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Applied Health Fitness Psychology considers behavioral issues regarding exercise and nutrition using a research-to-practice approach. This comprehensive text explains how health fitness psychology has emerged from other parent disciplines to become a wide-ranging discipline that can be addressed in various exercise, fitness, and health settings, allowing both current and future professionals to assist their patients or clients in adopting healthier lifestyles.
Applied Health Fitness Psychology uses contributions from sport and exercise psychology, counseling and clinical psychology, exercise science, sports medicine, and behavioral medicine to provide a scientific basis for presenting strategies for behavior change. Unique to this text is a critical consideration of cultural, spiritual, and religious components as a factor in initiating and maintaining exercise behavior. The evidence-based approach will help readers use techniques and interventions that promote positive changes among various populations.
Students will grasp the scope of this emerging field by studying the following topics:
• The theoretical foundation of health behavior change and motivational theories
• Physical, cognitive, and motivational obstacles to adopting a healthy lifestyle
• Use of cognitive and behavioral strategies and interventions to promote exercise adherence, set goals, and improve fitness and exercise performance
• Steps that will help students become professionals in health fitness psychology
• Considerations in working with special populations, such as older adults, pregnant women, individuals recovering from injuries, and individuals with chronic conditions or dysfunctional eating behaviors
Chapter objectives at the start and a summary, review of key concepts, and student activity at the end of each chapter help students and instructors stay focused on understanding the main concepts and putting this information into practice. Highlight boxes, tables, and figures throughout the book keep readers engaged with the material. From Research to Real World sidebars show students how the information in the text can be used in multiple professions and illustrate the many applications for health fitness psychology in today’s society. For instructors, Applied Health Fitness Psychology includes online access to a presentation package and test package.
While modifying a person’s—or a culture’s—disdain for exercise will not happen quickly, Applied Health Fitness Psychology equips aspiring and practicing professionals working in a variety of health, fitness, and allied health fields with strategies to help people make the shift to more active and healthy lifestyles.
Part I. Theoretical Foundations of Health Fitness Psychology
Chapter 1. Introduction to Applied Health Fitness Psychology
Psychological Benefits of Exercise
Physical Benefits of Exercise
Motives for Exercising
Why We Keep Our Unhealthy Habits
Challenges of Changing Health Behavior
Defining Applied Health Fitness Psychology
History of Applied Health Fitness Psychology
Summary
References
Chapter 2. Psychological Motivation Theories
Motivation Defined
Sources of Motivation
Achievement Motivation Theory
Achievement Goal Theory
Goal Orientation Theory
Competence Motivation Theory
Deci’s Cognitive Evaluation Theory
Self-Determination Theory
Attribution Theory
Weiner’s Attribution Model
Summary
References
Chapter 3. Theories and Models of Exercise Behavior
Health Belief Model
Theories of Reasoned Action and Planned Behavior
Self-Efficacy Theory
Transtheoretical Model
Relapse Prevention Model
Deterrence Theory
Drugs in Sport Deterrence Model
Summary
References
Part II. Factors That Influence Health Behavior
Chapter 4. Barriers to Positive Health Behavior
Causes of Self-Destructive Behaviors
Obstacles to Adopting a Healthy Lifestyle
Exercise Barriers and Sources of Negative Attitudes
Mental and Psychological Barriers
Health Behavior Intervention Research
Four Components of Health Behavior Change
Summary
References
Chapter 5. Personal Factors
Personality Traits as Predictors of Health Behavior
Orientations, Styles, and Exercise Adherence
Behavioral Tendencies
Summary
References
Chapter 6. Situational and Environmental Factors
Social Support of Exercise Habits
Fitness Coaching for Exercise Participation
Situational Factors That Promote Physical Activity
Environmental Factors That Promote Physical Activity
Job Incentives That Promote Healthy Lifestyle Choices
Summary
References
Chapter 7. Cultural, Religious, and Spiritual Components
Health Care in Multicultural Populations
Religious Community and Health Habits
Contradictions Between Religious Practice and Unhealthy Living
Health Benefits of Religiousness and Spirituality
Summary
References
Part III. Strategies for Health Behavior Interventions
Chapter 8. Exercise Adherence and Compliance
Reasons for Exercise Participation
Perceived Exercise Barriers
Defining Adherence and Compliance
Measuring Adherence
Developing an Exercise Habit
Steps to Achieving Exercise Adherence
Mental Barriers to Exercise Adherence
Weiner’s Attribution Model Applied to Exercise Adherence
Summary
References
Chapter 9. Cognitive and Behavioral Strategies
Interventions, Treatments, and Strategies
Cognitive Strategies
Behavioral Strategies
Exercise Programs and Interventions
Applying Motivation Theory
Summary
References
Chapter 10. Fitness Goal Setting and Leadership
Direction and Quality of Behavior
Goals and Personality
Performance and Outcome Goals
Goal-Setting Guidelines in Exercise Settings
Strategies for Fitness Coaches and Personal Trainers
Summary
References
Part IV. Professional Considerations
Chapter 11. Fitness Consulting With Special Populations
Older Adults
Injury Rehabilitation Patients
Cardiac and Pulmonary Rehabilitation Patients
Pregnant Women
People With Diabetes
People With Physical and Mental Disabilities
People With Chronic Conditions
Cancer Patients
Cultural Differences
Summary
References
Chapter 12. Dysfunctional Eating Behaviors
Disordered Eating and Eating Disorders
Emotional Eating
Body Dissatisfaction
Multidisciplinary Approach to Combating Eating Disorders
Strategies for Obesity Management
Weight Maintenance
Summary
References
Chapter 13. Professional Organizations and Ethics
Professional Organizations
Credentialing
Employment Opportunities
Professional Ethics
Summary
References
Mark H. Anshel, PhD, is a professor in the department of health and human performance with a joint appointment in the psychology department at Middle Tennessee State University in Murfreesboro. He is the author of more than 135 research publications, four fitness books, and multiple editions of the text Sport Psychology: From Theory to Practice. His research since 2007 has concerned the effectiveness of a cognitive-behavioral model on exercise participation and adherence called the Disconnected Values Model. Anshel is recognized as an international leader in providing evidence-based programs and linking research with practice in the areas of exercise and fitness psychology and sport psychology.
Over the course of his career, Anshel has gained hands-on experience consulting with more than 3,000 clients on healthy habits, particularly the use of exercise. His practical career experience began with seven years as a fitness director in community recreation. From 2000 to 2002 Anshel served as a performance coach at the Human Performance Institute in Orlando, Florida, where he provided corporate clients with a cognitive-behavioral program on replacing unhealthy habits with more desirable lifestyle routines. He also served as a performance consultant and researcher related to improving wellness and coping skills with the Murfreesboro Police Department from 2005 to 2011.
In 2009, Anshel was awarded the Distinguished Research Scholar Award from Middle Tennessee State University. Anshel is a fellow of the American Psychological Association (Division 47, Exercise and Sport Psychology). He is the founder and director of the Middle Tennessee State University Employee Health and Wellness Program, which received grant funding of $130,000 over two years. Anshel also served for 10 years on the editorial board of the Journal of Sport Behavior.
In his free time, Anshel enjoys jogging, writing on health-related topics, and reading current events and health-related research. He resides in Murfreesboro, Tennessee.
“With its easy-to-understand style, this book can be useful as a firm building block for students looking to further their studies in a related field in exercise psychology.”
Doody’s Book Review (5-star review)
Orientations and styles can be changed to promote exercise adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two.
Orientations, Styles, and Exercise Adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two. Personality traits are permanent, stable across situations, and partly a reflection of one's genetic predisposition, and therefore they are not subject to change. Orientations and styles, on the other hand, reflect common attitudes or a person's tendency to think or act in a predictable manner. The concepts of attributional style, coping style, and win orientation reflect predictable and persistent ways of thinking and acting under certain conditions. If, for instance, a person who demonstrates success or competence has an internal attributional style, the typical way the person explains success may be internal. That is, she may typically attribute the cause of her success as due to high effort or excellent skills, both internal explanations. Not taking responsibility for success or failure and perceiving the cause as something beyond the person's control reflects an external attributional style, at least for that particular situation (e.g., maintaining high fitness, improving performance on a given task, gaining excessive weight).
Orientations and styles also predict how people perceive the importance of a healthy lifestyle and to what they attribute their good or poor health. An internal disposition could reflect taking responsibility for one's excessive weight or poor fitness as due to poor dietary choices, excessive food intake, and lack of physical activity. Someone with an external disposition will be more likely to attribute weight gain to genetics or similarity to other family members, to not acknowledge there is a weight problem, or to believe that weight gain and consequent diseases (e.g., type 2 diabetes, high blood pressure, heart disease) are normal and part of the aging process. Other types of orientations and styles related to health behavior include self-control, self-awareness, and the interchangeable concepts of self-confidence and self-efficacy.
Self-Control
Self-control refers to the extent to which a person voluntarily and consciously creates, carries out, and maintains thoughts, emotions, and behaviors toward reaching desirable goals, even after encountering obstacles (Rosenbaum, 1990). Self-control behaviors are regulated by deliberate cognitive processes that are under the person's voluntary control. A good example of self-control in exercise settings is time management. Perhaps the primary reason people offer for not exercising is not having enough time (Sternfeld et al., 2009). People with high self-control plan their day and set aside time (i.e., day of the week, hour of the day, length of time) devoted to maintaining an exercise routine.
Self-control also means that the activity itself may be planned. For example, perhaps an exerciser who prefers the company of a friend during a workout plans to meet his friend at the exercise facility. Upon entering the facility, the individual has preplanned an hour devoted to various tasks that compose the exercise workout; specific routines are planned and carried out for the duration of the session, from entering to exiting the facility. The type of aerobic and resistance training may also be predetermined and executed in attempting to reach challenging goals. Presumably, the excuse of not having enough time now becomes having more time to do other things thanks to increased energy and vigor as a function of the workout. People with a high self-control orientation are more capable of carrying out preperformance and performance routines compared with their counterparts with low self-control (Faulkner et al., 2006). People with high self-control are schedule keepers and rarely waste time.
An important situational factor in developing an exercise habit is scheduling one's exercise sessions during the week. This requires good time management skills. Rather than saying, “I'll exercise when I get the time,” restate that view with, “I will exercise at x times on the following days.” A minimum of three times a week of intense exercise that expands one's fitness capacity and has a training effect (e.g., increased heart rate, increased muscular strength) is needed. However, finding opportunities to become physically active during the day (e.g., taking the stairs instead of the elevator, walking up or down the escalator, taking an evening or lunchtime walk) is also helpful for burning calories and managing weight.
Learned Resourcefulness
The pioneer writer and researcher in the literature on learned resourcefulness is Dr. Michael Rosenbaum (1990). He defined learned resourcefulness as “an acquired repertoire of behavioral and cognitive skills with which the person is able to regulate internal events such as emotions and cognitions that might otherwise interfere with the smooth execution of a target behavior” (p. xiv). High scorers on Rosenbaum's Self-Report Scale (Rosenbaum, 1990) are better able to
• tolerate physical discomfort,
• cope effectively with stress,
• succeed in weight-reduction programs,
• prevent or overcome feelings of helplessness,
• comply with medical and other health-related regimens,
• establish and maintain a relatively healthy lifestyle, and
• delay immediate gratification (e.g., binge eating) and understand the value of delayed gratification (e.g., exercising takes time, but the person receives more energy, better health, and improved performance quality).
In general, learned resourcefulness is particularly important in controlling negative thoughts and emotions while engendering desirable cognitive processes such as positive self-talk, optimism, self-motivation, and positive mood states. People high in learned resourcefulness are more confident; more likely to adopt an active lifestyle, including regular exercise; and less likely to engage in self-destructive behaviors (e.g., smoking, taking extreme risks). It is important to note that learned resourcefulness is not viewed as a personality trait. Instead, it is an orientation—a way of thinking that can be influenced through experience, counseling, and situational conditions.
Mental Toughness
Mental toughness is a disposition that represents the ability to reach and sustain high performance under pressure by expanding one's physical, mental, and emotional capacity (Connaughton, Hanton, and Jones, 2010). Mental toughness is learned, not inherited; it's an orientation. One common but false view of many athletes and coaches is that we are born with the right competitive instincts, and people who cannot handle failure lack the genetic predisposition to be mentally tough. The belief in a mental toughness gene is tempting because it absolves the person of taking responsibility for failure. However, the reality is that mental toughness can be taught, improved, and mastered. Exercisers need mental toughness to acknowledge their poor health and the need for physical activity, to withstand the challenges of physical exertion, to overcome physical fatigue, to continue to see the benefits of an exercise program, and to maintain exercise participation as a lifelong habit.
Mentally tough people are self-motivated and self-directed (their energy comes from internal sources; it is not forced from the outside); positive but realistic about handling adversity; in control of their emotions, especially in response to frustration and disappointment; and calm and relaxed under fire (rather than avoiding pressure, they are challenged by it). Mental toughness is also characterized by high energy, physical and mental readiness for action, a strong desire to succeed, relentlessness in the pursuit of challenging goals, superb concentration skills, self-confidence in the ability to perform well, and taking full responsibility for one's actions.
Self-Awareness
Think of self-awareness as the willingness to self-reflect, to engage introspectively, and to look at oneself through the eyes of others. This is not always easy to do, but others give us signals about their expectations and evaluations of us all the time, if we just take a good look. People react to us one way if they want our friendship and we have their respect. They react to us in a completely different way if they reject or disrespect us for whatever justified or unjustified reasons.
Self-awareness is an important component of health behavior because the ability to look inside and to be cognizant of our thoughts, emotions, and behaviors allows us to initiate steps for desirable change. If, for instance, we look in the mirror and see a person who is out of shape, overweight, and even unattractive, we can then begin the process of determining the reasons for our low energy, labored breathing, and general discomfort. Self-aware people also become more aware of the short-term costs and long-term consequences of their bad habits. They do not ignore their poor health and the negative habits that cause their current health status. This is why they are more likely to embrace support and opportunity to make lifelong changes that improve their health and happiness. They refuse to remain stuck in a self-destructive lifestyle. The challenges of self-awareness are addressed by Loehr and Schwartz (2003), who paraphrase John 32:8 from the Bible: “If the truth is to set us free, facing it cannot be a one-time event. Rather, it must become a practice. Like all of our ‘muscles,' self-awareness withers from disuse and deepens when we push past our resistance to see more of the truth” (p. 163).
Self-awareness, then, is an orientation. We differ in our willingness to become introspective about who we are and what we need to do to become better. As Loehr and Schwartz (2003) contend, “We must persistently shed light on those aspects of ourselves that we prefer not to see in order to build our mental, emotional and spiritual capacity” (p. 163). The authors also agree, however, that self-awareness can be self-defeating and overwhelming, bringing out negative thoughts, feelings, and emotions if it is absorbed in too big a dose. The right amount and frequency of self-awareness provides sufficient information to keep us on track and to be used as a source of information about what we need to become healthier and happier. As the authors conclude, “Facing the most difficult truths in our lives is challenging but also liberating” (p. 163).
Self-Efficacy
Confidence is a person's general feeling, perception, or belief that she has the capability to be successful in performing a skill and meeting task demands. Self-efficacy combines confidence with self-expectations. Self-efficacy, often associated and used interchangeably with self-confidence, is defined by Feltz and Lirgg (2001) as “the belief one has in being able to execute a specific task successfully . . .
to obtain a certain outcome” (p. 340). They further write, “Self-efficacy beliefs are not judgments about one's skills, objectively speaking, but rather are judgments of what one can accomplish with those skills” (p. 340). Thus, self-efficacy beliefs reflect a person's feelings not about what she can do but rather about what she has already done.
Self-efficacy is enormously important in an exercise setting and for changing and adhering to desirable, healthy behaviors. For example, people who experience self-doubt about their ability to join a fitness class and perform at least most of the exercises will be more likely to stop attending the class and either try some other form of exercise or return to their sedentary lifestyle. It is against human nature to continue participating in an activity in which we perceive our performance as incompetent or we fail to meet self-expectations or experience improved exercise performance and outcomes (e.g., better fitness). Therefore, building self-efficacy in an exercise setting bolsters the exercisers' perception that they are exercising properly, using correct technique, and improving performance. With respect to general health, clients will feel that following a certain set of routines will result or has resulted in superior health-related outcomes (e.g., more energy, positive mood, favorable results from medical tests). The objective of every worker in the health care industry, including fitness and nutrition coaches, is to provide instruction and positive feedback to build the person's self-efficacy about maintaining healthy habits.
Researchers have examined the link between self-efficacy and exercise behavior. Perhaps not surprising is the finding that as a person becomes more committed to an exercise habit, his self-efficacy improves. Self-efficacy is relatively low in the early stages of exercise, when a person is just beginning to develop an exercise routine or starting to make exercise a habit, and it increases dramatically as the person inserts exercise among his daily rituals. What is unknown is whether self-efficacy causes a person to adopt exercise as a lifestyle ritual or whether continued exercise increases self-efficacy. No doubt the two processes interact and self-efficacy is both the cause and the outcome of maintaining a regular exercise habit (Feltz and Lirgg, 2001; O'Leary, 1985).
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Religious institutions and spiritual leaders influence health behavior
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22).
Religious Community and Health Habits
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22). Religions, for example, promote beliefs that regulate behaviors related to alcohol, tobacco, diet, general hygiene, and medical care. Levin found that commitment to religion “may have a protective effect against subsequent illness . . . prevent or delay (illnesses), and have long-term benefits for physical and mental functioning and health” (p. 23).
The religious community is not immune from the health-related problems derived from an unhealthy lifestyle, however. The obesity epidemic still thrives in the religious and spiritual community (Cline and Ferraro, 2006). For example, the prevalence of obesity increased from 24% to 30% from 1986 to 1994 and likely has become much higher in more recent years among people of faith, that is, people who claim an affiliation with or membership in a denomination or religious institution. One potentially powerful source of health behavior change that has not been recognized in the war against obesity is the importance of religious and spiritual institutions and their leaders.
Next to physicians or other personal care providers, religious and spiritual leaders are some of the most credible people who influence the thoughts, emotions, and actions of a person of faith. People of faith often make a conscious decision to behave in a manner that is consistent with the expectations of their religious or spiritual messages.
In his book, Medicine, Religion, and Health: Where Science and Spirituality Meet (2008), Dr. Harold G. Koenig, MD, divides the benefits of religious practice or belief into six health-related areas:
1. Mental health
2. Immune function
3. Cardiovascular function
4. Stress and behavior-related diseases
5. Mortality
6. Physical disability
Based on his review of the research literature in each of these areas, Koenig (2008) concluded that religious practice or spirituality were strongly associated with superior health outcomes. He found, for example, that blood pressure and rates of stroke and cognitive impairment were each highly correlated with religious involvement (e.g., service attendance, frequency of prayer, strength of belief in a higher power). Although not always acknowledged by religious leaders, messages related to maintaining healthy habits are common throughout most religious texts.
To people of faith, arguably no one has more credibility for influencing behavior than their religious or spiritual leader. Should these leaders play a role in promoting healthy habits among congregants and the community at large? How can they address the apparent disconnect between people's religious practices, including a firm belief in religious or spiritual texts, and their lack of self-awareness about practicing healthy habits? And how can health professionals be involved in this process?
Role of Religious Leaders in Promoting and Modeling Healthy Habits
Many religious leaders contend that people who attend traditional ceremonies or services are looking for spiritual fulfillment, and that is the primary role of their institutions. Educating congregants about healthy habits is not. Perhaps this view, and the mission that propels it, needs to be reexamined. All sources of behavioral influence, including school systems, governments, corporations, the food industry, and religious institutions, need to be unified in providing information and incentives to replace self-destructive behavior patterns with healthier alternatives. One source of health behavior interventions that has received only minimal attention is the role of religious and spiritual leaders.
What should religious and spiritual leaders do to promote healthy habits, perhaps with assistance from health professionals? First, they need to look at themselves and determine if the change needs to start with them. Next, they must speak up and encourage their institution members—and other members of the community, when given the opportunity—to have discipline in all areas of their lives. One religious text, the Bible, addresses eating, indulgence, self-control, self-discipline, and gluttony. These topics need to be addressed in religious institutions and services without fear of offending attendees. Leaders of congregants who attend spiritual events and services should encourage their congregants to make lifestyle changes that will ultimately bring glory to God or some other higher power to whom they feel accountable. Religious leaders must stop being intimidated by the risk of losing members by offending them in order to acknowledge the importance of self-care as an inherent component of a religious and spiritual lifestyle (Colbert, 2002).
Perhaps the most serious obstacle to health behavior change in the religious community is persuading people of faith to take responsibility for their health and engage in the free will of healthy lifestyle choices, rather than surrender control to a higher power. Most religious texts, including the Bible, promote taking responsibility for health behavior. Philippians 2:13 states that God works within us to will his Holy Spirit and the free will to desire to create balance in our life—and the will to act on that desire.
For example, as Omartian (1996) contends, “The main reason to exercise is for your health. Without good health you cannot do all that the Lord has for you do to and you cannot be all the Lord wants you to be” (p. 117). Along these lines, Koenig (1999) asserts, “The world's religions encourage healthy living. . . .
All established religions discourage . . . any habit or activity harmful to the human body, which has traditionally been viewed as sacred, created in the image of God” (p. 72). And as Levin (2001) concludes, “All religions endorse the idea that we ought to take care of our bodies and not act in ways that are reckless and endanger our health” (p. 41).
There is an apparent need for religious institutions and their leaders to play a more prominent role in promoting community health and wellness and to serve as role models for their congregations. The credibility of pastors, priests, rabbis, imams, and other religious leaders will be further enhanced if their messages of health and wellness given in their sermons and programs are reflected in their own behavioral patterns. In other words, religious and spiritual leaders have to walk the walk, not just talk the talk.
