The Behavioral Theory In Mental Health

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Behaviorism is a theory of learning based on the idea that all behaviors are acquired through conditioning, and conditioning occurs through interaction with the environment. Behaviorists believe that our actions are shaped by environmental stimuli.

There are four models that present a logical and reasonable approach to behavioral change: the Health Belief Model, the Theory of Self Efficacy, the Theory of Reasoned Action, and the Multi-Attribute Utility Model. These behavioral models provide a framework for the development of interventions and strategies which will facilitate behavioral change.

Health Belief Model (HBM)- Uses of HBM are for patients' responses to symptoms and compliance with medical treatments. The HBM suggests that a person's belief in a personal threat of an illness or disease together with a person's belief in the effectiveness of the recommended health behavior or action will predict the likelihood the person will adopt the behavior.

The HBM derives from psychological and behavioral theory with the foundation that the two components of health-related behavior are 1) the desire to avoid illness, or conversely get well if already ill; and 2) the belief that a specific health action will prevent, or cure, illness. Ultimately, an individual's course of action often depends on the person's perceptions of the benefits and barriers related to health behavior.

There are six constructs of the HBM. The first four constructs were developed as the original tenets of the HBM. The last two were added as research about the HBM evolved.

  1. Perceived susceptibility- This refers to a person's subjective perception of the risk of acquiring an illness or disease. There is wide variation in a person's feelings of personal vulnerability to an illness or disease.
  2. Perceived severity- This refers to a person's feelings on the seriousness of contracting an illness or disease (or leaving the illness or disease untreated). There is wide variation in a person's feelings of severity, and often a person considers the medical consequences (e.g., death, disability) and social consequences (e.g., family life, social relationships) when evaluating the severity.
  3. Perceived benefits- This refers to a person's perception of the effectiveness of various actions available to reduce the threat of illness or disease (or to cure illness or disease). The course of action a person takes in preventing (or curing) illness or disease relies on consideration and evaluation of both perceived susceptibility and perceived benefit, such that the person would accept the recommended health action if it was perceived as beneficial.
  4. Perceived barriers- This refers to a person's feelings on the obstacles to performing a recommended health action. There is wide variation in a person's feelings of barriers, or impediments, which lead to a cost/benefit analysis. The person weighs the effectiveness of the actions against the perceptions that it may be expensive, dangerous (e.g., side effects), unpleasant (e.g., painful), time-consuming, or inconvenient.
  5. Cue to action- This is the stimulus needed to trigger the decision-making process to accept a recommended health action. These cues can be internal (e.g., chest pains, wheezing, etc.) or external (e.g., advice from others, illness of family member, newspaper article, etc.).
  6. Self-efficacy- This refers to the level of a person's confidence in his or her ability to successfully perform a behavior. This construct was added to the model most recently in mid-1980. Self-efficacy is a construct in many behavioral theories as it directly relates to whether a person performs the desired behavior.

Theory of Self Efficacy- refers to an individual's belief in his or her capacity to execute behaviors necessary to produce specific performance attainments. Self-efficacy reflects confidence in the ability to exert control over one's own motivation, behavior, and social environment. For an example consider, a person struggling to manage a chronic illness. If they are confident that they can get back on track and improve their health by working hard and following their Health Guardian’s recommendations.

  • Self-efficacy theory emphasizes the importance of the individual and the individual's perceptions of his/her personal health capabilities as key determinants of successful outcomes. This clearly endorses a democratic ideal suggesting that all individuals are competent and capable of being successful, provided they have the opportunities and self-efficacy necessary to pursue their goals. 
  • Self-efficacy theory explicitly focuses on how individuals can be empowered with a sense of agency that will facilitate goal attainment. This is important as self-efficacy theory does not presume that individuals who are currently successful are inherently better than those who are not as successful. Rather, self-efficacy theory would suggest that individuals who are currently struggling may not have been provided with opportunities to obtain mastery experiences or modeling necessary to develop high levels of self-efficacy. 
  • Self-efficacy theory emphasizes the relative importance of personal factors but acknowledges that behavioral and environmental factors have profound effects on outcomes. This theory of triadic reciprocal determinism therefore further reinforces the idea that if the effects of the environment are consistent (i.e., an even playing field for all), then self-efficacy beliefs will take on an even greater role in determining human behavior, and ultimately shaping outcomes.
  • Self-efficacy theory proposes a measured worldview in which opportunities to experience or witness success may promote positive evaluations of one's capacities to succeed in the future which in turn increases the likelihood of subsequent positive outcomes.

