anshel, Kang, & Brinthaupt, 2011). Evaluative validity, which addresses the objectivity of the quantitative nature of the data, was associated with significant improvements in fitness. Outcome validity was obtained from changes in specific behaviors that lead to successful outcomes under study and is applicable to future research (e.g., significant improvement from pre-test to post-test). Process validity reflects correct execution of the intervention.

Taken together, it is apparent that earlier fitness intervention research attempts have been replete with limitations, such as imposing exercise locations, programs, schedules, and coaches, failing to develop social support and coach-client relationships, and not addressing lifestyle change that integrate exercise with other healthy behavioral patterns, such as nutrition, sleep, and stress management. Perhaps even more important in recognizing the limitations of past empirical attempts to change health behavior has been the absence of client values. The client's recognition of living a life filled with unhealthy habits that is disconnected from his or her values has been an enlightening, even life-changing observation. One group of individuals who have the skills and background in carrying out the DVM's cognitive-behavioral components are sport psychology consultants.

Implications for Sport Psychology Consultants and Future Directions

Traditionally, research and practice of sport psychology have been concerned primarily with the psychological and behavioral factors that influence sport performance (e.g., McCann, 2005), and working with a coach to enact change in athletic performance, referred to as the supervisory consultation model (Poczwardowski, Sherman, & Ravizza, 2004). The role of sport psychology consultation in exercise settings, however, has been relatively rare in the extant applied literature. The DVM provides an opportunity for sport psychology consultants to play a significant role in health behavior change such as promoting more daily physical activity and improving nutrition. The same principles of changing sport behavior are applied in the DVM. In addition, if sport psychology consultants have completed their degree program in a sport and exercise science program they may have taken a course in exercise physiology or fitness. This background would be advantageous in developing an action plan for exercise clients and provide an additional source of social support, including prescribing an exercise routine and even exercising with the client.

Scholars in the health behavior change literature have suggested several avenues of future research. As Glasgow et al. (2004) have concluded about the future of health behavior change research, "If we are serious about evidence-based behavioral medicine and about closing the gap between research findings and application of these findings in applied settings, we cannot continue 'business as usual'" (p. 11). As Baranowski et al. (1998) contend, to increase the effectiveness of physical activity interventions more research should focus on determining the predictors of adopting and maintaining a physically active lifestyle. Nicassio, Meyerowitz, and Kerns (2004) suggest that future studies include "specific methodologies for selecting intervention approaches in individual clinical cases" and acknowledging "the mechanisms of action through which interventions achieve their effects" (p. 135). One of these mechanisms might be the time span between behavior and experiencing the payoffs from that behavior. In their study linking values and exercise behavior, for example, Segar et al. (2011) suggest that "because immediate payoffs motivate behavior better than distant goals, a more effective 'hook' for promoting sustainable participation might be to rebrand exercise as a primary way individuals can enhance the quality of their daily lives" (p. 94).

The DVM embraces these recommendations in examining the antecedents and clinical issues that affect the need to make healthy lifestyle changes, particularly in relation to promoting an exercise habit. This is one strategic approach to address possible ways to change behavior and prevent what is becoming a dangerous health crisis in the U.S. and elsewhere. New, creative approaches to changing health behavior including exercise are needed with a particular focus on examining the DVM's efficacy on initiating and adhering to regular exercise.

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Mark H. Anshel

Middle Tennessee State University

Address correspondence to: Mark H. Anshel, Ph.D., Department of Health & Human Performance, P.O. Box 96 Murfreesboro, TN 37132. Tel: 615-898-2812 Email: Mark. Anshel@mtsu.edu

Table 1.
Perceived costs and benefits of selected common negative habits.

Current
Unhealthy
Habit         Benefits Now                     Costs Now

No Exercise   More time for other things       Less mental capacity,
              to do; less effort and           weight gain, less
              discomfort, reduced chance       energy, negative
              of exercise-related injury,      emotions, poor sleep.
              less cost in purchasing
              exercise shoes and clothing,
              less embarrassment exercising
              in a public setting.

Poor Diet     Fast food saves time, not        High fat & LDL
              expensive, good taste, and       cholesterol,
              convenient.                      overweight/ obesity,
                                               poor concentration.

Current
Unhealthy
Habit         Long-term Consequences

No Exercise   Poorer overall health,
              obesity, onset of diseases,
              more chance of cogni
              tive impairment, greater
              chance of osteoporosis,
              poorer information pro
              cessing, reduced life span,
              less chance to survive a
              heart attack.

Poor Diet     Greater chance of heart
              disease and various forms
              of cancer, shorter lifespan,
              increased chance of Type
              2 diabetes.