Health Themes Addressed by Religious and Spiritual Leaders
Perhaps the strongest influence of a religious leader on the thoughts, emotions, and actions of attendees of religious services occurs when their attention is focused on the leader's words—the sermon. Health-related themes that extol the virtues of maintaining a healthy lifestyle need to be communicated more frequently and passionately, citing religious or spiritual text to reinforce main issues. For example, in the New Testament of the Christian Bible, the apostle Paul reminds his readers that their bodies are a dwelling place of the Holy Spirit, thereby bridging the gap between spiritual and physical dualism that may be keeping people of faith locked into unhealthy behavioral patterns. Paul contends that what we do with our bodies matters not only on a physical level but also on a spiritual level.
Religious leaders can also cite scripture to remind us that we are not owners but rather managers, or stewards, of our bodies. Maintaining healthy habits is a matter of personal stewardship. When we begin to perceive our bodies in a manner that is consistent with God's view, we begin to make decisions that affect our physical health that honors a higher power (i.e., God). Thus, maintaining unhealthy habits that lead to obesity and poor physical conditioning is a failure of that stewardship responsibility.
Another health theme found in religion is gluttony. The Gluttony in Religion highlight box lists examples of this theme from various religious texts that both religious leaders and health professionals may use with people of faith to address the association between healthy habits and spirituality or religion.
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Overcome mental barriers to reach exercise goals
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks.
Mental Barriers to Exercise Adherence
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks. However, it will not take a great deal of time to feel better and adjust to new physical demands they place on themselves. They simply need patience. Without it, they will quit. They will lack adherence, and this is exactly the problem with at least half the people who initiate exercise programs. Our high-achieving, impatient culture, made worse by personality traits such as negative perfectionism, high trait anxiety, and pessimism about the future, often does not allow us to set reasonable goals and to develop strategies to reach those goals.
Emotions, thoughts, and feelings drive behavior in one of two directions: positive, toward achieving success and developing a better, healthier, more energetic lifestyle, or negative, toward maintaining unhealthy habits, being overweight, lacking energy, and living a life inconsistent with one's values about what is important. Improving a client's lifestyle takes effort—and a plan. Health and fitness professionals need to revisit the client's values, connect each value to a new routine that will create and maintain a more active lifestyle, and improve physical and mental health. Adherence to a program of regular exercise, the theme of this chapter, is of paramount importance in doing everything in our power to take control of our destiny. In the words of former British prime minister Sir Winston Churchill, “Continuous effort—not strength or intelligence—is the key to unlocking our potential" (qtd. in Cook, 1993).
A person's decision to discontinue an exercise habit often has a psychological explanation. Here are some of the more common conditions that can lead to dropping out of an exercise program. Hopefully, health professionals can develop and apply effective responses to these excuses that will change the client's mind about quitting.
Anxiety
Anxiety consists of feelings of worry or threat about the future, as discussed in chapter 5. Anxious thoughts cause worry and distract the exerciser from the task at hand—and waste energy. Sources of exercise anxiety include worry about meeting goals, physical appearance, being accepted by others (even strangers at a fitness club), and using time to exercise instead of doing something else (“I could be watching TV or finishing a report instead of going to the gym”). Ironically, exercise actually reduces both short-term (acute) and long-term (chronic) anxiety. Exercise is what the doctor ordered for improved mental health, including reduced anxiety (deMoor et al., 2006). Health professionals should strongly consider exercise as one behavioral strategy for helping their clients manage anxiety, particularly if clients are given social support in their new exercise program.
Depression
Most people experience unhappiness and negative emotions; this is normal. Ongoing, deeply negative mood states, however, may be a more serious mood disorder referred to as clinical depression (APA, 2000). Depression is a mood disorder that ranges from mild to severe and can be due to a medical condition, substance use, or psychopathology (mental illness). A sedentary lifestyle may induce or promote depression, but exercise has been shown to reduce it in over 70 studies across various age groups and for both genders (Leith, 1998).
One factor that influences the effect of exercise on depression is whether the person has selected and is enjoying the type of physical activity. A second factor is whether the exercise is of sufficient intensity, frequency, and duration to improve fitness outcomes and lead to psychological benefits. Taking a quiet, slow walk through the park, although pleasant and relaxing, may not be sufficient to reduce depression (Brosse, Sheets, Lett, and Blumenthal, 2002). Buckworth and Dishman (2002), in support of recommendations from ACSM, suggest the following exercise guidelines for people with depression who are otherwise healthy: three to five days a week (frequency) for 20 to 60 minutes each session (duration) at 55% to 90% of maximal heart rate (intensity). Certified fitness coaches should aim to meet these standards when prescribing exercise for depressed clients.
Negativity
It is impossible to remain motivated and on task if self-talk is negative, such as, “I don't like this,” “I feel terrible,” or “I'm tired.” Replacing those thoughts with positive statements that are optimistic and enthusiastic induces more effort and energy. Examples include, “I can do this,” “I feel good,” “Just three more minutes to go,” and “Hang in there.” To quote an anonymous writer, “You cannot be unhappy and enthusiastic at the same time.
”Negative and antagonistic feelings and emotions can impair the development of an exercise habit, especially for novice performers. The problem with negative thinking is that it results in low effort and sets up the individual to fail. This process is similar to the self-fulfilling prophecy; one's performance level will be consistent with one's expectations.
Examples of negative thinking that serve as barriers to exercise success include lack of confidence (e.g., “I don't think I can do this”), intimidation (e.g., “I don't belong in this fitness facility,” “People are laughing at me”), pessimism (e.g., “I'll never lose weight,” “Exercise will never be enjoyable”), self-criticism (e.g., “I can't run even one lap of that track, so why even try?”, “Exercise is not for me; I'll always be weak”), impatience (e.g., “I've been exercising for three weeks and still run out of steam when jogging”), and irrational thinking (e.g., “I've always been heavy; why change now?”, “People just have to accept me the way I am,” “My spouse thinks my weight and appearance are just fine”).
There are several implications for health care professionals when it comes to addressing mental health. First, consultants should not attempt to diagnose or treat mental illness unless they are licensed psychologists or have other appropriate credentials related to this area. There are serious legal implications of providing treatment to a person who did not request it, was not diagnosed correctly, or did not receive the proper treatment. The key term that reflects the proper thing to do if mental illness is suspected is referral; that is, health care professionals must refer clients to a licensed mental health professional for diagnosis and treatment if mental illness, such as depression, chronic anxiety, or another condition, is suspected.
A second implication for dealing with psychological barriers to maintaining healthy habits, particularly related to exercise and nutrition, is the need to schedule meetings between the client and qualified health coaches, such as a certified personal trainer and a registered dietitian. Exercise and nutrition both influence mental health and should not be ignored when attempting to change client health behavior. Relationships with local experts in these areas should be established before referral in order to become familiar with the expert's background, skills, location, types of services rendered, and personal qualities. Sometimes clients prefer a male or female coach or can meet the consultant only on certain days at certain times. It is essential that the health care professional try to coordinate the client's needs and preferences with the coach's characteristics.
Perfectionism
Perfectionism is a trait reflecting a person's disposition toward "setting excessively high standards of performance in conjunction with a tendency to make overly critical self-evaluations" (Frost, Marten, Lahart, and Rosenblate, 1990, p. 450). It is usually studied as a trait measure—stable and cross-situational—not a state (situational) measure (Antony and Swinson, 2009).
Perfectionism has both positive and negative features. The positive aspects of perfectionism include setting and attempting to achieve high personal standards, striving to achieve lofty but realistic goals often leading to success, and being conscientious and self-confident (Flett, Hewitt, Blankstein, and Mosher, 1991). Negative features, not uncommon among people who go overboard in attempting to achieve goals, include feeling deep concern about making mistakes, which leads to heightened anxiety; having doubts about one's actions; setting excessively high standards; having difficulty recognizing success; and overemphasizing precision, neatness, order, and organization. People who fit these behavior and thought patterns are referred to by clinical psychologists as neurotic perfectionists. They have a propensity to engage in self-destructive behaviors, excessive self-criticism, failure to recognize achievement and competence, and feelings of “It's not good enough” (Antony and Swinson, 2009; Adderholdt-Elliott, 1987).
Neurotic perfectionists set unattainable goals and might engage in overtraining or exercise addiction. Their self-talk is based on messages they received when they were young, reminding themselves that “It's not good enough” and “I can do better.” Their expectations of others are also excessive. Perfectionists need to learn how to set reasonable goals and to recognize their own achievements and those of others, especially in exercise settings. They need to have indicators of success and to acknowledge when they have reached those indicators.
Implications for working with clients who reveal perfectionistic thinking include referral to a mental health professional so that its sources can be identified and treated. Perfectionism can play a role in attempts at self-improvement; however, when standards and goals are excessively high, when self-expectations for achievement are unrealistic, and when the person expects others to meet these same excessive standards, often at the expense of alienating others, then this condition becomes an obstacle to happiness, confidence, and mental health.
Another implication for working with perfectionistic clients is the need to help them set realistic but challenging goals that are measurable and observable, to help them detect times when they have met their performance expectations, and to verbally and directly recognize their accomplishments. One important strategy that validates positive feedback and gives the consultant credibility is to base feedback on numbers—perhaps fitness test results, blood test results, improved exercise performance (e.g., increased resistance in weight training, faster jogging times, reduced body-fat percentage), or some other measure that quantifies improved physical performance.
Finally, perfectionists often need to change their irrational thinking by being reminded of their accomplishments, favorably comparing their competence level with others, and being more realistic about their self-expectations. Perfectionism, particularly when excessive (also referred to by mental health professionals as irrational, maladaptive, or neurotic), has specific sources, such as parents, sport coaches, or teachers, and this may be pointed out as an issue that is nothing to be ashamed about and that might require professional consultation to address it.
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Orientations and styles can be changed to promote exercise adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two.
Orientations, Styles, and Exercise Adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two. Personality traits are permanent, stable across situations, and partly a reflection of one's genetic predisposition, and therefore they are not subject to change. Orientations and styles, on the other hand, reflect common attitudes or a person's tendency to think or act in a predictable manner. The concepts of attributional style, coping style, and win orientation reflect predictable and persistent ways of thinking and acting under certain conditions. If, for instance, a person who demonstrates success or competence has an internal attributional style, the typical way the person explains success may be internal. That is, she may typically attribute the cause of her success as due to high effort or excellent skills, both internal explanations. Not taking responsibility for success or failure and perceiving the cause as something beyond the person's control reflects an external attributional style, at least for that particular situation (e.g., maintaining high fitness, improving performance on a given task, gaining excessive weight).
Orientations and styles also predict how people perceive the importance of a healthy lifestyle and to what they attribute their good or poor health. An internal disposition could reflect taking responsibility for one's excessive weight or poor fitness as due to poor dietary choices, excessive food intake, and lack of physical activity. Someone with an external disposition will be more likely to attribute weight gain to genetics or similarity to other family members, to not acknowledge there is a weight problem, or to believe that weight gain and consequent diseases (e.g., type 2 diabetes, high blood pressure, heart disease) are normal and part of the aging process. Other types of orientations and styles related to health behavior include self-control, self-awareness, and the interchangeable concepts of self-confidence and self-efficacy.
Self-Control
Self-control refers to the extent to which a person voluntarily and consciously creates, carries out, and maintains thoughts, emotions, and behaviors toward reaching desirable goals, even after encountering obstacles (Rosenbaum, 1990). Self-control behaviors are regulated by deliberate cognitive processes that are under the person's voluntary control. A good example of self-control in exercise settings is time management. Perhaps the primary reason people offer for not exercising is not having enough time (Sternfeld et al., 2009). People with high self-control plan their day and set aside time (i.e., day of the week, hour of the day, length of time) devoted to maintaining an exercise routine.
Self-control also means that the activity itself may be planned. For example, perhaps an exerciser who prefers the company of a friend during a workout plans to meet his friend at the exercise facility. Upon entering the facility, the individual has preplanned an hour devoted to various tasks that compose the exercise workout; specific routines are planned and carried out for the duration of the session, from entering to exiting the facility. The type of aerobic and resistance training may also be predetermined and executed in attempting to reach challenging goals. Presumably, the excuse of not having enough time now becomes having more time to do other things thanks to increased energy and vigor as a function of the workout. People with a high self-control orientation are more capable of carrying out preperformance and performance routines compared with their counterparts with low self-control (Faulkner et al., 2006). People with high self-control are schedule keepers and rarely waste time.
An important situational factor in developing an exercise habit is scheduling one's exercise sessions during the week. This requires good time management skills. Rather than saying, “I'll exercise when I get the time,” restate that view with, “I will exercise at x times on the following days.” A minimum of three times a week of intense exercise that expands one's fitness capacity and has a training effect (e.g., increased heart rate, increased muscular strength) is needed. However, finding opportunities to become physically active during the day (e.g., taking the stairs instead of the elevator, walking up or down the escalator, taking an evening or lunchtime walk) is also helpful for burning calories and managing weight.
Learned Resourcefulness
The pioneer writer and researcher in the literature on learned resourcefulness is Dr. Michael Rosenbaum (1990). He defined learned resourcefulness as “an acquired repertoire of behavioral and cognitive skills with which the person is able to regulate internal events such as emotions and cognitions that might otherwise interfere with the smooth execution of a target behavior” (p. xiv). High scorers on Rosenbaum's Self-Report Scale (Rosenbaum, 1990) are better able to
• tolerate physical discomfort,
• cope effectively with stress,
• succeed in weight-reduction programs,
• prevent or overcome feelings of helplessness,
• comply with medical and other health-related regimens,
• establish and maintain a relatively healthy lifestyle, and
• delay immediate gratification (e.g., binge eating) and understand the value of delayed gratification (e.g., exercising takes time, but the person receives more energy, better health, and improved performance quality).
In general, learned resourcefulness is particularly important in controlling negative thoughts and emotions while engendering desirable cognitive processes such as positive self-talk, optimism, self-motivation, and positive mood states. People high in learned resourcefulness are more confident; more likely to adopt an active lifestyle, including regular exercise; and less likely to engage in self-destructive behaviors (e.g., smoking, taking extreme risks). It is important to note that learned resourcefulness is not viewed as a personality trait. Instead, it is an orientation—a way of thinking that can be influenced through experience, counseling, and situational conditions.
Mental Toughness
Mental toughness is a disposition that represents the ability to reach and sustain high performance under pressure by expanding one's physical, mental, and emotional capacity (Connaughton, Hanton, and Jones, 2010). Mental toughness is learned, not inherited; it's an orientation. One common but false view of many athletes and coaches is that we are born with the right competitive instincts, and people who cannot handle failure lack the genetic predisposition to be mentally tough. The belief in a mental toughness gene is tempting because it absolves the person of taking responsibility for failure. However, the reality is that mental toughness can be taught, improved, and mastered. Exercisers need mental toughness to acknowledge their poor health and the need for physical activity, to withstand the challenges of physical exertion, to overcome physical fatigue, to continue to see the benefits of an exercise program, and to maintain exercise participation as a lifelong habit.
Mentally tough people are self-motivated and self-directed (their energy comes from internal sources; it is not forced from the outside); positive but realistic about handling adversity; in control of their emotions, especially in response to frustration and disappointment; and calm and relaxed under fire (rather than avoiding pressure, they are challenged by it). Mental toughness is also characterized by high energy, physical and mental readiness for action, a strong desire to succeed, relentlessness in the pursuit of challenging goals, superb concentration skills, self-confidence in the ability to perform well, and taking full responsibility for one's actions.
Self-Awareness
Think of self-awareness as the willingness to self-reflect, to engage introspectively, and to look at oneself through the eyes of others. This is not always easy to do, but others give us signals about their expectations and evaluations of us all the time, if we just take a good look. People react to us one way if they want our friendship and we have their respect. They react to us in a completely different way if they reject or disrespect us for whatever justified or unjustified reasons.
Self-awareness is an important component of health behavior because the ability to look inside and to be cognizant of our thoughts, emotions, and behaviors allows us to initiate steps for desirable change. If, for instance, we look in the mirror and see a person who is out of shape, overweight, and even unattractive, we can then begin the process of determining the reasons for our low energy, labored breathing, and general discomfort. Self-aware people also become more aware of the short-term costs and long-term consequences of their bad habits. They do not ignore their poor health and the negative habits that cause their current health status. This is why they are more likely to embrace support and opportunity to make lifelong changes that improve their health and happiness. They refuse to remain stuck in a self-destructive lifestyle. The challenges of self-awareness are addressed by Loehr and Schwartz (2003), who paraphrase John 32:8 from the Bible: “If the truth is to set us free, facing it cannot be a one-time event. Rather, it must become a practice. Like all of our ‘muscles,' self-awareness withers from disuse and deepens when we push past our resistance to see more of the truth” (p. 163).
Self-awareness, then, is an orientation. We differ in our willingness to become introspective about who we are and what we need to do to become better. As Loehr and Schwartz (2003) contend, “We must persistently shed light on those aspects of ourselves that we prefer not to see in order to build our mental, emotional and spiritual capacity” (p. 163). The authors also agree, however, that self-awareness can be self-defeating and overwhelming, bringing out negative thoughts, feelings, and emotions if it is absorbed in too big a dose. The right amount and frequency of self-awareness provides sufficient information to keep us on track and to be used as a source of information about what we need to become healthier and happier. As the authors conclude, “Facing the most difficult truths in our lives is challenging but also liberating” (p. 163).
Self-Efficacy
Confidence is a person's general feeling, perception, or belief that she has the capability to be successful in performing a skill and meeting task demands. Self-efficacy combines confidence with self-expectations. Self-efficacy, often associated and used interchangeably with self-confidence, is defined by Feltz and Lirgg (2001) as “the belief one has in being able to execute a specific task successfully . . .
to obtain a certain outcome” (p. 340). They further write, “Self-efficacy beliefs are not judgments about one's skills, objectively speaking, but rather are judgments of what one can accomplish with those skills” (p. 340). Thus, self-efficacy beliefs reflect a person's feelings not about what she can do but rather about what she has already done.
Self-efficacy is enormously important in an exercise setting and for changing and adhering to desirable, healthy behaviors. For example, people who experience self-doubt about their ability to join a fitness class and perform at least most of the exercises will be more likely to stop attending the class and either try some other form of exercise or return to their sedentary lifestyle. It is against human nature to continue participating in an activity in which we perceive our performance as incompetent or we fail to meet self-expectations or experience improved exercise performance and outcomes (e.g., better fitness). Therefore, building self-efficacy in an exercise setting bolsters the exercisers' perception that they are exercising properly, using correct technique, and improving performance. With respect to general health, clients will feel that following a certain set of routines will result or has resulted in superior health-related outcomes (e.g., more energy, positive mood, favorable results from medical tests). The objective of every worker in the health care industry, including fitness and nutrition coaches, is to provide instruction and positive feedback to build the person's self-efficacy about maintaining healthy habits.
Researchers have examined the link between self-efficacy and exercise behavior. Perhaps not surprising is the finding that as a person becomes more committed to an exercise habit, his self-efficacy improves. Self-efficacy is relatively low in the early stages of exercise, when a person is just beginning to develop an exercise routine or starting to make exercise a habit, and it increases dramatically as the person inserts exercise among his daily rituals. What is unknown is whether self-efficacy causes a person to adopt exercise as a lifestyle ritual or whether continued exercise increases self-efficacy. No doubt the two processes interact and self-efficacy is both the cause and the outcome of maintaining a regular exercise habit (Feltz and Lirgg, 2001; O'Leary, 1985).
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Religious institutions and spiritual leaders influence health behavior
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22).
Religious Community and Health Habits
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22). Religions, for example, promote beliefs that regulate behaviors related to alcohol, tobacco, diet, general hygiene, and medical care. Levin found that commitment to religion “may have a protective effect against subsequent illness . . . prevent or delay (illnesses), and have long-term benefits for physical and mental functioning and health” (p. 23).
The religious community is not immune from the health-related problems derived from an unhealthy lifestyle, however. The obesity epidemic still thrives in the religious and spiritual community (Cline and Ferraro, 2006). For example, the prevalence of obesity increased from 24% to 30% from 1986 to 1994 and likely has become much higher in more recent years among people of faith, that is, people who claim an affiliation with or membership in a denomination or religious institution. One potentially powerful source of health behavior change that has not been recognized in the war against obesity is the importance of religious and spiritual institutions and their leaders.
Next to physicians or other personal care providers, religious and spiritual leaders are some of the most credible people who influence the thoughts, emotions, and actions of a person of faith. People of faith often make a conscious decision to behave in a manner that is consistent with the expectations of their religious or spiritual messages.
In his book, Medicine, Religion, and Health: Where Science and Spirituality Meet (2008), Dr. Harold G. Koenig, MD, divides the benefits of religious practice or belief into six health-related areas:
1. Mental health
2. Immune function
3. Cardiovascular function
4. Stress and behavior-related diseases
5. Mortality
6. Physical disability
Based on his review of the research literature in each of these areas, Koenig (2008) concluded that religious practice or spirituality were strongly associated with superior health outcomes. He found, for example, that blood pressure and rates of stroke and cognitive impairment were each highly correlated with religious involvement (e.g., service attendance, frequency of prayer, strength of belief in a higher power). Although not always acknowledged by religious leaders, messages related to maintaining healthy habits are common throughout most religious texts.
To people of faith, arguably no one has more credibility for influencing behavior than their religious or spiritual leader. Should these leaders play a role in promoting healthy habits among congregants and the community at large? How can they address the apparent disconnect between people's religious practices, including a firm belief in religious or spiritual texts, and their lack of self-awareness about practicing healthy habits? And how can health professionals be involved in this process?