Theory of Reasoned Action- suggests that a person's health behavior is determined by their intention to perform a behavior. A person's intention to perform a behavior (behavioral intention) is predicted by 1) a person's attitude toward the behavior, and 2) subjective norms regarding the behavior.

Subjective norms are the result of social and environmental surroundings and a person's perceived control over the behavior. Generally, positive attitude and positive subjective norms result in greater perceived control and increase the likelihood of intentions governing changes in behavior.

The Theory of Reasoned Action provides useful information for predicting health behaviors and for planning and implementing health promotion and disease prevention programs. Subjective norms can be used to describe the behaviors of healthcare providers, patients, care providers, and others in the community. These theories have been used to guide health promotion and disease prevention asthma counseling and treatment compliant, tobacco use interventions, and anti-drug media campaigns, among other topics.

TRA considers the individual’s attitude and social norms as well as the individual’s perceived control as accurate predictors of behavioral intentions. TRA is most successful when applied to behaviors that are under an individual’s voluntary control.

If behaviors are not fully under voluntary control, even though individuals may be highly motivated by their own attitudes and subjective norms, they may not actually perform the behavior due to intervening environmental conditions. 

It is easy to see how this theory may relate to the concept of motivation and adherence to physical activity and/or exercise, especially in the rehabilitation setting. If a patient’s perceived control or self-efficacy or self-esteem is low, the perception and belief that he or she can influence own behaviors in a positive manner is undermined.

In a study assessing risk behavior following coronary heart disease diagnosis, TRA was found to be the main factor in predicting self-reported exercise and observed fitness levels.

When exercise intention and behavior were assessed in a sample of 225 older women aged 65 years and older, significant predictors of exercise intention were behavioral beliefs, normative beliefs, and perceived control beliefs. In other words, these women were more likely to exercise if they perceived more positive than negative consequences of performing the behavior (i.e., behavior beliefs), if they believed that people close or important to them approved versus disapproved of their behavior (i.e., normative beliefs), and, lastly, if they believed the difficulty of the task was manageable by them (i.e., perceived control belief).

Multi-attribute Utility Model (MUM)- Multi-attribute utility theory (MUM) combines a class of psychological measurement models and scaling procedures which can be applied to the evaluation of alternatives which have multiple value relevant attributes.

This theory helps address the known fact that in health, antecedents are never singular. These components could be perceived benefits, functions, product features, etc., and are collectively known as Health Attributes.

The MUM states that a patient’s attitude towards a health benefit is a function of their perception and belief of the key attributes as well as their own assessment of the key attributes.

MUM is a structured approach to decision making that employs systematic analyses that give the decision makers a better understanding of the problem and thus facilitates a better-informed choice. There are seven steps used in conducting this analysis.

  1. Establish Objective- Determine the value of two elements of goodwill, personal and enterprise, such that a reasonable, well-founded basis can be communicated as the support for the opinion of value Two equally important objectives
    1. What is the answer?
    2. How did we get there?
  2. Establish Outcome Alternatives
    1. Alternatives define possible outcomes of MUM
    2. Discrete possibilities
    3. Determine what level of precision you can reasonably obtain
    4. An answer within a range result in a specific estimate
    5. The total of personal and enterprise goodwill percentages is always 100%
  3. Define Attributes
    1. Attribute (noun) – a quality, property, or characteristic
    2. Attribute (verb) – a feature taking on the qualities of causation
    3. We are interested in the characteristics and features that cause earnings, so we use both definitions
  4. Assess Attributes’ Utility
    1. Assess the utility of each attribute as it relates to personal and enterprise goodwill
    2. Start with a balance of personal and enterprise attributes
    3. Importance Utility – How important?
    4. Existence Utility – How prevalent?
  5. Aggregate Results
    1. Do the math
    2. Multiplicative utility = Importance x Existence
    3. Provides a framework to distill your industry research and specific company research into one place
    4. Determines relative weight of personal health and family health, as a percentage
  6. Fit Results to Alternatives
    1. Determine the scenario based on results
    2. Test sensitivity
    3. What if analysis on high impact utilities
    4. What would it take to shift scenarios?
    5. What if you overestimate (or underestimate) management’s abilities?
    6. Finalize opinion
  7. Express Opinion- Develop a conclusion of value in accordance with whatever report writing standards are required. As it relates to MUM, explain:
    1. What the objective was
    2. How MUM works
    3. How you determined importance
    4. How you determined existence
    5. What your resulting opinion of the allocation was
    6. Any external reference points / checks to the allocation

 

 

 

 

 

 

 

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