Role of Religious Leaders in Promoting and Modeling Healthy Habits
Many religious leaders contend that people who attend traditional ceremonies or services are looking for spiritual fulfillment, and that is the primary role of their institutions. Educating congregants about healthy habits is not. Perhaps this view, and the mission that propels it, needs to be reexamined. All sources of behavioral influence, including school systems, governments, corporations, the food industry, and religious institutions, need to be unified in providing information and incentives to replace self-destructive behavior patterns with healthier alternatives. One source of health behavior interventions that has received only minimal attention is the role of religious and spiritual leaders.
What should religious and spiritual leaders do to promote healthy habits, perhaps with assistance from health professionals? First, they need to look at themselves and determine if the change needs to start with them. Next, they must speak up and encourage their institution members—and other members of the community, when given the opportunity—to have discipline in all areas of their lives. One religious text, the Bible, addresses eating, indulgence, self-control, self-discipline, and gluttony. These topics need to be addressed in religious institutions and services without fear of offending attendees. Leaders of congregants who attend spiritual events and services should encourage their congregants to make lifestyle changes that will ultimately bring glory to God or some other higher power to whom they feel accountable. Religious leaders must stop being intimidated by the risk of losing members by offending them in order to acknowledge the importance of self-care as an inherent component of a religious and spiritual lifestyle (Colbert, 2002).
Perhaps the most serious obstacle to health behavior change in the religious community is persuading people of faith to take responsibility for their health and engage in the free will of healthy lifestyle choices, rather than surrender control to a higher power. Most religious texts, including the Bible, promote taking responsibility for health behavior. Philippians 2:13 states that God works within us to will his Holy Spirit and the free will to desire to create balance in our life—and the will to act on that desire.
For example, as Omartian (1996) contends, “The main reason to exercise is for your health. Without good health you cannot do all that the Lord has for you do to and you cannot be all the Lord wants you to be” (p. 117). Along these lines, Koenig (1999) asserts, “The world's religions encourage healthy living. . . .
All established religions discourage . . . any habit or activity harmful to the human body, which has traditionally been viewed as sacred, created in the image of God” (p. 72). And as Levin (2001) concludes, “All religions endorse the idea that we ought to take care of our bodies and not act in ways that are reckless and endanger our health” (p. 41).
There is an apparent need for religious institutions and their leaders to play a more prominent role in promoting community health and wellness and to serve as role models for their congregations. The credibility of pastors, priests, rabbis, imams, and other religious leaders will be further enhanced if their messages of health and wellness given in their sermons and programs are reflected in their own behavioral patterns. In other words, religious and spiritual leaders have to walk the walk, not just talk the talk.
Health Themes Addressed by Religious and Spiritual Leaders
Perhaps the strongest influence of a religious leader on the thoughts, emotions, and actions of attendees of religious services occurs when their attention is focused on the leader's words—the sermon. Health-related themes that extol the virtues of maintaining a healthy lifestyle need to be communicated more frequently and passionately, citing religious or spiritual text to reinforce main issues. For example, in the New Testament of the Christian Bible, the apostle Paul reminds his readers that their bodies are a dwelling place of the Holy Spirit, thereby bridging the gap between spiritual and physical dualism that may be keeping people of faith locked into unhealthy behavioral patterns. Paul contends that what we do with our bodies matters not only on a physical level but also on a spiritual level.
Religious leaders can also cite scripture to remind us that we are not owners but rather managers, or stewards, of our bodies. Maintaining healthy habits is a matter of personal stewardship. When we begin to perceive our bodies in a manner that is consistent with God's view, we begin to make decisions that affect our physical health that honors a higher power (i.e., God). Thus, maintaining unhealthy habits that lead to obesity and poor physical conditioning is a failure of that stewardship responsibility.
Another health theme found in religion is gluttony. The Gluttony in Religion highlight box lists examples of this theme from various religious texts that both religious leaders and health professionals may use with people of faith to address the association between healthy habits and spirituality or religion.
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Overcome mental barriers to reach exercise goals
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks.
Mental Barriers to Exercise Adherence
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks. However, it will not take a great deal of time to feel better and adjust to new physical demands they place on themselves. They simply need patience. Without it, they will quit. They will lack adherence, and this is exactly the problem with at least half the people who initiate exercise programs. Our high-achieving, impatient culture, made worse by personality traits such as negative perfectionism, high trait anxiety, and pessimism about the future, often does not allow us to set reasonable goals and to develop strategies to reach those goals.
Emotions, thoughts, and feelings drive behavior in one of two directions: positive, toward achieving success and developing a better, healthier, more energetic lifestyle, or negative, toward maintaining unhealthy habits, being overweight, lacking energy, and living a life inconsistent with one's values about what is important. Improving a client's lifestyle takes effort—and a plan. Health and fitness professionals need to revisit the client's values, connect each value to a new routine that will create and maintain a more active lifestyle, and improve physical and mental health. Adherence to a program of regular exercise, the theme of this chapter, is of paramount importance in doing everything in our power to take control of our destiny. In the words of former British prime minister Sir Winston Churchill, “Continuous effort—not strength or intelligence—is the key to unlocking our potential" (qtd. in Cook, 1993).
A person's decision to discontinue an exercise habit often has a psychological explanation. Here are some of the more common conditions that can lead to dropping out of an exercise program. Hopefully, health professionals can develop and apply effective responses to these excuses that will change the client's mind about quitting.
Anxiety
Anxiety consists of feelings of worry or threat about the future, as discussed in chapter 5. Anxious thoughts cause worry and distract the exerciser from the task at hand—and waste energy. Sources of exercise anxiety include worry about meeting goals, physical appearance, being accepted by others (even strangers at a fitness club), and using time to exercise instead of doing something else (“I could be watching TV or finishing a report instead of going to the gym”). Ironically, exercise actually reduces both short-term (acute) and long-term (chronic) anxiety. Exercise is what the doctor ordered for improved mental health, including reduced anxiety (deMoor et al., 2006). Health professionals should strongly consider exercise as one behavioral strategy for helping their clients manage anxiety, particularly if clients are given social support in their new exercise program.
Depression
Most people experience unhappiness and negative emotions; this is normal. Ongoing, deeply negative mood states, however, may be a more serious mood disorder referred to as clinical depression (APA, 2000). Depression is a mood disorder that ranges from mild to severe and can be due to a medical condition, substance use, or psychopathology (mental illness). A sedentary lifestyle may induce or promote depression, but exercise has been shown to reduce it in over 70 studies across various age groups and for both genders (Leith, 1998).
One factor that influences the effect of exercise on depression is whether the person has selected and is enjoying the type of physical activity. A second factor is whether the exercise is of sufficient intensity, frequency, and duration to improve fitness outcomes and lead to psychological benefits. Taking a quiet, slow walk through the park, although pleasant and relaxing, may not be sufficient to reduce depression (Brosse, Sheets, Lett, and Blumenthal, 2002). Buckworth and Dishman (2002), in support of recommendations from ACSM, suggest the following exercise guidelines for people with depression who are otherwise healthy: three to five days a week (frequency) for 20 to 60 minutes each session (duration) at 55% to 90% of maximal heart rate (intensity). Certified fitness coaches should aim to meet these standards when prescribing exercise for depressed clients.
Negativity
It is impossible to remain motivated and on task if self-talk is negative, such as, “I don't like this,” “I feel terrible,” or “I'm tired.” Replacing those thoughts with positive statements that are optimistic and enthusiastic induces more effort and energy. Examples include, “I can do this,” “I feel good,” “Just three more minutes to go,” and “Hang in there.” To quote an anonymous writer, “You cannot be unhappy and enthusiastic at the same time.
”Negative and antagonistic feelings and emotions can impair the development of an exercise habit, especially for novice performers. The problem with negative thinking is that it results in low effort and sets up the individual to fail. This process is similar to the self-fulfilling prophecy; one's performance level will be consistent with one's expectations.
Examples of negative thinking that serve as barriers to exercise success include lack of confidence (e.g., “I don't think I can do this”), intimidation (e.g., “I don't belong in this fitness facility,” “People are laughing at me”), pessimism (e.g., “I'll never lose weight,” “Exercise will never be enjoyable”), self-criticism (e.g., “I can't run even one lap of that track, so why even try?”, “Exercise is not for me; I'll always be weak”), impatience (e.g., “I've been exercising for three weeks and still run out of steam when jogging”), and irrational thinking (e.g., “I've always been heavy; why change now?”, “People just have to accept me the way I am,” “My spouse thinks my weight and appearance are just fine”).
There are several implications for health care professionals when it comes to addressing mental health. First, consultants should not attempt to diagnose or treat mental illness unless they are licensed psychologists or have other appropriate credentials related to this area. There are serious legal implications of providing treatment to a person who did not request it, was not diagnosed correctly, or did not receive the proper treatment. The key term that reflects the proper thing to do if mental illness is suspected is referral; that is, health care professionals must refer clients to a licensed mental health professional for diagnosis and treatment if mental illness, such as depression, chronic anxiety, or another condition, is suspected.
A second implication for dealing with psychological barriers to maintaining healthy habits, particularly related to exercise and nutrition, is the need to schedule meetings between the client and qualified health coaches, such as a certified personal trainer and a registered dietitian. Exercise and nutrition both influence mental health and should not be ignored when attempting to change client health behavior. Relationships with local experts in these areas should be established before referral in order to become familiar with the expert's background, skills, location, types of services rendered, and personal qualities. Sometimes clients prefer a male or female coach or can meet the consultant only on certain days at certain times. It is essential that the health care professional try to coordinate the client's needs and preferences with the coach's characteristics.
Perfectionism
Perfectionism is a trait reflecting a person's disposition toward "setting excessively high standards of performance in conjunction with a tendency to make overly critical self-evaluations" (Frost, Marten, Lahart, and Rosenblate, 1990, p. 450). It is usually studied as a trait measure—stable and cross-situational—not a state (situational) measure (Antony and Swinson, 2009).
Perfectionism has both positive and negative features. The positive aspects of perfectionism include setting and attempting to achieve high personal standards, striving to achieve lofty but realistic goals often leading to success, and being conscientious and self-confident (Flett, Hewitt, Blankstein, and Mosher, 1991). Negative features, not uncommon among people who go overboard in attempting to achieve goals, include feeling deep concern about making mistakes, which leads to heightened anxiety; having doubts about one's actions; setting excessively high standards; having difficulty recognizing success; and overemphasizing precision, neatness, order, and organization. People who fit these behavior and thought patterns are referred to by clinical psychologists as neurotic perfectionists. They have a propensity to engage in self-destructive behaviors, excessive self-criticism, failure to recognize achievement and competence, and feelings of “It's not good enough” (Antony and Swinson, 2009; Adderholdt-Elliott, 1987).
Neurotic perfectionists set unattainable goals and might engage in overtraining or exercise addiction. Their self-talk is based on messages they received when they were young, reminding themselves that “It's not good enough” and “I can do better.” Their expectations of others are also excessive. Perfectionists need to learn how to set reasonable goals and to recognize their own achievements and those of others, especially in exercise settings. They need to have indicators of success and to acknowledge when they have reached those indicators.
Implications for working with clients who reveal perfectionistic thinking include referral to a mental health professional so that its sources can be identified and treated. Perfectionism can play a role in attempts at self-improvement; however, when standards and goals are excessively high, when self-expectations for achievement are unrealistic, and when the person expects others to meet these same excessive standards, often at the expense of alienating others, then this condition becomes an obstacle to happiness, confidence, and mental health.
Another implication for working with perfectionistic clients is the need to help them set realistic but challenging goals that are measurable and observable, to help them detect times when they have met their performance expectations, and to verbally and directly recognize their accomplishments. One important strategy that validates positive feedback and gives the consultant credibility is to base feedback on numbers—perhaps fitness test results, blood test results, improved exercise performance (e.g., increased resistance in weight training, faster jogging times, reduced body-fat percentage), or some other measure that quantifies improved physical performance.
Finally, perfectionists often need to change their irrational thinking by being reminded of their accomplishments, favorably comparing their competence level with others, and being more realistic about their self-expectations. Perfectionism, particularly when excessive (also referred to by mental health professionals as irrational, maladaptive, or neurotic), has specific sources, such as parents, sport coaches, or teachers, and this may be pointed out as an issue that is nothing to be ashamed about and that might require professional consultation to address it.
Learn more about Applied Health Fitness Psychology.
Orientations and styles can be changed to promote exercise adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two.
Orientations, Styles, and Exercise Adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two. Personality traits are permanent, stable across situations, and partly a reflection of one's genetic predisposition, and therefore they are not subject to change. Orientations and styles, on the other hand, reflect common attitudes or a person's tendency to think or act in a predictable manner. The concepts of attributional style, coping style, and win orientation reflect predictable and persistent ways of thinking and acting under certain conditions. If, for instance, a person who demonstrates success or competence has an internal attributional style, the typical way the person explains success may be internal. That is, she may typically attribute the cause of her success as due to high effort or excellent skills, both internal explanations. Not taking responsibility for success or failure and perceiving the cause as something beyond the person's control reflects an external attributional style, at least for that particular situation (e.g., maintaining high fitness, improving performance on a given task, gaining excessive weight).
Orientations and styles also predict how people perceive the importance of a healthy lifestyle and to what they attribute their good or poor health. An internal disposition could reflect taking responsibility for one's excessive weight or poor fitness as due to poor dietary choices, excessive food intake, and lack of physical activity. Someone with an external disposition will be more likely to attribute weight gain to genetics or similarity to other family members, to not acknowledge there is a weight problem, or to believe that weight gain and consequent diseases (e.g., type 2 diabetes, high blood pressure, heart disease) are normal and part of the aging process. Other types of orientations and styles related to health behavior include self-control, self-awareness, and the interchangeable concepts of self-confidence and self-efficacy.
Self-Control
Self-control refers to the extent to which a person voluntarily and consciously creates, carries out, and maintains thoughts, emotions, and behaviors toward reaching desirable goals, even after encountering obstacles (Rosenbaum, 1990). Self-control behaviors are regulated by deliberate cognitive processes that are under the person's voluntary control. A good example of self-control in exercise settings is time management. Perhaps the primary reason people offer for not exercising is not having enough time (Sternfeld et al., 2009). People with high self-control plan their day and set aside time (i.e., day of the week, hour of the day, length of time) devoted to maintaining an exercise routine.
Self-control also means that the activity itself may be planned. For example, perhaps an exerciser who prefers the company of a friend during a workout plans to meet his friend at the exercise facility. Upon entering the facility, the individual has preplanned an hour devoted to various tasks that compose the exercise workout; specific routines are planned and carried out for the duration of the session, from entering to exiting the facility. The type of aerobic and resistance training may also be predetermined and executed in attempting to reach challenging goals. Presumably, the excuse of not having enough time now becomes having more time to do other things thanks to increased energy and vigor as a function of the workout. People with a high self-control orientation are more capable of carrying out preperformance and performance routines compared with their counterparts with low self-control (Faulkner et al., 2006). People with high self-control are schedule keepers and rarely waste time.
An important situational factor in developing an exercise habit is scheduling one's exercise sessions during the week. This requires good time management skills. Rather than saying, “I'll exercise when I get the time,” restate that view with, “I will exercise at x times on the following days.” A minimum of three times a week of intense exercise that expands one's fitness capacity and has a training effect (e.g., increased heart rate, increased muscular strength) is needed. However, finding opportunities to become physically active during the day (e.g., taking the stairs instead of the elevator, walking up or down the escalator, taking an evening or lunchtime walk) is also helpful for burning calories and managing weight.
Learned Resourcefulness
The pioneer writer and researcher in the literature on learned resourcefulness is Dr. Michael Rosenbaum (1990). He defined learned resourcefulness as “an acquired repertoire of behavioral and cognitive skills with which the person is able to regulate internal events such as emotions and cognitions that might otherwise interfere with the smooth execution of a target behavior” (p. xiv). High scorers on Rosenbaum's Self-Report Scale (Rosenbaum, 1990) are better able to
• tolerate physical discomfort,
• cope effectively with stress,
• succeed in weight-reduction programs,
• prevent or overcome feelings of helplessness,
• comply with medical and other health-related regimens,
• establish and maintain a relatively healthy lifestyle, and
• delay immediate gratification (e.g., binge eating) and understand the value of delayed gratification (e.g., exercising takes time, but the person receives more energy, better health, and improved performance quality).
In general, learned resourcefulness is particularly important in controlling negative thoughts and emotions while engendering desirable cognitive processes such as positive self-talk, optimism, self-motivation, and positive mood states. People high in learned resourcefulness are more confident; more likely to adopt an active lifestyle, including regular exercise; and less likely to engage in self-destructive behaviors (e.g., smoking, taking extreme risks). It is important to note that learned resourcefulness is not viewed as a personality trait. Instead, it is an orientation—a way of thinking that can be influenced through experience, counseling, and situational conditions.
Mental Toughness
Mental toughness is a disposition that represents the ability to reach and sustain high performance under pressure by expanding one's physical, mental, and emotional capacity (Connaughton, Hanton, and Jones, 2010). Mental toughness is learned, not inherited; it's an orientation. One common but false view of many athletes and coaches is that we are born with the right competitive instincts, and people who cannot handle failure lack the genetic predisposition to be mentally tough. The belief in a mental toughness gene is tempting because it absolves the person of taking responsibility for failure. However, the reality is that mental toughness can be taught, improved, and mastered. Exercisers need mental toughness to acknowledge their poor health and the need for physical activity, to withstand the challenges of physical exertion, to overcome physical fatigue, to continue to see the benefits of an exercise program, and to maintain exercise participation as a lifelong habit.
Mentally tough people are self-motivated and self-directed (their energy comes from internal sources; it is not forced from the outside); positive but realistic about handling adversity; in control of their emotions, especially in response to frustration and disappointment; and calm and relaxed under fire (rather than avoiding pressure, they are challenged by it). Mental toughness is also characterized by high energy, physical and mental readiness for action, a strong desire to succeed, relentlessness in the pursuit of challenging goals, superb concentration skills, self-confidence in the ability to perform well, and taking full responsibility for one's actions.
Self-Awareness
Think of self-awareness as the willingness to self-reflect, to engage introspectively, and to look at oneself through the eyes of others. This is not always easy to do, but others give us signals about their expectations and evaluations of us all the time, if we just take a good look. People react to us one way if they want our friendship and we have their respect. They react to us in a completely different way if they reject or disrespect us for whatever justified or unjustified reasons.
Self-awareness is an important component of health behavior because the ability to look inside and to be cognizant of our thoughts, emotions, and behaviors allows us to initiate steps for desirable change. If, for instance, we look in the mirror and see a person who is out of shape, overweight, and even unattractive, we can then begin the process of determining the reasons for our low energy, labored breathing, and general discomfort. Self-aware people also become more aware of the short-term costs and long-term consequences of their bad habits. They do not ignore their poor health and the negative habits that cause their current health status. This is why they are more likely to embrace support and opportunity to make lifelong changes that improve their health and happiness. They refuse to remain stuck in a self-destructive lifestyle. The challenges of self-awareness are addressed by Loehr and Schwartz (2003), who paraphrase John 32:8 from the Bible: “If the truth is to set us free, facing it cannot be a one-time event. Rather, it must become a practice. Like all of our ‘muscles,' self-awareness withers from disuse and deepens when we push past our resistance to see more of the truth” (p. 163).
Self-awareness, then, is an orientation. We differ in our willingness to become introspective about who we are and what we need to do to become better. As Loehr and Schwartz (2003) contend, “We must persistently shed light on those aspects of ourselves that we prefer not to see in order to build our mental, emotional and spiritual capacity” (p. 163). The authors also agree, however, that self-awareness can be self-defeating and overwhelming, bringing out negative thoughts, feelings, and emotions if it is absorbed in too big a dose. The right amount and frequency of self-awareness provides sufficient information to keep us on track and to be used as a source of information about what we need to become healthier and happier. As the authors conclude, “Facing the most difficult truths in our lives is challenging but also liberating” (p. 163).
Self-Efficacy
Confidence is a person's general feeling, perception, or belief that she has the capability to be successful in performing a skill and meeting task demands. Self-efficacy combines confidence with self-expectations. Self-efficacy, often associated and used interchangeably with self-confidence, is defined by Feltz and Lirgg (2001) as “the belief one has in being able to execute a specific task successfully . . .
to obtain a certain outcome” (p. 340). They further write, “Self-efficacy beliefs are not judgments about one's skills, objectively speaking, but rather are judgments of what one can accomplish with those skills” (p. 340). Thus, self-efficacy beliefs reflect a person's feelings not about what she can do but rather about what she has already done.
Self-efficacy is enormously important in an exercise setting and for changing and adhering to desirable, healthy behaviors. For example, people who experience self-doubt about their ability to join a fitness class and perform at least most of the exercises will be more likely to stop attending the class and either try some other form of exercise or return to their sedentary lifestyle. It is against human nature to continue participating in an activity in which we perceive our performance as incompetent or we fail to meet self-expectations or experience improved exercise performance and outcomes (e.g., better fitness). Therefore, building self-efficacy in an exercise setting bolsters the exercisers' perception that they are exercising properly, using correct technique, and improving performance. With respect to general health, clients will feel that following a certain set of routines will result or has resulted in superior health-related outcomes (e.g., more energy, positive mood, favorable results from medical tests). The objective of every worker in the health care industry, including fitness and nutrition coaches, is to provide instruction and positive feedback to build the person's self-efficacy about maintaining healthy habits.
Researchers have examined the link between self-efficacy and exercise behavior. Perhaps not surprising is the finding that as a person becomes more committed to an exercise habit, his self-efficacy improves. Self-efficacy is relatively low in the early stages of exercise, when a person is just beginning to develop an exercise routine or starting to make exercise a habit, and it increases dramatically as the person inserts exercise among his daily rituals. What is unknown is whether self-efficacy causes a person to adopt exercise as a lifestyle ritual or whether continued exercise increases self-efficacy. No doubt the two processes interact and self-efficacy is both the cause and the outcome of maintaining a regular exercise habit (Feltz and Lirgg, 2001; O'Leary, 1985).
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Religious institutions and spiritual leaders influence health behavior
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22).
Religious Community and Health Habits
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22). Religions, for example, promote beliefs that regulate behaviors related to alcohol, tobacco, diet, general hygiene, and medical care. Levin found that commitment to religion “may have a protective effect against subsequent illness . . . prevent or delay (illnesses), and have long-term benefits for physical and mental functioning and health” (p. 23).
The religious community is not immune from the health-related problems derived from an unhealthy lifestyle, however. The obesity epidemic still thrives in the religious and spiritual community (Cline and Ferraro, 2006). For example, the prevalence of obesity increased from 24% to 30% from 1986 to 1994 and likely has become much higher in more recent years among people of faith, that is, people who claim an affiliation with or membership in a denomination or religious institution. One potentially powerful source of health behavior change that has not been recognized in the war against obesity is the importance of religious and spiritual institutions and their leaders.
Next to physicians or other personal care providers, religious and spiritual leaders are some of the most credible people who influence the thoughts, emotions, and actions of a person of faith. People of faith often make a conscious decision to behave in a manner that is consistent with the expectations of their religious or spiritual messages.
In his book, Medicine, Religion, and Health: Where Science and Spirituality Meet (2008), Dr. Harold G. Koenig, MD, divides the benefits of religious practice or belief into six health-related areas:
1. Mental health
2. Immune function
3. Cardiovascular function
4. Stress and behavior-related diseases
5. Mortality
6. Physical disability
Based on his review of the research literature in each of these areas, Koenig (2008) concluded that religious practice or spirituality were strongly associated with superior health outcomes. He found, for example, that blood pressure and rates of stroke and cognitive impairment were each highly correlated with religious involvement (e.g., service attendance, frequency of prayer, strength of belief in a higher power). Although not always acknowledged by religious leaders, messages related to maintaining healthy habits are common throughout most religious texts.
To people of faith, arguably no one has more credibility for influencing behavior than their religious or spiritual leader. Should these leaders play a role in promoting healthy habits among congregants and the community at large? How can they address the apparent disconnect between people's religious practices, including a firm belief in religious or spiritual texts, and their lack of self-awareness about practicing healthy habits? And how can health professionals be involved in this process?
Role of Religious Leaders in Promoting and Modeling Healthy Habits
Many religious leaders contend that people who attend traditional ceremonies or services are looking for spiritual fulfillment, and that is the primary role of their institutions. Educating congregants about healthy habits is not. Perhaps this view, and the mission that propels it, needs to be reexamined. All sources of behavioral influence, including school systems, governments, corporations, the food industry, and religious institutions, need to be unified in providing information and incentives to replace self-destructive behavior patterns with healthier alternatives. One source of health behavior interventions that has received only minimal attention is the role of religious and spiritual leaders.
What should religious and spiritual leaders do to promote healthy habits, perhaps with assistance from health professionals? First, they need to look at themselves and determine if the change needs to start with them. Next, they must speak up and encourage their institution members—and other members of the community, when given the opportunity—to have discipline in all areas of their lives. One religious text, the Bible, addresses eating, indulgence, self-control, self-discipline, and gluttony. These topics need to be addressed in religious institutions and services without fear of offending attendees. Leaders of congregants who attend spiritual events and services should encourage their congregants to make lifestyle changes that will ultimately bring glory to God or some other higher power to whom they feel accountable. Religious leaders must stop being intimidated by the risk of losing members by offending them in order to acknowledge the importance of self-care as an inherent component of a religious and spiritual lifestyle (Colbert, 2002).
Perhaps the most serious obstacle to health behavior change in the religious community is persuading people of faith to take responsibility for their health and engage in the free will of healthy lifestyle choices, rather than surrender control to a higher power. Most religious texts, including the Bible, promote taking responsibility for health behavior. Philippians 2:13 states that God works within us to will his Holy Spirit and the free will to desire to create balance in our life—and the will to act on that desire.
For example, as Omartian (1996) contends, “The main reason to exercise is for your health. Without good health you cannot do all that the Lord has for you do to and you cannot be all the Lord wants you to be” (p. 117). Along these lines, Koenig (1999) asserts, “The world's religions encourage healthy living. . . .
All established religions discourage . . . any habit or activity harmful to the human body, which has traditionally been viewed as sacred, created in the image of God” (p. 72). And as Levin (2001) concludes, “All religions endorse the idea that we ought to take care of our bodies and not act in ways that are reckless and endanger our health” (p. 41).
There is an apparent need for religious institutions and their leaders to play a more prominent role in promoting community health and wellness and to serve as role models for their congregations. The credibility of pastors, priests, rabbis, imams, and other religious leaders will be further enhanced if their messages of health and wellness given in their sermons and programs are reflected in their own behavioral patterns. In other words, religious and spiritual leaders have to walk the walk, not just talk the talk.
Health Themes Addressed by Religious and Spiritual Leaders
Perhaps the strongest influence of a religious leader on the thoughts, emotions, and actions of attendees of religious services occurs when their attention is focused on the leader's words—the sermon. Health-related themes that extol the virtues of maintaining a healthy lifestyle need to be communicated more frequently and passionately, citing religious or spiritual text to reinforce main issues. For example, in the New Testament of the Christian Bible, the apostle Paul reminds his readers that their bodies are a dwelling place of the Holy Spirit, thereby bridging the gap between spiritual and physical dualism that may be keeping people of faith locked into unhealthy behavioral patterns. Paul contends that what we do with our bodies matters not only on a physical level but also on a spiritual level.
Religious leaders can also cite scripture to remind us that we are not owners but rather managers, or stewards, of our bodies. Maintaining healthy habits is a matter of personal stewardship. When we begin to perceive our bodies in a manner that is consistent with God's view, we begin to make decisions that affect our physical health that honors a higher power (i.e., God). Thus, maintaining unhealthy habits that lead to obesity and poor physical conditioning is a failure of that stewardship responsibility.
Another health theme found in religion is gluttony. The Gluttony in Religion highlight box lists examples of this theme from various religious texts that both religious leaders and health professionals may use with people of faith to address the association between healthy habits and spirituality or religion.
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Overcome mental barriers to reach exercise goals
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks.
Mental Barriers to Exercise Adherence
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks. However, it will not take a great deal of time to feel better and adjust to new physical demands they place on themselves. They simply need patience. Without it, they will quit. They will lack adherence, and this is exactly the problem with at least half the people who initiate exercise programs. Our high-achieving, impatient culture, made worse by personality traits such as negative perfectionism, high trait anxiety, and pessimism about the future, often does not allow us to set reasonable goals and to develop strategies to reach those goals.
Emotions, thoughts, and feelings drive behavior in one of two directions: positive, toward achieving success and developing a better, healthier, more energetic lifestyle, or negative, toward maintaining unhealthy habits, being overweight, lacking energy, and living a life inconsistent with one's values about what is important. Improving a client's lifestyle takes effort—and a plan. Health and fitness professionals need to revisit the client's values, connect each value to a new routine that will create and maintain a more active lifestyle, and improve physical and mental health. Adherence to a program of regular exercise, the theme of this chapter, is of paramount importance in doing everything in our power to take control of our destiny. In the words of former British prime minister Sir Winston Churchill, “Continuous effort—not strength or intelligence—is the key to unlocking our potential" (qtd. in Cook, 1993).
A person's decision to discontinue an exercise habit often has a psychological explanation. Here are some of the more common conditions that can lead to dropping out of an exercise program. Hopefully, health professionals can develop and apply effective responses to these excuses that will change the client's mind about quitting.
Anxiety
Anxiety consists of feelings of worry or threat about the future, as discussed in chapter 5. Anxious thoughts cause worry and distract the exerciser from the task at hand—and waste energy. Sources of exercise anxiety include worry about meeting goals, physical appearance, being accepted by others (even strangers at a fitness club), and using time to exercise instead of doing something else (“I could be watching TV or finishing a report instead of going to the gym”). Ironically, exercise actually reduces both short-term (acute) and long-term (chronic) anxiety. Exercise is what the doctor ordered for improved mental health, including reduced anxiety (deMoor et al., 2006). Health professionals should strongly consider exercise as one behavioral strategy for helping their clients manage anxiety, particularly if clients are given social support in their new exercise program.
Depression
Most people experience unhappiness and negative emotions; this is normal. Ongoing, deeply negative mood states, however, may be a more serious mood disorder referred to as clinical depression (APA, 2000). Depression is a mood disorder that ranges from mild to severe and can be due to a medical condition, substance use, or psychopathology (mental illness). A sedentary lifestyle may induce or promote depression, but exercise has been shown to reduce it in over 70 studies across various age groups and for both genders (Leith, 1998).
One factor that influences the effect of exercise on depression is whether the person has selected and is enjoying the type of physical activity. A second factor is whether the exercise is of sufficient intensity, frequency, and duration to improve fitness outcomes and lead to psychological benefits. Taking a quiet, slow walk through the park, although pleasant and relaxing, may not be sufficient to reduce depression (Brosse, Sheets, Lett, and Blumenthal, 2002). Buckworth and Dishman (2002), in support of recommendations from ACSM, suggest the following exercise guidelines for people with depression who are otherwise healthy: three to five days a week (frequency) for 20 to 60 minutes each session (duration) at 55% to 90% of maximal heart rate (intensity). Certified fitness coaches should aim to meet these standards when prescribing exercise for depressed clients.
Negativity
It is impossible to remain motivated and on task if self-talk is negative, such as, “I don't like this,” “I feel terrible,” or “I'm tired.” Replacing those thoughts with positive statements that are optimistic and enthusiastic induces more effort and energy. Examples include, “I can do this,” “I feel good,” “Just three more minutes to go,” and “Hang in there.” To quote an anonymous writer, “You cannot be unhappy and enthusiastic at the same time.
”Negative and antagonistic feelings and emotions can impair the development of an exercise habit, especially for novice performers. The problem with negative thinking is that it results in low effort and sets up the individual to fail. This process is similar to the self-fulfilling prophecy; one's performance level will be consistent with one's expectations.
Examples of negative thinking that serve as barriers to exercise success include lack of confidence (e.g., “I don't think I can do this”), intimidation (e.g., “I don't belong in this fitness facility,” “People are laughing at me”), pessimism (e.g., “I'll never lose weight,” “Exercise will never be enjoyable”), self-criticism (e.g., “I can't run even one lap of that track, so why even try?”, “Exercise is not for me; I'll always be weak”), impatience (e.g., “I've been exercising for three weeks and still run out of steam when jogging”), and irrational thinking (e.g., “I've always been heavy; why change now?”, “People just have to accept me the way I am,” “My spouse thinks my weight and appearance are just fine”).
There are several implications for health care professionals when it comes to addressing mental health. First, consultants should not attempt to diagnose or treat mental illness unless they are licensed psychologists or have other appropriate credentials related to this area. There are serious legal implications of providing treatment to a person who did not request it, was not diagnosed correctly, or did not receive the proper treatment. The key term that reflects the proper thing to do if mental illness is suspected is referral; that is, health care professionals must refer clients to a licensed mental health professional for diagnosis and treatment if mental illness, such as depression, chronic anxiety, or another condition, is suspected.
A second implication for dealing with psychological barriers to maintaining healthy habits, particularly related to exercise and nutrition, is the need to schedule meetings between the client and qualified health coaches, such as a certified personal trainer and a registered dietitian. Exercise and nutrition both influence mental health and should not be ignored when attempting to change client health behavior. Relationships with local experts in these areas should be established before referral in order to become familiar with the expert's background, skills, location, types of services rendered, and personal qualities. Sometimes clients prefer a male or female coach or can meet the consultant only on certain days at certain times. It is essential that the health care professional try to coordinate the client's needs and preferences with the coach's characteristics.
Perfectionism
Perfectionism is a trait reflecting a person's disposition toward "setting excessively high standards of performance in conjunction with a tendency to make overly critical self-evaluations" (Frost, Marten, Lahart, and Rosenblate, 1990, p. 450). It is usually studied as a trait measure—stable and cross-situational—not a state (situational) measure (Antony and Swinson, 2009).
Perfectionism has both positive and negative features. The positive aspects of perfectionism include setting and attempting to achieve high personal standards, striving to achieve lofty but realistic goals often leading to success, and being conscientious and self-confident (Flett, Hewitt, Blankstein, and Mosher, 1991). Negative features, not uncommon among people who go overboard in attempting to achieve goals, include feeling deep concern about making mistakes, which leads to heightened anxiety; having doubts about one's actions; setting excessively high standards; having difficulty recognizing success; and overemphasizing precision, neatness, order, and organization. People who fit these behavior and thought patterns are referred to by clinical psychologists as neurotic perfectionists. They have a propensity to engage in self-destructive behaviors, excessive self-criticism, failure to recognize achievement and competence, and feelings of “It's not good enough” (Antony and Swinson, 2009; Adderholdt-Elliott, 1987).
Neurotic perfectionists set unattainable goals and might engage in overtraining or exercise addiction. Their self-talk is based on messages they received when they were young, reminding themselves that “It's not good enough” and “I can do better.” Their expectations of others are also excessive. Perfectionists need to learn how to set reasonable goals and to recognize their own achievements and those of others, especially in exercise settings. They need to have indicators of success and to acknowledge when they have reached those indicators.
Implications for working with clients who reveal perfectionistic thinking include referral to a mental health professional so that its sources can be identified and treated. Perfectionism can play a role in attempts at self-improvement; however, when standards and goals are excessively high, when self-expectations for achievement are unrealistic, and when the person expects others to meet these same excessive standards, often at the expense of alienating others, then this condition becomes an obstacle to happiness, confidence, and mental health.
Another implication for working with perfectionistic clients is the need to help them set realistic but challenging goals that are measurable and observable, to help them detect times when they have met their performance expectations, and to verbally and directly recognize their accomplishments. One important strategy that validates positive feedback and gives the consultant credibility is to base feedback on numbers—perhaps fitness test results, blood test results, improved exercise performance (e.g., increased resistance in weight training, faster jogging times, reduced body-fat percentage), or some other measure that quantifies improved physical performance.
Finally, perfectionists often need to change their irrational thinking by being reminded of their accomplishments, favorably comparing their competence level with others, and being more realistic about their self-expectations. Perfectionism, particularly when excessive (also referred to by mental health professionals as irrational, maladaptive, or neurotic), has specific sources, such as parents, sport coaches, or teachers, and this may be pointed out as an issue that is nothing to be ashamed about and that might require professional consultation to address it.
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Orientations and styles can be changed to promote exercise adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two.
Orientations, Styles, and Exercise Adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two. Personality traits are permanent, stable across situations, and partly a reflection of one's genetic predisposition, and therefore they are not subject to change. Orientations and styles, on the other hand, reflect common attitudes or a person's tendency to think or act in a predictable manner. The concepts of attributional style, coping style, and win orientation reflect predictable and persistent ways of thinking and acting under certain conditions. If, for instance, a person who demonstrates success or competence has an internal attributional style, the typical way the person explains success may be internal. That is, she may typically attribute the cause of her success as due to high effort or excellent skills, both internal explanations. Not taking responsibility for success or failure and perceiving the cause as something beyond the person's control reflects an external attributional style, at least for that particular situation (e.g., maintaining high fitness, improving performance on a given task, gaining excessive weight).
Orientations and styles also predict how people perceive the importance of a healthy lifestyle and to what they attribute their good or poor health. An internal disposition could reflect taking responsibility for one's excessive weight or poor fitness as due to poor dietary choices, excessive food intake, and lack of physical activity. Someone with an external disposition will be more likely to attribute weight gain to genetics or similarity to other family members, to not acknowledge there is a weight problem, or to believe that weight gain and consequent diseases (e.g., type 2 diabetes, high blood pressure, heart disease) are normal and part of the aging process. Other types of orientations and styles related to health behavior include self-control, self-awareness, and the interchangeable concepts of self-confidence and self-efficacy.
Self-Control
Self-control refers to the extent to which a person voluntarily and consciously creates, carries out, and maintains thoughts, emotions, and behaviors toward reaching desirable goals, even after encountering obstacles (Rosenbaum, 1990). Self-control behaviors are regulated by deliberate cognitive processes that are under the person's voluntary control. A good example of self-control in exercise settings is time management. Perhaps the primary reason people offer for not exercising is not having enough time (Sternfeld et al., 2009). People with high self-control plan their day and set aside time (i.e., day of the week, hour of the day, length of time) devoted to maintaining an exercise routine.
Self-control also means that the activity itself may be planned. For example, perhaps an exerciser who prefers the company of a friend during a workout plans to meet his friend at the exercise facility. Upon entering the facility, the individual has preplanned an hour devoted to various tasks that compose the exercise workout; specific routines are planned and carried out for the duration of the session, from entering to exiting the facility. The type of aerobic and resistance training may also be predetermined and executed in attempting to reach challenging goals. Presumably, the excuse of not having enough time now becomes having more time to do other things thanks to increased energy and vigor as a function of the workout. People with a high self-control orientation are more capable of carrying out preperformance and performance routines compared with their counterparts with low self-control (Faulkner et al., 2006). People with high self-control are schedule keepers and rarely waste time.
An important situational factor in developing an exercise habit is scheduling one's exercise sessions during the week. This requires good time management skills. Rather than saying, “I'll exercise when I get the time,” restate that view with, “I will exercise at x times on the following days.” A minimum of three times a week of intense exercise that expands one's fitness capacity and has a training effect (e.g., increased heart rate, increased muscular strength) is needed. However, finding opportunities to become physically active during the day (e.g., taking the stairs instead of the elevator, walking up or down the escalator, taking an evening or lunchtime walk) is also helpful for burning calories and managing weight.
Learned Resourcefulness
The pioneer writer and researcher in the literature on learned resourcefulness is Dr. Michael Rosenbaum (1990). He defined learned resourcefulness as “an acquired repertoire of behavioral and cognitive skills with which the person is able to regulate internal events such as emotions and cognitions that might otherwise interfere with the smooth execution of a target behavior” (p. xiv). High scorers on Rosenbaum's Self-Report Scale (Rosenbaum, 1990) are better able to
• tolerate physical discomfort,
• cope effectively with stress,
• succeed in weight-reduction programs,
• prevent or overcome feelings of helplessness,
• comply with medical and other health-related regimens,
• establish and maintain a relatively healthy lifestyle, and
• delay immediate gratification (e.g., binge eating) and understand the value of delayed gratification (e.g., exercising takes time, but the person receives more energy, better health, and improved performance quality).
In general, learned resourcefulness is particularly important in controlling negative thoughts and emotions while engendering desirable cognitive processes such as positive self-talk, optimism, self-motivation, and positive mood states. People high in learned resourcefulness are more confident; more likely to adopt an active lifestyle, including regular exercise; and less likely to engage in self-destructive behaviors (e.g., smoking, taking extreme risks). It is important to note that learned resourcefulness is not viewed as a personality trait. Instead, it is an orientation—a way of thinking that can be influenced through experience, counseling, and situational conditions.
Mental Toughness
Mental toughness is a disposition that represents the ability to reach and sustain high performance under pressure by expanding one's physical, mental, and emotional capacity (Connaughton, Hanton, and Jones, 2010). Mental toughness is learned, not inherited; it's an orientation. One common but false view of many athletes and coaches is that we are born with the right competitive instincts, and people who cannot handle failure lack the genetic predisposition to be mentally tough. The belief in a mental toughness gene is tempting because it absolves the person of taking responsibility for failure. However, the reality is that mental toughness can be taught, improved, and mastered. Exercisers need mental toughness to acknowledge their poor health and the need for physical activity, to withstand the challenges of physical exertion, to overcome physical fatigue, to continue to see the benefits of an exercise program, and to maintain exercise participation as a lifelong habit.
Mentally tough people are self-motivated and self-directed (their energy comes from internal sources; it is not forced from the outside); positive but realistic about handling adversity; in control of their emotions, especially in response to frustration and disappointment; and calm and relaxed under fire (rather than avoiding pressure, they are challenged by it). Mental toughness is also characterized by high energy, physical and mental readiness for action, a strong desire to succeed, relentlessness in the pursuit of challenging goals, superb concentration skills, self-confidence in the ability to perform well, and taking full responsibility for one's actions.
Self-Awareness
Think of self-awareness as the willingness to self-reflect, to engage introspectively, and to look at oneself through the eyes of others. This is not always easy to do, but others give us signals about their expectations and evaluations of us all the time, if we just take a good look. People react to us one way if they want our friendship and we have their respect. They react to us in a completely different way if they reject or disrespect us for whatever justified or unjustified reasons.
Self-awareness is an important component of health behavior because the ability to look inside and to be cognizant of our thoughts, emotions, and behaviors allows us to initiate steps for desirable change. If, for instance, we look in the mirror and see a person who is out of shape, overweight, and even unattractive, we can then begin the process of determining the reasons for our low energy, labored breathing, and general discomfort. Self-aware people also become more aware of the short-term costs and long-term consequences of their bad habits. They do not ignore their poor health and the negative habits that cause their current health status. This is why they are more likely to embrace support and opportunity to make lifelong changes that improve their health and happiness. They refuse to remain stuck in a self-destructive lifestyle. The challenges of self-awareness are addressed by Loehr and Schwartz (2003), who paraphrase John 32:8 from the Bible: “If the truth is to set us free, facing it cannot be a one-time event. Rather, it must become a practice. Like all of our ‘muscles,' self-awareness withers from disuse and deepens when we push past our resistance to see more of the truth” (p. 163).
Self-awareness, then, is an orientation. We differ in our willingness to become introspective about who we are and what we need to do to become better. As Loehr and Schwartz (2003) contend, “We must persistently shed light on those aspects of ourselves that we prefer not to see in order to build our mental, emotional and spiritual capacity” (p. 163). The authors also agree, however, that self-awareness can be self-defeating and overwhelming, bringing out negative thoughts, feelings, and emotions if it is absorbed in too big a dose. The right amount and frequency of self-awareness provides sufficient information to keep us on track and to be used as a source of information about what we need to become healthier and happier. As the authors conclude, “Facing the most difficult truths in our lives is challenging but also liberating” (p. 163).
Self-Efficacy
Confidence is a person's general feeling, perception, or belief that she has the capability to be successful in performing a skill and meeting task demands. Self-efficacy combines confidence with self-expectations. Self-efficacy, often associated and used interchangeably with self-confidence, is defined by Feltz and Lirgg (2001) as “the belief one has in being able to execute a specific task successfully . . .
to obtain a certain outcome” (p. 340). They further write, “Self-efficacy beliefs are not judgments about one's skills, objectively speaking, but rather are judgments of what one can accomplish with those skills” (p. 340). Thus, self-efficacy beliefs reflect a person's feelings not about what she can do but rather about what she has already done.
Self-efficacy is enormously important in an exercise setting and for changing and adhering to desirable, healthy behaviors. For example, people who experience self-doubt about their ability to join a fitness class and perform at least most of the exercises will be more likely to stop attending the class and either try some other form of exercise or return to their sedentary lifestyle. It is against human nature to continue participating in an activity in which we perceive our performance as incompetent or we fail to meet self-expectations or experience improved exercise performance and outcomes (e.g., better fitness). Therefore, building self-efficacy in an exercise setting bolsters the exercisers' perception that they are exercising properly, using correct technique, and improving performance. With respect to general health, clients will feel that following a certain set of routines will result or has resulted in superior health-related outcomes (e.g., more energy, positive mood, favorable results from medical tests). The objective of every worker in the health care industry, including fitness and nutrition coaches, is to provide instruction and positive feedback to build the person's self-efficacy about maintaining healthy habits.
Researchers have examined the link between self-efficacy and exercise behavior. Perhaps not surprising is the finding that as a person becomes more committed to an exercise habit, his self-efficacy improves. Self-efficacy is relatively low in the early stages of exercise, when a person is just beginning to develop an exercise routine or starting to make exercise a habit, and it increases dramatically as the person inserts exercise among his daily rituals. What is unknown is whether self-efficacy causes a person to adopt exercise as a lifestyle ritual or whether continued exercise increases self-efficacy. No doubt the two processes interact and self-efficacy is both the cause and the outcome of maintaining a regular exercise habit (Feltz and Lirgg, 2001; O'Leary, 1985).
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Religious institutions and spiritual leaders influence health behavior
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22).
Religious Community and Health Habits
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22). Religions, for example, promote beliefs that regulate behaviors related to alcohol, tobacco, diet, general hygiene, and medical care. Levin found that commitment to religion “may have a protective effect against subsequent illness . . . prevent or delay (illnesses), and have long-term benefits for physical and mental functioning and health” (p. 23).
The religious community is not immune from the health-related problems derived from an unhealthy lifestyle, however. The obesity epidemic still thrives in the religious and spiritual community (Cline and Ferraro, 2006). For example, the prevalence of obesity increased from 24% to 30% from 1986 to 1994 and likely has become much higher in more recent years among people of faith, that is, people who claim an affiliation with or membership in a denomination or religious institution. One potentially powerful source of health behavior change that has not been recognized in the war against obesity is the importance of religious and spiritual institutions and their leaders.
Next to physicians or other personal care providers, religious and spiritual leaders are some of the most credible people who influence the thoughts, emotions, and actions of a person of faith. People of faith often make a conscious decision to behave in a manner that is consistent with the expectations of their religious or spiritual messages.
In his book, Medicine, Religion, and Health: Where Science and Spirituality Meet (2008), Dr. Harold G. Koenig, MD, divides the benefits of religious practice or belief into six health-related areas:
1. Mental health
2. Immune function
3. Cardiovascular function
4. Stress and behavior-related diseases
5. Mortality
6. Physical disability
Based on his review of the research literature in each of these areas, Koenig (2008) concluded that religious practice or spirituality were strongly associated with superior health outcomes. He found, for example, that blood pressure and rates of stroke and cognitive impairment were each highly correlated with religious involvement (e.g., service attendance, frequency of prayer, strength of belief in a higher power). Although not always acknowledged by religious leaders, messages related to maintaining healthy habits are common throughout most religious texts.
To people of faith, arguably no one has more credibility for influencing behavior than their religious or spiritual leader. Should these leaders play a role in promoting healthy habits among congregants and the community at large? How can they address the apparent disconnect between people's religious practices, including a firm belief in religious or spiritual texts, and their lack of self-awareness about practicing healthy habits? And how can health professionals be involved in this process?
Role of Religious Leaders in Promoting and Modeling Healthy Habits
Many religious leaders contend that people who attend traditional ceremonies or services are looking for spiritual fulfillment, and that is the primary role of their institutions. Educating congregants about healthy habits is not. Perhaps this view, and the mission that propels it, needs to be reexamined. All sources of behavioral influence, including school systems, governments, corporations, the food industry, and religious institutions, need to be unified in providing information and incentives to replace self-destructive behavior patterns with healthier alternatives. One source of health behavior interventions that has received only minimal attention is the role of religious and spiritual leaders.
What should religious and spiritual leaders do to promote healthy habits, perhaps with assistance from health professionals? First, they need to look at themselves and determine if the change needs to start with them. Next, they must speak up and encourage their institution members—and other members of the community, when given the opportunity—to have discipline in all areas of their lives. One religious text, the Bible, addresses eating, indulgence, self-control, self-discipline, and gluttony. These topics need to be addressed in religious institutions and services without fear of offending attendees. Leaders of congregants who attend spiritual events and services should encourage their congregants to make lifestyle changes that will ultimately bring glory to God or some other higher power to whom they feel accountable. Religious leaders must stop being intimidated by the risk of losing members by offending them in order to acknowledge the importance of self-care as an inherent component of a religious and spiritual lifestyle (Colbert, 2002).
Perhaps the most serious obstacle to health behavior change in the religious community is persuading people of faith to take responsibility for their health and engage in the free will of healthy lifestyle choices, rather than surrender control to a higher power. Most religious texts, including the Bible, promote taking responsibility for health behavior. Philippians 2:13 states that God works within us to will his Holy Spirit and the free will to desire to create balance in our life—and the will to act on that desire.
For example, as Omartian (1996) contends, “The main reason to exercise is for your health. Without good health you cannot do all that the Lord has for you do to and you cannot be all the Lord wants you to be” (p. 117). Along these lines, Koenig (1999) asserts, “The world's religions encourage healthy living. . . .
All established religions discourage . . . any habit or activity harmful to the human body, which has traditionally been viewed as sacred, created in the image of God” (p. 72). And as Levin (2001) concludes, “All religions endorse the idea that we ought to take care of our bodies and not act in ways that are reckless and endanger our health” (p. 41).
There is an apparent need for religious institutions and their leaders to play a more prominent role in promoting community health and wellness and to serve as role models for their congregations. The credibility of pastors, priests, rabbis, imams, and other religious leaders will be further enhanced if their messages of health and wellness given in their sermons and programs are reflected in their own behavioral patterns. In other words, religious and spiritual leaders have to walk the walk, not just talk the talk.
Health Themes Addressed by Religious and Spiritual Leaders
Perhaps the strongest influence of a religious leader on the thoughts, emotions, and actions of attendees of religious services occurs when their attention is focused on the leader's words—the sermon. Health-related themes that extol the virtues of maintaining a healthy lifestyle need to be communicated more frequently and passionately, citing religious or spiritual text to reinforce main issues. For example, in the New Testament of the Christian Bible, the apostle Paul reminds his readers that their bodies are a dwelling place of the Holy Spirit, thereby bridging the gap between spiritual and physical dualism that may be keeping people of faith locked into unhealthy behavioral patterns. Paul contends that what we do with our bodies matters not only on a physical level but also on a spiritual level.
Religious leaders can also cite scripture to remind us that we are not owners but rather managers, or stewards, of our bodies. Maintaining healthy habits is a matter of personal stewardship. When we begin to perceive our bodies in a manner that is consistent with God's view, we begin to make decisions that affect our physical health that honors a higher power (i.e., God). Thus, maintaining unhealthy habits that lead to obesity and poor physical conditioning is a failure of that stewardship responsibility.
Another health theme found in religion is gluttony. The Gluttony in Religion highlight box lists examples of this theme from various religious texts that both religious leaders and health professionals may use with people of faith to address the association between healthy habits and spirituality or religion.
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Overcome mental barriers to reach exercise goals
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks.
Mental Barriers to Exercise Adherence
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks. However, it will not take a great deal of time to feel better and adjust to new physical demands they place on themselves. They simply need patience. Without it, they will quit. They will lack adherence, and this is exactly the problem with at least half the people who initiate exercise programs. Our high-achieving, impatient culture, made worse by personality traits such as negative perfectionism, high trait anxiety, and pessimism about the future, often does not allow us to set reasonable goals and to develop strategies to reach those goals.
Emotions, thoughts, and feelings drive behavior in one of two directions: positive, toward achieving success and developing a better, healthier, more energetic lifestyle, or negative, toward maintaining unhealthy habits, being overweight, lacking energy, and living a life inconsistent with one's values about what is important. Improving a client's lifestyle takes effort—and a plan. Health and fitness professionals need to revisit the client's values, connect each value to a new routine that will create and maintain a more active lifestyle, and improve physical and mental health. Adherence to a program of regular exercise, the theme of this chapter, is of paramount importance in doing everything in our power to take control of our destiny. In the words of former British prime minister Sir Winston Churchill, “Continuous effort—not strength or intelligence—is the key to unlocking our potential" (qtd. in Cook, 1993).
A person's decision to discontinue an exercise habit often has a psychological explanation. Here are some of the more common conditions that can lead to dropping out of an exercise program. Hopefully, health professionals can develop and apply effective responses to these excuses that will change the client's mind about quitting.
Anxiety
Anxiety consists of feelings of worry or threat about the future, as discussed in chapter 5. Anxious thoughts cause worry and distract the exerciser from the task at hand—and waste energy. Sources of exercise anxiety include worry about meeting goals, physical appearance, being accepted by others (even strangers at a fitness club), and using time to exercise instead of doing something else (“I could be watching TV or finishing a report instead of going to the gym”). Ironically, exercise actually reduces both short-term (acute) and long-term (chronic) anxiety. Exercise is what the doctor ordered for improved mental health, including reduced anxiety (deMoor et al., 2006). Health professionals should strongly consider exercise as one behavioral strategy for helping their clients manage anxiety, particularly if clients are given social support in their new exercise program.
Depression
Most people experience unhappiness and negative emotions; this is normal. Ongoing, deeply negative mood states, however, may be a more serious mood disorder referred to as clinical depression (APA, 2000). Depression is a mood disorder that ranges from mild to severe and can be due to a medical condition, substance use, or psychopathology (mental illness). A sedentary lifestyle may induce or promote depression, but exercise has been shown to reduce it in over 70 studies across various age groups and for both genders (Leith, 1998).
One factor that influences the effect of exercise on depression is whether the person has selected and is enjoying the type of physical activity. A second factor is whether the exercise is of sufficient intensity, frequency, and duration to improve fitness outcomes and lead to psychological benefits. Taking a quiet, slow walk through the park, although pleasant and relaxing, may not be sufficient to reduce depression (Brosse, Sheets, Lett, and Blumenthal, 2002). Buckworth and Dishman (2002), in support of recommendations from ACSM, suggest the following exercise guidelines for people with depression who are otherwise healthy: three to five days a week (frequency) for 20 to 60 minutes each session (duration) at 55% to 90% of maximal heart rate (intensity). Certified fitness coaches should aim to meet these standards when prescribing exercise for depressed clients.
Negativity
It is impossible to remain motivated and on task if self-talk is negative, such as, “I don't like this,” “I feel terrible,” or “I'm tired.” Replacing those thoughts with positive statements that are optimistic and enthusiastic induces more effort and energy. Examples include, “I can do this,” “I feel good,” “Just three more minutes to go,” and “Hang in there.” To quote an anonymous writer, “You cannot be unhappy and enthusiastic at the same time.
”Negative and antagonistic feelings and emotions can impair the development of an exercise habit, especially for novice performers. The problem with negative thinking is that it results in low effort and sets up the individual to fail. This process is similar to the self-fulfilling prophecy; one's performance level will be consistent with one's expectations.
Examples of negative thinking that serve as barriers to exercise success include lack of confidence (e.g., “I don't think I can do this”), intimidation (e.g., “I don't belong in this fitness facility,” “People are laughing at me”), pessimism (e.g., “I'll never lose weight,” “Exercise will never be enjoyable”), self-criticism (e.g., “I can't run even one lap of that track, so why even try?”, “Exercise is not for me; I'll always be weak”), impatience (e.g., “I've been exercising for three weeks and still run out of steam when jogging”), and irrational thinking (e.g., “I've always been heavy; why change now?”, “People just have to accept me the way I am,” “My spouse thinks my weight and appearance are just fine”).
There are several implications for health care professionals when it comes to addressing mental health. First, consultants should not attempt to diagnose or treat mental illness unless they are licensed psychologists or have other appropriate credentials related to this area. There are serious legal implications of providing treatment to a person who did not request it, was not diagnosed correctly, or did not receive the proper treatment. The key term that reflects the proper thing to do if mental illness is suspected is referral; that is, health care professionals must refer clients to a licensed mental health professional for diagnosis and treatment if mental illness, such as depression, chronic anxiety, or another condition, is suspected.
A second implication for dealing with psychological barriers to maintaining healthy habits, particularly related to exercise and nutrition, is the need to schedule meetings between the client and qualified health coaches, such as a certified personal trainer and a registered dietitian. Exercise and nutrition both influence mental health and should not be ignored when attempting to change client health behavior. Relationships with local experts in these areas should be established before referral in order to become familiar with the expert's background, skills, location, types of services rendered, and personal qualities. Sometimes clients prefer a male or female coach or can meet the consultant only on certain days at certain times. It is essential that the health care professional try to coordinate the client's needs and preferences with the coach's characteristics.
Perfectionism
Perfectionism is a trait reflecting a person's disposition toward "setting excessively high standards of performance in conjunction with a tendency to make overly critical self-evaluations" (Frost, Marten, Lahart, and Rosenblate, 1990, p. 450). It is usually studied as a trait measure—stable and cross-situational—not a state (situational) measure (Antony and Swinson, 2009).
Perfectionism has both positive and negative features. The positive aspects of perfectionism include setting and attempting to achieve high personal standards, striving to achieve lofty but realistic goals often leading to success, and being conscientious and self-confident (Flett, Hewitt, Blankstein, and Mosher, 1991). Negative features, not uncommon among people who go overboard in attempting to achieve goals, include feeling deep concern about making mistakes, which leads to heightened anxiety; having doubts about one's actions; setting excessively high standards; having difficulty recognizing success; and overemphasizing precision, neatness, order, and organization. People who fit these behavior and thought patterns are referred to by clinical psychologists as neurotic perfectionists. They have a propensity to engage in self-destructive behaviors, excessive self-criticism, failure to recognize achievement and competence, and feelings of “It's not good enough” (Antony and Swinson, 2009; Adderholdt-Elliott, 1987).
Neurotic perfectionists set unattainable goals and might engage in overtraining or exercise addiction. Their self-talk is based on messages they received when they were young, reminding themselves that “It's not good enough” and “I can do better.” Their expectations of others are also excessive. Perfectionists need to learn how to set reasonable goals and to recognize their own achievements and those of others, especially in exercise settings. They need to have indicators of success and to acknowledge when they have reached those indicators.
Implications for working with clients who reveal perfectionistic thinking include referral to a mental health professional so that its sources can be identified and treated. Perfectionism can play a role in attempts at self-improvement; however, when standards and goals are excessively high, when self-expectations for achievement are unrealistic, and when the person expects others to meet these same excessive standards, often at the expense of alienating others, then this condition becomes an obstacle to happiness, confidence, and mental health.
Another implication for working with perfectionistic clients is the need to help them set realistic but challenging goals that are measurable and observable, to help them detect times when they have met their performance expectations, and to verbally and directly recognize their accomplishments. One important strategy that validates positive feedback and gives the consultant credibility is to base feedback on numbers—perhaps fitness test results, blood test results, improved exercise performance (e.g., increased resistance in weight training, faster jogging times, reduced body-fat percentage), or some other measure that quantifies improved physical performance.
Finally, perfectionists often need to change their irrational thinking by being reminded of their accomplishments, favorably comparing their competence level with others, and being more realistic about their self-expectations. Perfectionism, particularly when excessive (also referred to by mental health professionals as irrational, maladaptive, or neurotic), has specific sources, such as parents, sport coaches, or teachers, and this may be pointed out as an issue that is nothing to be ashamed about and that might require professional consultation to address it.
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Orientations and styles can be changed to promote exercise adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two.
Orientations, Styles, and Exercise Adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two. Personality traits are permanent, stable across situations, and partly a reflection of one's genetic predisposition, and therefore they are not subject to change. Orientations and styles, on the other hand, reflect common attitudes or a person's tendency to think or act in a predictable manner. The concepts of attributional style, coping style, and win orientation reflect predictable and persistent ways of thinking and acting under certain conditions. If, for instance, a person who demonstrates success or competence has an internal attributional style, the typical way the person explains success may be internal. That is, she may typically attribute the cause of her success as due to high effort or excellent skills, both internal explanations. Not taking responsibility for success or failure and perceiving the cause as something beyond the person's control reflects an external attributional style, at least for that particular situation (e.g., maintaining high fitness, improving performance on a given task, gaining excessive weight).
Orientations and styles also predict how people perceive the importance of a healthy lifestyle and to what they attribute their good or poor health. An internal disposition could reflect taking responsibility for one's excessive weight or poor fitness as due to poor dietary choices, excessive food intake, and lack of physical activity. Someone with an external disposition will be more likely to attribute weight gain to genetics or similarity to other family members, to not acknowledge there is a weight problem, or to believe that weight gain and consequent diseases (e.g., type 2 diabetes, high blood pressure, heart disease) are normal and part of the aging process. Other types of orientations and styles related to health behavior include self-control, self-awareness, and the interchangeable concepts of self-confidence and self-efficacy.
Self-Control
Self-control refers to the extent to which a person voluntarily and consciously creates, carries out, and maintains thoughts, emotions, and behaviors toward reaching desirable goals, even after encountering obstacles (Rosenbaum, 1990). Self-control behaviors are regulated by deliberate cognitive processes that are under the person's voluntary control. A good example of self-control in exercise settings is time management. Perhaps the primary reason people offer for not exercising is not having enough time (Sternfeld et al., 2009). People with high self-control plan their day and set aside time (i.e., day of the week, hour of the day, length of time) devoted to maintaining an exercise routine.
Self-control also means that the activity itself may be planned. For example, perhaps an exerciser who prefers the company of a friend during a workout plans to meet his friend at the exercise facility. Upon entering the facility, the individual has preplanned an hour devoted to various tasks that compose the exercise workout; specific routines are planned and carried out for the duration of the session, from entering to exiting the facility. The type of aerobic and resistance training may also be predetermined and executed in attempting to reach challenging goals. Presumably, the excuse of not having enough time now becomes having more time to do other things thanks to increased energy and vigor as a function of the workout. People with a high self-control orientation are more capable of carrying out preperformance and performance routines compared with their counterparts with low self-control (Faulkner et al., 2006). People with high self-control are schedule keepers and rarely waste time.
An important situational factor in developing an exercise habit is scheduling one's exercise sessions during the week. This requires good time management skills. Rather than saying, “I'll exercise when I get the time,” restate that view with, “I will exercise at x times on the following days.” A minimum of three times a week of intense exercise that expands one's fitness capacity and has a training effect (e.g., increased heart rate, increased muscular strength) is needed. However, finding opportunities to become physically active during the day (e.g., taking the stairs instead of the elevator, walking up or down the escalator, taking an evening or lunchtime walk) is also helpful for burning calories and managing weight.
Learned Resourcefulness
The pioneer writer and researcher in the literature on learned resourcefulness is Dr. Michael Rosenbaum (1990). He defined learned resourcefulness as “an acquired repertoire of behavioral and cognitive skills with which the person is able to regulate internal events such as emotions and cognitions that might otherwise interfere with the smooth execution of a target behavior” (p. xiv). High scorers on Rosenbaum's Self-Report Scale (Rosenbaum, 1990) are better able to
• tolerate physical discomfort,
• cope effectively with stress,
• succeed in weight-reduction programs,
• prevent or overcome feelings of helplessness,
• comply with medical and other health-related regimens,
• establish and maintain a relatively healthy lifestyle, and
• delay immediate gratification (e.g., binge eating) and understand the value of delayed gratification (e.g., exercising takes time, but the person receives more energy, better health, and improved performance quality).
In general, learned resourcefulness is particularly important in controlling negative thoughts and emotions while engendering desirable cognitive processes such as positive self-talk, optimism, self-motivation, and positive mood states. People high in learned resourcefulness are more confident; more likely to adopt an active lifestyle, including regular exercise; and less likely to engage in self-destructive behaviors (e.g., smoking, taking extreme risks). It is important to note that learned resourcefulness is not viewed as a personality trait. Instead, it is an orientation—a way of thinking that can be influenced through experience, counseling, and situational conditions.
Mental Toughness
Mental toughness is a disposition that represents the ability to reach and sustain high performance under pressure by expanding one's physical, mental, and emotional capacity (Connaughton, Hanton, and Jones, 2010). Mental toughness is learned, not inherited; it's an orientation. One common but false view of many athletes and coaches is that we are born with the right competitive instincts, and people who cannot handle failure lack the genetic predisposition to be mentally tough. The belief in a mental toughness gene is tempting because it absolves the person of taking responsibility for failure. However, the reality is that mental toughness can be taught, improved, and mastered. Exercisers need mental toughness to acknowledge their poor health and the need for physical activity, to withstand the challenges of physical exertion, to overcome physical fatigue, to continue to see the benefits of an exercise program, and to maintain exercise participation as a lifelong habit.
Mentally tough people are self-motivated and self-directed (their energy comes from internal sources; it is not forced from the outside); positive but realistic about handling adversity; in control of their emotions, especially in response to frustration and disappointment; and calm and relaxed under fire (rather than avoiding pressure, they are challenged by it). Mental toughness is also characterized by high energy, physical and mental readiness for action, a strong desire to succeed, relentlessness in the pursuit of challenging goals, superb concentration skills, self-confidence in the ability to perform well, and taking full responsibility for one's actions.
Self-Awareness
Think of self-awareness as the willingness to self-reflect, to engage introspectively, and to look at oneself through the eyes of others. This is not always easy to do, but others give us signals about their expectations and evaluations of us all the time, if we just take a good look. People react to us one way if they want our friendship and we have their respect. They react to us in a completely different way if they reject or disrespect us for whatever justified or unjustified reasons.
Self-awareness is an important component of health behavior because the ability to look inside and to be cognizant of our thoughts, emotions, and behaviors allows us to initiate steps for desirable change. If, for instance, we look in the mirror and see a person who is out of shape, overweight, and even unattractive, we can then begin the process of determining the reasons for our low energy, labored breathing, and general discomfort. Self-aware people also become more aware of the short-term costs and long-term consequences of their bad habits. They do not ignore their poor health and the negative habits that cause their current health status. This is why they are more likely to embrace support and opportunity to make lifelong changes that improve their health and happiness. They refuse to remain stuck in a self-destructive lifestyle. The challenges of self-awareness are addressed by Loehr and Schwartz (2003), who paraphrase John 32:8 from the Bible: “If the truth is to set us free, facing it cannot be a one-time event. Rather, it must become a practice. Like all of our ‘muscles,' self-awareness withers from disuse and deepens when we push past our resistance to see more of the truth” (p. 163).
Self-awareness, then, is an orientation. We differ in our willingness to become introspective about who we are and what we need to do to become better. As Loehr and Schwartz (2003) contend, “We must persistently shed light on those aspects of ourselves that we prefer not to see in order to build our mental, emotional and spiritual capacity” (p. 163). The authors also agree, however, that self-awareness can be self-defeating and overwhelming, bringing out negative thoughts, feelings, and emotions if it is absorbed in too big a dose. The right amount and frequency of self-awareness provides sufficient information to keep us on track and to be used as a source of information about what we need to become healthier and happier. As the authors conclude, “Facing the most difficult truths in our lives is challenging but also liberating” (p. 163).
Self-Efficacy
Confidence is a person's general feeling, perception, or belief that she has the capability to be successful in performing a skill and meeting task demands. Self-efficacy combines confidence with self-expectations. Self-efficacy, often associated and used interchangeably with self-confidence, is defined by Feltz and Lirgg (2001) as “the belief one has in being able to execute a specific task successfully . . .
to obtain a certain outcome” (p. 340). They further write, “Self-efficacy beliefs are not judgments about one's skills, objectively speaking, but rather are judgments of what one can accomplish with those skills” (p. 340). Thus, self-efficacy beliefs reflect a person's feelings not about what she can do but rather about what she has already done.
Self-efficacy is enormously important in an exercise setting and for changing and adhering to desirable, healthy behaviors. For example, people who experience self-doubt about their ability to join a fitness class and perform at least most of the exercises will be more likely to stop attending the class and either try some other form of exercise or return to their sedentary lifestyle. It is against human nature to continue participating in an activity in which we perceive our performance as incompetent or we fail to meet self-expectations or experience improved exercise performance and outcomes (e.g., better fitness). Therefore, building self-efficacy in an exercise setting bolsters the exercisers' perception that they are exercising properly, using correct technique, and improving performance. With respect to general health, clients will feel that following a certain set of routines will result or has resulted in superior health-related outcomes (e.g., more energy, positive mood, favorable results from medical tests). The objective of every worker in the health care industry, including fitness and nutrition coaches, is to provide instruction and positive feedback to build the person's self-efficacy about maintaining healthy habits.
Researchers have examined the link between self-efficacy and exercise behavior. Perhaps not surprising is the finding that as a person becomes more committed to an exercise habit, his self-efficacy improves. Self-efficacy is relatively low in the early stages of exercise, when a person is just beginning to develop an exercise routine or starting to make exercise a habit, and it increases dramatically as the person inserts exercise among his daily rituals. What is unknown is whether self-efficacy causes a person to adopt exercise as a lifestyle ritual or whether continued exercise increases self-efficacy. No doubt the two processes interact and self-efficacy is both the cause and the outcome of maintaining a regular exercise habit (Feltz and Lirgg, 2001; O'Leary, 1985).
Learn more about Applied Health Fitness Psychology.
Religious institutions and spiritual leaders influence health behavior
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22).
Religious Community and Health Habits
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22). Religions, for example, promote beliefs that regulate behaviors related to alcohol, tobacco, diet, general hygiene, and medical care. Levin found that commitment to religion “may have a protective effect against subsequent illness . . . prevent or delay (illnesses), and have long-term benefits for physical and mental functioning and health” (p. 23).
The religious community is not immune from the health-related problems derived from an unhealthy lifestyle, however. The obesity epidemic still thrives in the religious and spiritual community (Cline and Ferraro, 2006). For example, the prevalence of obesity increased from 24% to 30% from 1986 to 1994 and likely has become much higher in more recent years among people of faith, that is, people who claim an affiliation with or membership in a denomination or religious institution. One potentially powerful source of health behavior change that has not been recognized in the war against obesity is the importance of religious and spiritual institutions and their leaders.
Next to physicians or other personal care providers, religious and spiritual leaders are some of the most credible people who influence the thoughts, emotions, and actions of a person of faith. People of faith often make a conscious decision to behave in a manner that is consistent with the expectations of their religious or spiritual messages.
In his book, Medicine, Religion, and Health: Where Science and Spirituality Meet (2008), Dr. Harold G. Koenig, MD, divides the benefits of religious practice or belief into six health-related areas:
1. Mental health
2. Immune function
3. Cardiovascular function
4. Stress and behavior-related diseases
5. Mortality
6. Physical disability
Based on his review of the research literature in each of these areas, Koenig (2008) concluded that religious practice or spirituality were strongly associated with superior health outcomes. He found, for example, that blood pressure and rates of stroke and cognitive impairment were each highly correlated with religious involvement (e.g., service attendance, frequency of prayer, strength of belief in a higher power). Although not always acknowledged by religious leaders, messages related to maintaining healthy habits are common throughout most religious texts.
To people of faith, arguably no one has more credibility for influencing behavior than their religious or spiritual leader. Should these leaders play a role in promoting healthy habits among congregants and the community at large? How can they address the apparent disconnect between people's religious practices, including a firm belief in religious or spiritual texts, and their lack of self-awareness about practicing healthy habits? And how can health professionals be involved in this process?
Role of Religious Leaders in Promoting and Modeling Healthy Habits
Many religious leaders contend that people who attend traditional ceremonies or services are looking for spiritual fulfillment, and that is the primary role of their institutions. Educating congregants about healthy habits is not. Perhaps this view, and the mission that propels it, needs to be reexamined. All sources of behavioral influence, including school systems, governments, corporations, the food industry, and religious institutions, need to be unified in providing information and incentives to replace self-destructive behavior patterns with healthier alternatives. One source of health behavior interventions that has received only minimal attention is the role of religious and spiritual leaders.
What should religious and spiritual leaders do to promote healthy habits, perhaps with assistance from health professionals? First, they need to look at themselves and determine if the change needs to start with them. Next, they must speak up and encourage their institution members—and other members of the community, when given the opportunity—to have discipline in all areas of their lives. One religious text, the Bible, addresses eating, indulgence, self-control, self-discipline, and gluttony. These topics need to be addressed in religious institutions and services without fear of offending attendees. Leaders of congregants who attend spiritual events and services should encourage their congregants to make lifestyle changes that will ultimately bring glory to God or some other higher power to whom they feel accountable. Religious leaders must stop being intimidated by the risk of losing members by offending them in order to acknowledge the importance of self-care as an inherent component of a religious and spiritual lifestyle (Colbert, 2002).
Perhaps the most serious obstacle to health behavior change in the religious community is persuading people of faith to take responsibility for their health and engage in the free will of healthy lifestyle choices, rather than surrender control to a higher power. Most religious texts, including the Bible, promote taking responsibility for health behavior. Philippians 2:13 states that God works within us to will his Holy Spirit and the free will to desire to create balance in our life—and the will to act on that desire.
For example, as Omartian (1996) contends, “The main reason to exercise is for your health. Without good health you cannot do all that the Lord has for you do to and you cannot be all the Lord wants you to be” (p. 117). Along these lines, Koenig (1999) asserts, “The world's religions encourage healthy living. . . .
All established religions discourage . . . any habit or activity harmful to the human body, which has traditionally been viewed as sacred, created in the image of God” (p. 72). And as Levin (2001) concludes, “All religions endorse the idea that we ought to take care of our bodies and not act in ways that are reckless and endanger our health” (p. 41).
There is an apparent need for religious institutions and their leaders to play a more prominent role in promoting community health and wellness and to serve as role models for their congregations. The credibility of pastors, priests, rabbis, imams, and other religious leaders will be further enhanced if their messages of health and wellness given in their sermons and programs are reflected in their own behavioral patterns. In other words, religious and spiritual leaders have to walk the walk, not just talk the talk.
Health Themes Addressed by Religious and Spiritual Leaders
Perhaps the strongest influence of a religious leader on the thoughts, emotions, and actions of attendees of religious services occurs when their attention is focused on the leader's words—the sermon. Health-related themes that extol the virtues of maintaining a healthy lifestyle need to be communicated more frequently and passionately, citing religious or spiritual text to reinforce main issues. For example, in the New Testament of the Christian Bible, the apostle Paul reminds his readers that their bodies are a dwelling place of the Holy Spirit, thereby bridging the gap between spiritual and physical dualism that may be keeping people of faith locked into unhealthy behavioral patterns. Paul contends that what we do with our bodies matters not only on a physical level but also on a spiritual level.
Religious leaders can also cite scripture to remind us that we are not owners but rather managers, or stewards, of our bodies. Maintaining healthy habits is a matter of personal stewardship. When we begin to perceive our bodies in a manner that is consistent with God's view, we begin to make decisions that affect our physical health that honors a higher power (i.e., God). Thus, maintaining unhealthy habits that lead to obesity and poor physical conditioning is a failure of that stewardship responsibility.
Another health theme found in religion is gluttony. The Gluttony in Religion highlight box lists examples of this theme from various religious texts that both religious leaders and health professionals may use with people of faith to address the association between healthy habits and spirituality or religion.
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Overcome mental barriers to reach exercise goals
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks.
Mental Barriers to Exercise Adherence
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks. However, it will not take a great deal of time to feel better and adjust to new physical demands they place on themselves. They simply need patience. Without it, they will quit. They will lack adherence, and this is exactly the problem with at least half the people who initiate exercise programs. Our high-achieving, impatient culture, made worse by personality traits such as negative perfectionism, high trait anxiety, and pessimism about the future, often does not allow us to set reasonable goals and to develop strategies to reach those goals.
Emotions, thoughts, and feelings drive behavior in one of two directions: positive, toward achieving success and developing a better, healthier, more energetic lifestyle, or negative, toward maintaining unhealthy habits, being overweight, lacking energy, and living a life inconsistent with one's values about what is important. Improving a client's lifestyle takes effort—and a plan. Health and fitness professionals need to revisit the client's values, connect each value to a new routine that will create and maintain a more active lifestyle, and improve physical and mental health. Adherence to a program of regular exercise, the theme of this chapter, is of paramount importance in doing everything in our power to take control of our destiny. In the words of former British prime minister Sir Winston Churchill, “Continuous effort—not strength or intelligence—is the key to unlocking our potential" (qtd. in Cook, 1993).
A person's decision to discontinue an exercise habit often has a psychological explanation. Here are some of the more common conditions that can lead to dropping out of an exercise program. Hopefully, health professionals can develop and apply effective responses to these excuses that will change the client's mind about quitting.
Anxiety
Anxiety consists of feelings of worry or threat about the future, as discussed in chapter 5. Anxious thoughts cause worry and distract the exerciser from the task at hand—and waste energy. Sources of exercise anxiety include worry about meeting goals, physical appearance, being accepted by others (even strangers at a fitness club), and using time to exercise instead of doing something else (“I could be watching TV or finishing a report instead of going to the gym”). Ironically, exercise actually reduces both short-term (acute) and long-term (chronic) anxiety. Exercise is what the doctor ordered for improved mental health, including reduced anxiety (deMoor et al., 2006). Health professionals should strongly consider exercise as one behavioral strategy for helping their clients manage anxiety, particularly if clients are given social support in their new exercise program.
Depression
Most people experience unhappiness and negative emotions; this is normal. Ongoing, deeply negative mood states, however, may be a more serious mood disorder referred to as clinical depression (APA, 2000). Depression is a mood disorder that ranges from mild to severe and can be due to a medical condition, substance use, or psychopathology (mental illness). A sedentary lifestyle may induce or promote depression, but exercise has been shown to reduce it in over 70 studies across various age groups and for both genders (Leith, 1998).
One factor that influences the effect of exercise on depression is whether the person has selected and is enjoying the type of physical activity. A second factor is whether the exercise is of sufficient intensity, frequency, and duration to improve fitness outcomes and lead to psychological benefits. Taking a quiet, slow walk through the park, although pleasant and relaxing, may not be sufficient to reduce depression (Brosse, Sheets, Lett, and Blumenthal, 2002). Buckworth and Dishman (2002), in support of recommendations from ACSM, suggest the following exercise guidelines for people with depression who are otherwise healthy: three to five days a week (frequency) for 20 to 60 minutes each session (duration) at 55% to 90% of maximal heart rate (intensity). Certified fitness coaches should aim to meet these standards when prescribing exercise for depressed clients.
Negativity
It is impossible to remain motivated and on task if self-talk is negative, such as, “I don't like this,” “I feel terrible,” or “I'm tired.” Replacing those thoughts with positive statements that are optimistic and enthusiastic induces more effort and energy. Examples include, “I can do this,” “I feel good,” “Just three more minutes to go,” and “Hang in there.” To quote an anonymous writer, “You cannot be unhappy and enthusiastic at the same time.
”Negative and antagonistic feelings and emotions can impair the development of an exercise habit, especially for novice performers. The problem with negative thinking is that it results in low effort and sets up the individual to fail. This process is similar to the self-fulfilling prophecy; one's performance level will be consistent with one's expectations.
Examples of negative thinking that serve as barriers to exercise success include lack of confidence (e.g., “I don't think I can do this”), intimidation (e.g., “I don't belong in this fitness facility,” “People are laughing at me”), pessimism (e.g., “I'll never lose weight,” “Exercise will never be enjoyable”), self-criticism (e.g., “I can't run even one lap of that track, so why even try?”, “Exercise is not for me; I'll always be weak”), impatience (e.g., “I've been exercising for three weeks and still run out of steam when jogging”), and irrational thinking (e.g., “I've always been heavy; why change now?”, “People just have to accept me the way I am,” “My spouse thinks my weight and appearance are just fine”).
There are several implications for health care professionals when it comes to addressing mental health. First, consultants should not attempt to diagnose or treat mental illness unless they are licensed psychologists or have other appropriate credentials related to this area. There are serious legal implications of providing treatment to a person who did not request it, was not diagnosed correctly, or did not receive the proper treatment. The key term that reflects the proper thing to do if mental illness is suspected is referral; that is, health care professionals must refer clients to a licensed mental health professional for diagnosis and treatment if mental illness, such as depression, chronic anxiety, or another condition, is suspected.
A second implication for dealing with psychological barriers to maintaining healthy habits, particularly related to exercise and nutrition, is the need to schedule meetings between the client and qualified health coaches, such as a certified personal trainer and a registered dietitian. Exercise and nutrition both influence mental health and should not be ignored when attempting to change client health behavior. Relationships with local experts in these areas should be established before referral in order to become familiar with the expert's background, skills, location, types of services rendered, and personal qualities. Sometimes clients prefer a male or female coach or can meet the consultant only on certain days at certain times. It is essential that the health care professional try to coordinate the client's needs and preferences with the coach's characteristics.
Perfectionism
Perfectionism is a trait reflecting a person's disposition toward "setting excessively high standards of performance in conjunction with a tendency to make overly critical self-evaluations" (Frost, Marten, Lahart, and Rosenblate, 1990, p. 450). It is usually studied as a trait measure—stable and cross-situational—not a state (situational) measure (Antony and Swinson, 2009).
Perfectionism has both positive and negative features. The positive aspects of perfectionism include setting and attempting to achieve high personal standards, striving to achieve lofty but realistic goals often leading to success, and being conscientious and self-confident (Flett, Hewitt, Blankstein, and Mosher, 1991). Negative features, not uncommon among people who go overboard in attempting to achieve goals, include feeling deep concern about making mistakes, which leads to heightened anxiety; having doubts about one's actions; setting excessively high standards; having difficulty recognizing success; and overemphasizing precision, neatness, order, and organization. People who fit these behavior and thought patterns are referred to by clinical psychologists as neurotic perfectionists. They have a propensity to engage in self-destructive behaviors, excessive self-criticism, failure to recognize achievement and competence, and feelings of “It's not good enough” (Antony and Swinson, 2009; Adderholdt-Elliott, 1987).
Neurotic perfectionists set unattainable goals and might engage in overtraining or exercise addiction. Their self-talk is based on messages they received when they were young, reminding themselves that “It's not good enough” and “I can do better.” Their expectations of others are also excessive. Perfectionists need to learn how to set reasonable goals and to recognize their own achievements and those of others, especially in exercise settings. They need to have indicators of success and to acknowledge when they have reached those indicators.
Implications for working with clients who reveal perfectionistic thinking include referral to a mental health professional so that its sources can be identified and treated. Perfectionism can play a role in attempts at self-improvement; however, when standards and goals are excessively high, when self-expectations for achievement are unrealistic, and when the person expects others to meet these same excessive standards, often at the expense of alienating others, then this condition becomes an obstacle to happiness, confidence, and mental health.
Another implication for working with perfectionistic clients is the need to help them set realistic but challenging goals that are measurable and observable, to help them detect times when they have met their performance expectations, and to verbally and directly recognize their accomplishments. One important strategy that validates positive feedback and gives the consultant credibility is to base feedback on numbers—perhaps fitness test results, blood test results, improved exercise performance (e.g., increased resistance in weight training, faster jogging times, reduced body-fat percentage), or some other measure that quantifies improved physical performance.
Finally, perfectionists often need to change their irrational thinking by being reminded of their accomplishments, favorably comparing their competence level with others, and being more realistic about their self-expectations. Perfectionism, particularly when excessive (also referred to by mental health professionals as irrational, maladaptive, or neurotic), has specific sources, such as parents, sport coaches, or teachers, and this may be pointed out as an issue that is nothing to be ashamed about and that might require professional consultation to address it.
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Orientations and styles can be changed to promote exercise adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two.
Orientations, Styles, and Exercise Adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two. Personality traits are permanent, stable across situations, and partly a reflection of one's genetic predisposition, and therefore they are not subject to change. Orientations and styles, on the other hand, reflect common attitudes or a person's tendency to think or act in a predictable manner. The concepts of attributional style, coping style, and win orientation reflect predictable and persistent ways of thinking and acting under certain conditions. If, for instance, a person who demonstrates success or competence has an internal attributional style, the typical way the person explains success may be internal. That is, she may typically attribute the cause of her success as due to high effort or excellent skills, both internal explanations. Not taking responsibility for success or failure and perceiving the cause as something beyond the person's control reflects an external attributional style, at least for that particular situation (e.g., maintaining high fitness, improving performance on a given task, gaining excessive weight).
Orientations and styles also predict how people perceive the importance of a healthy lifestyle and to what they attribute their good or poor health. An internal disposition could reflect taking responsibility for one's excessive weight or poor fitness as due to poor dietary choices, excessive food intake, and lack of physical activity. Someone with an external disposition will be more likely to attribute weight gain to genetics or similarity to other family members, to not acknowledge there is a weight problem, or to believe that weight gain and consequent diseases (e.g., type 2 diabetes, high blood pressure, heart disease) are normal and part of the aging process. Other types of orientations and styles related to health behavior include self-control, self-awareness, and the interchangeable concepts of self-confidence and self-efficacy.
Self-Control
Self-control refers to the extent to which a person voluntarily and consciously creates, carries out, and maintains thoughts, emotions, and behaviors toward reaching desirable goals, even after encountering obstacles (Rosenbaum, 1990). Self-control behaviors are regulated by deliberate cognitive processes that are under the person's voluntary control. A good example of self-control in exercise settings is time management. Perhaps the primary reason people offer for not exercising is not having enough time (Sternfeld et al., 2009). People with high self-control plan their day and set aside time (i.e., day of the week, hour of the day, length of time) devoted to maintaining an exercise routine.
Self-control also means that the activity itself may be planned. For example, perhaps an exerciser who prefers the company of a friend during a workout plans to meet his friend at the exercise facility. Upon entering the facility, the individual has preplanned an hour devoted to various tasks that compose the exercise workout; specific routines are planned and carried out for the duration of the session, from entering to exiting the facility. The type of aerobic and resistance training may also be predetermined and executed in attempting to reach challenging goals. Presumably, the excuse of not having enough time now becomes having more time to do other things thanks to increased energy and vigor as a function of the workout. People with a high self-control orientation are more capable of carrying out preperformance and performance routines compared with their counterparts with low self-control (Faulkner et al., 2006). People with high self-control are schedule keepers and rarely waste time.
An important situational factor in developing an exercise habit is scheduling one's exercise sessions during the week. This requires good time management skills. Rather than saying, “I'll exercise when I get the time,” restate that view with, “I will exercise at x times on the following days.” A minimum of three times a week of intense exercise that expands one's fitness capacity and has a training effect (e.g., increased heart rate, increased muscular strength) is needed. However, finding opportunities to become physically active during the day (e.g., taking the stairs instead of the elevator, walking up or down the escalator, taking an evening or lunchtime walk) is also helpful for burning calories and managing weight.
Learned Resourcefulness
The pioneer writer and researcher in the literature on learned resourcefulness is Dr. Michael Rosenbaum (1990). He defined learned resourcefulness as “an acquired repertoire of behavioral and cognitive skills with which the person is able to regulate internal events such as emotions and cognitions that might otherwise interfere with the smooth execution of a target behavior” (p. xiv). High scorers on Rosenbaum's Self-Report Scale (Rosenbaum, 1990) are better able to
• tolerate physical discomfort,
• cope effectively with stress,
• succeed in weight-reduction programs,
• prevent or overcome feelings of helplessness,
• comply with medical and other health-related regimens,
• establish and maintain a relatively healthy lifestyle, and
• delay immediate gratification (e.g., binge eating) and understand the value of delayed gratification (e.g., exercising takes time, but the person receives more energy, better health, and improved performance quality).
In general, learned resourcefulness is particularly important in controlling negative thoughts and emotions while engendering desirable cognitive processes such as positive self-talk, optimism, self-motivation, and positive mood states. People high in learned resourcefulness are more confident; more likely to adopt an active lifestyle, including regular exercise; and less likely to engage in self-destructive behaviors (e.g., smoking, taking extreme risks). It is important to note that learned resourcefulness is not viewed as a personality trait. Instead, it is an orientation—a way of thinking that can be influenced through experience, counseling, and situational conditions.
Mental Toughness
Mental toughness is a disposition that represents the ability to reach and sustain high performance under pressure by expanding one's physical, mental, and emotional capacity (Connaughton, Hanton, and Jones, 2010). Mental toughness is learned, not inherited; it's an orientation. One common but false view of many athletes and coaches is that we are born with the right competitive instincts, and people who cannot handle failure lack the genetic predisposition to be mentally tough. The belief in a mental toughness gene is tempting because it absolves the person of taking responsibility for failure. However, the reality is that mental toughness can be taught, improved, and mastered. Exercisers need mental toughness to acknowledge their poor health and the need for physical activity, to withstand the challenges of physical exertion, to overcome physical fatigue, to continue to see the benefits of an exercise program, and to maintain exercise participation as a lifelong habit.
Mentally tough people are self-motivated and self-directed (their energy comes from internal sources; it is not forced from the outside); positive but realistic about handling adversity; in control of their emotions, especially in response to frustration and disappointment; and calm and relaxed under fire (rather than avoiding pressure, they are challenged by it). Mental toughness is also characterized by high energy, physical and mental readiness for action, a strong desire to succeed, relentlessness in the pursuit of challenging goals, superb concentration skills, self-confidence in the ability to perform well, and taking full responsibility for one's actions.
Self-Awareness
Think of self-awareness as the willingness to self-reflect, to engage introspectively, and to look at oneself through the eyes of others. This is not always easy to do, but others give us signals about their expectations and evaluations of us all the time, if we just take a good look. People react to us one way if they want our friendship and we have their respect. They react to us in a completely different way if they reject or disrespect us for whatever justified or unjustified reasons.
Self-awareness is an important component of health behavior because the ability to look inside and to be cognizant of our thoughts, emotions, and behaviors allows us to initiate steps for desirable change. If, for instance, we look in the mirror and see a person who is out of shape, overweight, and even unattractive, we can then begin the process of determining the reasons for our low energy, labored breathing, and general discomfort. Self-aware people also become more aware of the short-term costs and long-term consequences of their bad habits. They do not ignore their poor health and the negative habits that cause their current health status. This is why they are more likely to embrace support and opportunity to make lifelong changes that improve their health and happiness. They refuse to remain stuck in a self-destructive lifestyle. The challenges of self-awareness are addressed by Loehr and Schwartz (2003), who paraphrase John 32:8 from the Bible: “If the truth is to set us free, facing it cannot be a one-time event. Rather, it must become a practice. Like all of our ‘muscles,' self-awareness withers from disuse and deepens when we push past our resistance to see more of the truth” (p. 163).
Self-awareness, then, is an orientation. We differ in our willingness to become introspective about who we are and what we need to do to become better. As Loehr and Schwartz (2003) contend, “We must persistently shed light on those aspects of ourselves that we prefer not to see in order to build our mental, emotional and spiritual capacity” (p. 163). The authors also agree, however, that self-awareness can be self-defeating and overwhelming, bringing out negative thoughts, feelings, and emotions if it is absorbed in too big a dose. The right amount and frequency of self-awareness provides sufficient information to keep us on track and to be used as a source of information about what we need to become healthier and happier. As the authors conclude, “Facing the most difficult truths in our lives is challenging but also liberating” (p. 163).
Self-Efficacy
Confidence is a person's general feeling, perception, or belief that she has the capability to be successful in performing a skill and meeting task demands. Self-efficacy combines confidence with self-expectations. Self-efficacy, often associated and used interchangeably with self-confidence, is defined by Feltz and Lirgg (2001) as “the belief one has in being able to execute a specific task successfully . . .
to obtain a certain outcome” (p. 340). They further write, “Self-efficacy beliefs are not judgments about one's skills, objectively speaking, but rather are judgments of what one can accomplish with those skills” (p. 340). Thus, self-efficacy beliefs reflect a person's feelings not about what she can do but rather about what she has already done.
Self-efficacy is enormously important in an exercise setting and for changing and adhering to desirable, healthy behaviors. For example, people who experience self-doubt about their ability to join a fitness class and perform at least most of the exercises will be more likely to stop attending the class and either try some other form of exercise or return to their sedentary lifestyle. It is against human nature to continue participating in an activity in which we perceive our performance as incompetent or we fail to meet self-expectations or experience improved exercise performance and outcomes (e.g., better fitness). Therefore, building self-efficacy in an exercise setting bolsters the exercisers' perception that they are exercising properly, using correct technique, and improving performance. With respect to general health, clients will feel that following a certain set of routines will result or has resulted in superior health-related outcomes (e.g., more energy, positive mood, favorable results from medical tests). The objective of every worker in the health care industry, including fitness and nutrition coaches, is to provide instruction and positive feedback to build the person's self-efficacy about maintaining healthy habits.
Researchers have examined the link between self-efficacy and exercise behavior. Perhaps not surprising is the finding that as a person becomes more committed to an exercise habit, his self-efficacy improves. Self-efficacy is relatively low in the early stages of exercise, when a person is just beginning to develop an exercise routine or starting to make exercise a habit, and it increases dramatically as the person inserts exercise among his daily rituals. What is unknown is whether self-efficacy causes a person to adopt exercise as a lifestyle ritual or whether continued exercise increases self-efficacy. No doubt the two processes interact and self-efficacy is both the cause and the outcome of maintaining a regular exercise habit (Feltz and Lirgg, 2001; O'Leary, 1985).
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Religious institutions and spiritual leaders influence health behavior
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22).
Religious Community and Health Habits
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22). Religions, for example, promote beliefs that regulate behaviors related to alcohol, tobacco, diet, general hygiene, and medical care. Levin found that commitment to religion “may have a protective effect against subsequent illness . . . prevent or delay (illnesses), and have long-term benefits for physical and mental functioning and health” (p. 23).
The religious community is not immune from the health-related problems derived from an unhealthy lifestyle, however. The obesity epidemic still thrives in the religious and spiritual community (Cline and Ferraro, 2006). For example, the prevalence of obesity increased from 24% to 30% from 1986 to 1994 and likely has become much higher in more recent years among people of faith, that is, people who claim an affiliation with or membership in a denomination or religious institution. One potentially powerful source of health behavior change that has not been recognized in the war against obesity is the importance of religious and spiritual institutions and their leaders.
Next to physicians or other personal care providers, religious and spiritual leaders are some of the most credible people who influence the thoughts, emotions, and actions of a person of faith. People of faith often make a conscious decision to behave in a manner that is consistent with the expectations of their religious or spiritual messages.
In his book, Medicine, Religion, and Health: Where Science and Spirituality Meet (2008), Dr. Harold G. Koenig, MD, divides the benefits of religious practice or belief into six health-related areas:
1. Mental health
2. Immune function
3. Cardiovascular function
4. Stress and behavior-related diseases
5. Mortality
6. Physical disability
Based on his review of the research literature in each of these areas, Koenig (2008) concluded that religious practice or spirituality were strongly associated with superior health outcomes. He found, for example, that blood pressure and rates of stroke and cognitive impairment were each highly correlated with religious involvement (e.g., service attendance, frequency of prayer, strength of belief in a higher power). Although not always acknowledged by religious leaders, messages related to maintaining healthy habits are common throughout most religious texts.
To people of faith, arguably no one has more credibility for influencing behavior than their religious or spiritual leader. Should these leaders play a role in promoting healthy habits among congregants and the community at large? How can they address the apparent disconnect between people's religious practices, including a firm belief in religious or spiritual texts, and their lack of self-awareness about practicing healthy habits? And how can health professionals be involved in this process?
Role of Religious Leaders in Promoting and Modeling Healthy Habits
Many religious leaders contend that people who attend traditional ceremonies or services are looking for spiritual fulfillment, and that is the primary role of their institutions. Educating congregants about healthy habits is not. Perhaps this view, and the mission that propels it, needs to be reexamined. All sources of behavioral influence, including school systems, governments, corporations, the food industry, and religious institutions, need to be unified in providing information and incentives to replace self-destructive behavior patterns with healthier alternatives. One source of health behavior interventions that has received only minimal attention is the role of religious and spiritual leaders.
What should religious and spiritual leaders do to promote healthy habits, perhaps with assistance from health professionals? First, they need to look at themselves and determine if the change needs to start with them. Next, they must speak up and encourage their institution members—and other members of the community, when given the opportunity—to have discipline in all areas of their lives. One religious text, the Bible, addresses eating, indulgence, self-control, self-discipline, and gluttony. These topics need to be addressed in religious institutions and services without fear of offending attendees. Leaders of congregants who attend spiritual events and services should encourage their congregants to make lifestyle changes that will ultimately bring glory to God or some other higher power to whom they feel accountable. Religious leaders must stop being intimidated by the risk of losing members by offending them in order to acknowledge the importance of self-care as an inherent component of a religious and spiritual lifestyle (Colbert, 2002).
Perhaps the most serious obstacle to health behavior change in the religious community is persuading people of faith to take responsibility for their health and engage in the free will of healthy lifestyle choices, rather than surrender control to a higher power. Most religious texts, including the Bible, promote taking responsibility for health behavior. Philippians 2:13 states that God works within us to will his Holy Spirit and the free will to desire to create balance in our life—and the will to act on that desire.
For example, as Omartian (1996) contends, “The main reason to exercise is for your health. Without good health you cannot do all that the Lord has for you do to and you cannot be all the Lord wants you to be” (p. 117). Along these lines, Koenig (1999) asserts, “The world's religions encourage healthy living. . . .
All established religions discourage . . . any habit or activity harmful to the human body, which has traditionally been viewed as sacred, created in the image of God” (p. 72). And as Levin (2001) concludes, “All religions endorse the idea that we ought to take care of our bodies and not act in ways that are reckless and endanger our health” (p. 41).
There is an apparent need for religious institutions and their leaders to play a more prominent role in promoting community health and wellness and to serve as role models for their congregations. The credibility of pastors, priests, rabbis, imams, and other religious leaders will be further enhanced if their messages of health and wellness given in their sermons and programs are reflected in their own behavioral patterns. In other words, religious and spiritual leaders have to walk the walk, not just talk the talk.
Health Themes Addressed by Religious and Spiritual Leaders
Perhaps the strongest influence of a religious leader on the thoughts, emotions, and actions of attendees of religious services occurs when their attention is focused on the leader's words—the sermon. Health-related themes that extol the virtues of maintaining a healthy lifestyle need to be communicated more frequently and passionately, citing religious or spiritual text to reinforce main issues. For example, in the New Testament of the Christian Bible, the apostle Paul reminds his readers that their bodies are a dwelling place of the Holy Spirit, thereby bridging the gap between spiritual and physical dualism that may be keeping people of faith locked into unhealthy behavioral patterns. Paul contends that what we do with our bodies matters not only on a physical level but also on a spiritual level.
Religious leaders can also cite scripture to remind us that we are not owners but rather managers, or stewards, of our bodies. Maintaining healthy habits is a matter of personal stewardship. When we begin to perceive our bodies in a manner that is consistent with God's view, we begin to make decisions that affect our physical health that honors a higher power (i.e., God). Thus, maintaining unhealthy habits that lead to obesity and poor physical conditioning is a failure of that stewardship responsibility.
Another health theme found in religion is gluttony. The Gluttony in Religion highlight box lists examples of this theme from various religious texts that both religious leaders and health professionals may use with people of faith to address the association between healthy habits and spirituality or religion.
Learn more about Applied Health Fitness Psychology.
Overcome mental barriers to reach exercise goals
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks.
Mental Barriers to Exercise Adherence
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks. However, it will not take a great deal of time to feel better and adjust to new physical demands they place on themselves. They simply need patience. Without it, they will quit. They will lack adherence, and this is exactly the problem with at least half the people who initiate exercise programs. Our high-achieving, impatient culture, made worse by personality traits such as negative perfectionism, high trait anxiety, and pessimism about the future, often does not allow us to set reasonable goals and to develop strategies to reach those goals.
Emotions, thoughts, and feelings drive behavior in one of two directions: positive, toward achieving success and developing a better, healthier, more energetic lifestyle, or negative, toward maintaining unhealthy habits, being overweight, lacking energy, and living a life inconsistent with one's values about what is important. Improving a client's lifestyle takes effort—and a plan. Health and fitness professionals need to revisit the client's values, connect each value to a new routine that will create and maintain a more active lifestyle, and improve physical and mental health. Adherence to a program of regular exercise, the theme of this chapter, is of paramount importance in doing everything in our power to take control of our destiny. In the words of former British prime minister Sir Winston Churchill, “Continuous effort—not strength or intelligence—is the key to unlocking our potential" (qtd. in Cook, 1993).
A person's decision to discontinue an exercise habit often has a psychological explanation. Here are some of the more common conditions that can lead to dropping out of an exercise program. Hopefully, health professionals can develop and apply effective responses to these excuses that will change the client's mind about quitting.
Anxiety
Anxiety consists of feelings of worry or threat about the future, as discussed in chapter 5. Anxious thoughts cause worry and distract the exerciser from the task at hand—and waste energy. Sources of exercise anxiety include worry about meeting goals, physical appearance, being accepted by others (even strangers at a fitness club), and using time to exercise instead of doing something else (“I could be watching TV or finishing a report instead of going to the gym”). Ironically, exercise actually reduces both short-term (acute) and long-term (chronic) anxiety. Exercise is what the doctor ordered for improved mental health, including reduced anxiety (deMoor et al., 2006). Health professionals should strongly consider exercise as one behavioral strategy for helping their clients manage anxiety, particularly if clients are given social support in their new exercise program.
Depression
Most people experience unhappiness and negative emotions; this is normal. Ongoing, deeply negative mood states, however, may be a more serious mood disorder referred to as clinical depression (APA, 2000). Depression is a mood disorder that ranges from mild to severe and can be due to a medical condition, substance use, or psychopathology (mental illness). A sedentary lifestyle may induce or promote depression, but exercise has been shown to reduce it in over 70 studies across various age groups and for both genders (Leith, 1998).
One factor that influences the effect of exercise on depression is whether the person has selected and is enjoying the type of physical activity. A second factor is whether the exercise is of sufficient intensity, frequency, and duration to improve fitness outcomes and lead to psychological benefits. Taking a quiet, slow walk through the park, although pleasant and relaxing, may not be sufficient to reduce depression (Brosse, Sheets, Lett, and Blumenthal, 2002). Buckworth and Dishman (2002), in support of recommendations from ACSM, suggest the following exercise guidelines for people with depression who are otherwise healthy: three to five days a week (frequency) for 20 to 60 minutes each session (duration) at 55% to 90% of maximal heart rate (intensity). Certified fitness coaches should aim to meet these standards when prescribing exercise for depressed clients.
Negativity
It is impossible to remain motivated and on task if self-talk is negative, such as, “I don't like this,” “I feel terrible,” or “I'm tired.” Replacing those thoughts with positive statements that are optimistic and enthusiastic induces more effort and energy. Examples include, “I can do this,” “I feel good,” “Just three more minutes to go,” and “Hang in there.” To quote an anonymous writer, “You cannot be unhappy and enthusiastic at the same time.
”Negative and antagonistic feelings and emotions can impair the development of an exercise habit, especially for novice performers. The problem with negative thinking is that it results in low effort and sets up the individual to fail. This process is similar to the self-fulfilling prophecy; one's performance level will be consistent with one's expectations.
Examples of negative thinking that serve as barriers to exercise success include lack of confidence (e.g., “I don't think I can do this”), intimidation (e.g., “I don't belong in this fitness facility,” “People are laughing at me”), pessimism (e.g., “I'll never lose weight,” “Exercise will never be enjoyable”), self-criticism (e.g., “I can't run even one lap of that track, so why even try?”, “Exercise is not for me; I'll always be weak”), impatience (e.g., “I've been exercising for three weeks and still run out of steam when jogging”), and irrational thinking (e.g., “I've always been heavy; why change now?”, “People just have to accept me the way I am,” “My spouse thinks my weight and appearance are just fine”).
There are several implications for health care professionals when it comes to addressing mental health. First, consultants should not attempt to diagnose or treat mental illness unless they are licensed psychologists or have other appropriate credentials related to this area. There are serious legal implications of providing treatment to a person who did not request it, was not diagnosed correctly, or did not receive the proper treatment. The key term that reflects the proper thing to do if mental illness is suspected is referral; that is, health care professionals must refer clients to a licensed mental health professional for diagnosis and treatment if mental illness, such as depression, chronic anxiety, or another condition, is suspected.
A second implication for dealing with psychological barriers to maintaining healthy habits, particularly related to exercise and nutrition, is the need to schedule meetings between the client and qualified health coaches, such as a certified personal trainer and a registered dietitian. Exercise and nutrition both influence mental health and should not be ignored when attempting to change client health behavior. Relationships with local experts in these areas should be established before referral in order to become familiar with the expert's background, skills, location, types of services rendered, and personal qualities. Sometimes clients prefer a male or female coach or can meet the consultant only on certain days at certain times. It is essential that the health care professional try to coordinate the client's needs and preferences with the coach's characteristics.
Perfectionism
Perfectionism is a trait reflecting a person's disposition toward "setting excessively high standards of performance in conjunction with a tendency to make overly critical self-evaluations" (Frost, Marten, Lahart, and Rosenblate, 1990, p. 450). It is usually studied as a trait measure—stable and cross-situational—not a state (situational) measure (Antony and Swinson, 2009).
Perfectionism has both positive and negative features. The positive aspects of perfectionism include setting and attempting to achieve high personal standards, striving to achieve lofty but realistic goals often leading to success, and being conscientious and self-confident (Flett, Hewitt, Blankstein, and Mosher, 1991). Negative features, not uncommon among people who go overboard in attempting to achieve goals, include feeling deep concern about making mistakes, which leads to heightened anxiety; having doubts about one's actions; setting excessively high standards; having difficulty recognizing success; and overemphasizing precision, neatness, order, and organization. People who fit these behavior and thought patterns are referred to by clinical psychologists as neurotic perfectionists. They have a propensity to engage in self-destructive behaviors, excessive self-criticism, failure to recognize achievement and competence, and feelings of “It's not good enough” (Antony and Swinson, 2009; Adderholdt-Elliott, 1987).
Neurotic perfectionists set unattainable goals and might engage in overtraining or exercise addiction. Their self-talk is based on messages they received when they were young, reminding themselves that “It's not good enough” and “I can do better.” Their expectations of others are also excessive. Perfectionists need to learn how to set reasonable goals and to recognize their own achievements and those of others, especially in exercise settings. They need to have indicators of success and to acknowledge when they have reached those indicators.
Implications for working with clients who reveal perfectionistic thinking include referral to a mental health professional so that its sources can be identified and treated. Perfectionism can play a role in attempts at self-improvement; however, when standards and goals are excessively high, when self-expectations for achievement are unrealistic, and when the person expects others to meet these same excessive standards, often at the expense of alienating others, then this condition becomes an obstacle to happiness, confidence, and mental health.
Another implication for working with perfectionistic clients is the need to help them set realistic but challenging goals that are measurable and observable, to help them detect times when they have met their performance expectations, and to verbally and directly recognize their accomplishments. One important strategy that validates positive feedback and gives the consultant credibility is to base feedback on numbers—perhaps fitness test results, blood test results, improved exercise performance (e.g., increased resistance in weight training, faster jogging times, reduced body-fat percentage), or some other measure that quantifies improved physical performance.
Finally, perfectionists often need to change their irrational thinking by being reminded of their accomplishments, favorably comparing their competence level with others, and being more realistic about their self-expectations. Perfectionism, particularly when excessive (also referred to by mental health professionals as irrational, maladaptive, or neurotic), has specific sources, such as parents, sport coaches, or teachers, and this may be pointed out as an issue that is nothing to be ashamed about and that might require professional consultation to address it.
Learn more about Applied Health Fitness Psychology.
Orientations and styles can be changed to promote exercise adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two.
Orientations, Styles, and Exercise Adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two. Personality traits are permanent, stable across situations, and partly a reflection of one's genetic predisposition, and therefore they are not subject to change. Orientations and styles, on the other hand, reflect common attitudes or a person's tendency to think or act in a predictable manner. The concepts of attributional style, coping style, and win orientation reflect predictable and persistent ways of thinking and acting under certain conditions. If, for instance, a person who demonstrates success or competence has an internal attributional style, the typical way the person explains success may be internal. That is, she may typically attribute the cause of her success as due to high effort or excellent skills, both internal explanations. Not taking responsibility for success or failure and perceiving the cause as something beyond the person's control reflects an external attributional style, at least for that particular situation (e.g., maintaining high fitness, improving performance on a given task, gaining excessive weight).
Orientations and styles also predict how people perceive the importance of a healthy lifestyle and to what they attribute their good or poor health. An internal disposition could reflect taking responsibility for one's excessive weight or poor fitness as due to poor dietary choices, excessive food intake, and lack of physical activity. Someone with an external disposition will be more likely to attribute weight gain to genetics or similarity to other family members, to not acknowledge there is a weight problem, or to believe that weight gain and consequent diseases (e.g., type 2 diabetes, high blood pressure, heart disease) are normal and part of the aging process. Other types of orientations and styles related to health behavior include self-control, self-awareness, and the interchangeable concepts of self-confidence and self-efficacy.
Self-Control
Self-control refers to the extent to which a person voluntarily and consciously creates, carries out, and maintains thoughts, emotions, and behaviors toward reaching desirable goals, even after encountering obstacles (Rosenbaum, 1990). Self-control behaviors are regulated by deliberate cognitive processes that are under the person's voluntary control. A good example of self-control in exercise settings is time management. Perhaps the primary reason people offer for not exercising is not having enough time (Sternfeld et al., 2009). People with high self-control plan their day and set aside time (i.e., day of the week, hour of the day, length of time) devoted to maintaining an exercise routine.
Self-control also means that the activity itself may be planned. For example, perhaps an exerciser who prefers the company of a friend during a workout plans to meet his friend at the exercise facility. Upon entering the facility, the individual has preplanned an hour devoted to various tasks that compose the exercise workout; specific routines are planned and carried out for the duration of the session, from entering to exiting the facility. The type of aerobic and resistance training may also be predetermined and executed in attempting to reach challenging goals. Presumably, the excuse of not having enough time now becomes having more time to do other things thanks to increased energy and vigor as a function of the workout. People with a high self-control orientation are more capable of carrying out preperformance and performance routines compared with their counterparts with low self-control (Faulkner et al., 2006). People with high self-control are schedule keepers and rarely waste time.
An important situational factor in developing an exercise habit is scheduling one's exercise sessions during the week. This requires good time management skills. Rather than saying, “I'll exercise when I get the time,” restate that view with, “I will exercise at x times on the following days.” A minimum of three times a week of intense exercise that expands one's fitness capacity and has a training effect (e.g., increased heart rate, increased muscular strength) is needed. However, finding opportunities to become physically active during the day (e.g., taking the stairs instead of the elevator, walking up or down the escalator, taking an evening or lunchtime walk) is also helpful for burning calories and managing weight.
Learned Resourcefulness
The pioneer writer and researcher in the literature on learned resourcefulness is Dr. Michael Rosenbaum (1990). He defined learned resourcefulness as “an acquired repertoire of behavioral and cognitive skills with which the person is able to regulate internal events such as emotions and cognitions that might otherwise interfere with the smooth execution of a target behavior” (p. xiv). High scorers on Rosenbaum's Self-Report Scale (Rosenbaum, 1990) are better able to
• tolerate physical discomfort,
• cope effectively with stress,
• succeed in weight-reduction programs,
• prevent or overcome feelings of helplessness,
• comply with medical and other health-related regimens,
• establish and maintain a relatively healthy lifestyle, and
• delay immediate gratification (e.g., binge eating) and understand the value of delayed gratification (e.g., exercising takes time, but the person receives more energy, better health, and improved performance quality).
In general, learned resourcefulness is particularly important in controlling negative thoughts and emotions while engendering desirable cognitive processes such as positive self-talk, optimism, self-motivation, and positive mood states. People high in learned resourcefulness are more confident; more likely to adopt an active lifestyle, including regular exercise; and less likely to engage in self-destructive behaviors (e.g., smoking, taking extreme risks). It is important to note that learned resourcefulness is not viewed as a personality trait. Instead, it is an orientation—a way of thinking that can be influenced through experience, counseling, and situational conditions.
Mental Toughness
Mental toughness is a disposition that represents the ability to reach and sustain high performance under pressure by expanding one's physical, mental, and emotional capacity (Connaughton, Hanton, and Jones, 2010). Mental toughness is learned, not inherited; it's an orientation. One common but false view of many athletes and coaches is that we are born with the right competitive instincts, and people who cannot handle failure lack the genetic predisposition to be mentally tough. The belief in a mental toughness gene is tempting because it absolves the person of taking responsibility for failure. However, the reality is that mental toughness can be taught, improved, and mastered. Exercisers need mental toughness to acknowledge their poor health and the need for physical activity, to withstand the challenges of physical exertion, to overcome physical fatigue, to continue to see the benefits of an exercise program, and to maintain exercise participation as a lifelong habit.
Mentally tough people are self-motivated and self-directed (their energy comes from internal sources; it is not forced from the outside); positive but realistic about handling adversity; in control of their emotions, especially in response to frustration and disappointment; and calm and relaxed under fire (rather than avoiding pressure, they are challenged by it). Mental toughness is also characterized by high energy, physical and mental readiness for action, a strong desire to succeed, relentlessness in the pursuit of challenging goals, superb concentration skills, self-confidence in the ability to perform well, and taking full responsibility for one's actions.
Self-Awareness
Think of self-awareness as the willingness to self-reflect, to engage introspectively, and to look at oneself through the eyes of others. This is not always easy to do, but others give us signals about their expectations and evaluations of us all the time, if we just take a good look. People react to us one way if they want our friendship and we have their respect. They react to us in a completely different way if they reject or disrespect us for whatever justified or unjustified reasons.
Self-awareness is an important component of health behavior because the ability to look inside and to be cognizant of our thoughts, emotions, and behaviors allows us to initiate steps for desirable change. If, for instance, we look in the mirror and see a person who is out of shape, overweight, and even unattractive, we can then begin the process of determining the reasons for our low energy, labored breathing, and general discomfort. Self-aware people also become more aware of the short-term costs and long-term consequences of their bad habits. They do not ignore their poor health and the negative habits that cause their current health status. This is why they are more likely to embrace support and opportunity to make lifelong changes that improve their health and happiness. They refuse to remain stuck in a self-destructive lifestyle. The challenges of self-awareness are addressed by Loehr and Schwartz (2003), who paraphrase John 32:8 from the Bible: “If the truth is to set us free, facing it cannot be a one-time event. Rather, it must become a practice. Like all of our ‘muscles,' self-awareness withers from disuse and deepens when we push past our resistance to see more of the truth” (p. 163).
Self-awareness, then, is an orientation. We differ in our willingness to become introspective about who we are and what we need to do to become better. As Loehr and Schwartz (2003) contend, “We must persistently shed light on those aspects of ourselves that we prefer not to see in order to build our mental, emotional and spiritual capacity” (p. 163). The authors also agree, however, that self-awareness can be self-defeating and overwhelming, bringing out negative thoughts, feelings, and emotions if it is absorbed in too big a dose. The right amount and frequency of self-awareness provides sufficient information to keep us on track and to be used as a source of information about what we need to become healthier and happier. As the authors conclude, “Facing the most difficult truths in our lives is challenging but also liberating” (p. 163).
Self-Efficacy
Confidence is a person's general feeling, perception, or belief that she has the capability to be successful in performing a skill and meeting task demands. Self-efficacy combines confidence with self-expectations. Self-efficacy, often associated and used interchangeably with self-confidence, is defined by Feltz and Lirgg (2001) as “the belief one has in being able to execute a specific task successfully . . .
to obtain a certain outcome” (p. 340). They further write, “Self-efficacy beliefs are not judgments about one's skills, objectively speaking, but rather are judgments of what one can accomplish with those skills” (p. 340). Thus, self-efficacy beliefs reflect a person's feelings not about what she can do but rather about what she has already done.
Self-efficacy is enormously important in an exercise setting and for changing and adhering to desirable, healthy behaviors. For example, people who experience self-doubt about their ability to join a fitness class and perform at least most of the exercises will be more likely to stop attending the class and either try some other form of exercise or return to their sedentary lifestyle. It is against human nature to continue participating in an activity in which we perceive our performance as incompetent or we fail to meet self-expectations or experience improved exercise performance and outcomes (e.g., better fitness). Therefore, building self-efficacy in an exercise setting bolsters the exercisers' perception that they are exercising properly, using correct technique, and improving performance. With respect to general health, clients will feel that following a certain set of routines will result or has resulted in superior health-related outcomes (e.g., more energy, positive mood, favorable results from medical tests). The objective of every worker in the health care industry, including fitness and nutrition coaches, is to provide instruction and positive feedback to build the person's self-efficacy about maintaining healthy habits.
Researchers have examined the link between self-efficacy and exercise behavior. Perhaps not surprising is the finding that as a person becomes more committed to an exercise habit, his self-efficacy improves. Self-efficacy is relatively low in the early stages of exercise, when a person is just beginning to develop an exercise routine or starting to make exercise a habit, and it increases dramatically as the person inserts exercise among his daily rituals. What is unknown is whether self-efficacy causes a person to adopt exercise as a lifestyle ritual or whether continued exercise increases self-efficacy. No doubt the two processes interact and self-efficacy is both the cause and the outcome of maintaining a regular exercise habit (Feltz and Lirgg, 2001; O'Leary, 1985).
Learn more about Applied Health Fitness Psychology.
Religious institutions and spiritual leaders influence health behavior
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22).
Religious Community and Health Habits
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22). Religions, for example, promote beliefs that regulate behaviors related to alcohol, tobacco, diet, general hygiene, and medical care. Levin found that commitment to religion “may have a protective effect against subsequent illness . . . prevent or delay (illnesses), and have long-term benefits for physical and mental functioning and health” (p. 23).
The religious community is not immune from the health-related problems derived from an unhealthy lifestyle, however. The obesity epidemic still thrives in the religious and spiritual community (Cline and Ferraro, 2006). For example, the prevalence of obesity increased from 24% to 30% from 1986 to 1994 and likely has become much higher in more recent years among people of faith, that is, people who claim an affiliation with or membership in a denomination or religious institution. One potentially powerful source of health behavior change that has not been recognized in the war against obesity is the importance of religious and spiritual institutions and their leaders.
Next to physicians or other personal care providers, religious and spiritual leaders are some of the most credible people who influence the thoughts, emotions, and actions of a person of faith. People of faith often make a conscious decision to behave in a manner that is consistent with the expectations of their religious or spiritual messages.
In his book, Medicine, Religion, and Health: Where Science and Spirituality Meet (2008), Dr. Harold G. Koenig, MD, divides the benefits of religious practice or belief into six health-related areas:
1. Mental health
2. Immune function
3. Cardiovascular function
4. Stress and behavior-related diseases
5. Mortality
6. Physical disability
Based on his review of the research literature in each of these areas, Koenig (2008) concluded that religious practice or spirituality were strongly associated with superior health outcomes. He found, for example, that blood pressure and rates of stroke and cognitive impairment were each highly correlated with religious involvement (e.g., service attendance, frequency of prayer, strength of belief in a higher power). Although not always acknowledged by religious leaders, messages related to maintaining healthy habits are common throughout most religious texts.
To people of faith, arguably no one has more credibility for influencing behavior than their religious or spiritual leader. Should these leaders play a role in promoting healthy habits among congregants and the community at large? How can they address the apparent disconnect between people's religious practices, including a firm belief in religious or spiritual texts, and their lack of self-awareness about practicing healthy habits? And how can health professionals be involved in this process?
Role of Religious Leaders in Promoting and Modeling Healthy Habits
Many religious leaders contend that people who attend traditional ceremonies or services are looking for spiritual fulfillment, and that is the primary role of their institutions. Educating congregants about healthy habits is not. Perhaps this view, and the mission that propels it, needs to be reexamined. All sources of behavioral influence, including school systems, governments, corporations, the food industry, and religious institutions, need to be unified in providing information and incentives to replace self-destructive behavior patterns with healthier alternatives. One source of health behavior interventions that has received only minimal attention is the role of religious and spiritual leaders.
What should religious and spiritual leaders do to promote healthy habits, perhaps with assistance from health professionals? First, they need to look at themselves and determine if the change needs to start with them. Next, they must speak up and encourage their institution members—and other members of the community, when given the opportunity—to have discipline in all areas of their lives. One religious text, the Bible, addresses eating, indulgence, self-control, self-discipline, and gluttony. These topics need to be addressed in religious institutions and services without fear of offending attendees. Leaders of congregants who attend spiritual events and services should encourage their congregants to make lifestyle changes that will ultimately bring glory to God or some other higher power to whom they feel accountable. Religious leaders must stop being intimidated by the risk of losing members by offending them in order to acknowledge the importance of self-care as an inherent component of a religious and spiritual lifestyle (Colbert, 2002).
Perhaps the most serious obstacle to health behavior change in the religious community is persuading people of faith to take responsibility for their health and engage in the free will of healthy lifestyle choices, rather than surrender control to a higher power. Most religious texts, including the Bible, promote taking responsibility for health behavior. Philippians 2:13 states that God works within us to will his Holy Spirit and the free will to desire to create balance in our life—and the will to act on that desire.
For example, as Omartian (1996) contends, “The main reason to exercise is for your health. Without good health you cannot do all that the Lord has for you do to and you cannot be all the Lord wants you to be” (p. 117). Along these lines, Koenig (1999) asserts, “The world's religions encourage healthy living. . . .
All established religions discourage . . . any habit or activity harmful to the human body, which has traditionally been viewed as sacred, created in the image of God” (p. 72). And as Levin (2001) concludes, “All religions endorse the idea that we ought to take care of our bodies and not act in ways that are reckless and endanger our health” (p. 41).
There is an apparent need for religious institutions and their leaders to play a more prominent role in promoting community health and wellness and to serve as role models for their congregations. The credibility of pastors, priests, rabbis, imams, and other religious leaders will be further enhanced if their messages of health and wellness given in their sermons and programs are reflected in their own behavioral patterns. In other words, religious and spiritual leaders have to walk the walk, not just talk the talk.
Health Themes Addressed by Religious and Spiritual Leaders
Perhaps the strongest influence of a religious leader on the thoughts, emotions, and actions of attendees of religious services occurs when their attention is focused on the leader's words—the sermon. Health-related themes that extol the virtues of maintaining a healthy lifestyle need to be communicated more frequently and passionately, citing religious or spiritual text to reinforce main issues. For example, in the New Testament of the Christian Bible, the apostle Paul reminds his readers that their bodies are a dwelling place of the Holy Spirit, thereby bridging the gap between spiritual and physical dualism that may be keeping people of faith locked into unhealthy behavioral patterns. Paul contends that what we do with our bodies matters not only on a physical level but also on a spiritual level.
Religious leaders can also cite scripture to remind us that we are not owners but rather managers, or stewards, of our bodies. Maintaining healthy habits is a matter of personal stewardship. When we begin to perceive our bodies in a manner that is consistent with God's view, we begin to make decisions that affect our physical health that honors a higher power (i.e., God). Thus, maintaining unhealthy habits that lead to obesity and poor physical conditioning is a failure of that stewardship responsibility.
Another health theme found in religion is gluttony. The Gluttony in Religion highlight box lists examples of this theme from various religious texts that both religious leaders and health professionals may use with people of faith to address the association between healthy habits and spirituality or religion.
Learn more about Applied Health Fitness Psychology.
Overcome mental barriers to reach exercise goals
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks.
Mental Barriers to Exercise Adherence
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks. However, it will not take a great deal of time to feel better and adjust to new physical demands they place on themselves. They simply need patience. Without it, they will quit. They will lack adherence, and this is exactly the problem with at least half the people who initiate exercise programs. Our high-achieving, impatient culture, made worse by personality traits such as negative perfectionism, high trait anxiety, and pessimism about the future, often does not allow us to set reasonable goals and to develop strategies to reach those goals.
Emotions, thoughts, and feelings drive behavior in one of two directions: positive, toward achieving success and developing a better, healthier, more energetic lifestyle, or negative, toward maintaining unhealthy habits, being overweight, lacking energy, and living a life inconsistent with one's values about what is important. Improving a client's lifestyle takes effort—and a plan. Health and fitness professionals need to revisit the client's values, connect each value to a new routine that will create and maintain a more active lifestyle, and improve physical and mental health. Adherence to a program of regular exercise, the theme of this chapter, is of paramount importance in doing everything in our power to take control of our destiny. In the words of former British prime minister Sir Winston Churchill, “Continuous effort—not strength or intelligence—is the key to unlocking our potential" (qtd. in Cook, 1993).
A person's decision to discontinue an exercise habit often has a psychological explanation. Here are some of the more common conditions that can lead to dropping out of an exercise program. Hopefully, health professionals can develop and apply effective responses to these excuses that will change the client's mind about quitting.
Anxiety
Anxiety consists of feelings of worry or threat about the future, as discussed in chapter 5. Anxious thoughts cause worry and distract the exerciser from the task at hand—and waste energy. Sources of exercise anxiety include worry about meeting goals, physical appearance, being accepted by others (even strangers at a fitness club), and using time to exercise instead of doing something else (“I could be watching TV or finishing a report instead of going to the gym”). Ironically, exercise actually reduces both short-term (acute) and long-term (chronic) anxiety. Exercise is what the doctor ordered for improved mental health, including reduced anxiety (deMoor et al., 2006). Health professionals should strongly consider exercise as one behavioral strategy for helping their clients manage anxiety, particularly if clients are given social support in their new exercise program.
Depression
Most people experience unhappiness and negative emotions; this is normal. Ongoing, deeply negative mood states, however, may be a more serious mood disorder referred to as clinical depression (APA, 2000). Depression is a mood disorder that ranges from mild to severe and can be due to a medical condition, substance use, or psychopathology (mental illness). A sedentary lifestyle may induce or promote depression, but exercise has been shown to reduce it in over 70 studies across various age groups and for both genders (Leith, 1998).
One factor that influences the effect of exercise on depression is whether the person has selected and is enjoying the type of physical activity. A second factor is whether the exercise is of sufficient intensity, frequency, and duration to improve fitness outcomes and lead to psychological benefits. Taking a quiet, slow walk through the park, although pleasant and relaxing, may not be sufficient to reduce depression (Brosse, Sheets, Lett, and Blumenthal, 2002). Buckworth and Dishman (2002), in support of recommendations from ACSM, suggest the following exercise guidelines for people with depression who are otherwise healthy: three to five days a week (frequency) for 20 to 60 minutes each session (duration) at 55% to 90% of maximal heart rate (intensity). Certified fitness coaches should aim to meet these standards when prescribing exercise for depressed clients.
Negativity
It is impossible to remain motivated and on task if self-talk is negative, such as, “I don't like this,” “I feel terrible,” or “I'm tired.” Replacing those thoughts with positive statements that are optimistic and enthusiastic induces more effort and energy. Examples include, “I can do this,” “I feel good,” “Just three more minutes to go,” and “Hang in there.” To quote an anonymous writer, “You cannot be unhappy and enthusiastic at the same time.
”Negative and antagonistic feelings and emotions can impair the development of an exercise habit, especially for novice performers. The problem with negative thinking is that it results in low effort and sets up the individual to fail. This process is similar to the self-fulfilling prophecy; one's performance level will be consistent with one's expectations.
Examples of negative thinking that serve as barriers to exercise success include lack of confidence (e.g., “I don't think I can do this”), intimidation (e.g., “I don't belong in this fitness facility,” “People are laughing at me”), pessimism (e.g., “I'll never lose weight,” “Exercise will never be enjoyable”), self-criticism (e.g., “I can't run even one lap of that track, so why even try?”, “Exercise is not for me; I'll always be weak”), impatience (e.g., “I've been exercising for three weeks and still run out of steam when jogging”), and irrational thinking (e.g., “I've always been heavy; why change now?”, “People just have to accept me the way I am,” “My spouse thinks my weight and appearance are just fine”).
There are several implications for health care professionals when it comes to addressing mental health. First, consultants should not attempt to diagnose or treat mental illness unless they are licensed psychologists or have other appropriate credentials related to this area. There are serious legal implications of providing treatment to a person who did not request it, was not diagnosed correctly, or did not receive the proper treatment. The key term that reflects the proper thing to do if mental illness is suspected is referral; that is, health care professionals must refer clients to a licensed mental health professional for diagnosis and treatment if mental illness, such as depression, chronic anxiety, or another condition, is suspected.
A second implication for dealing with psychological barriers to maintaining healthy habits, particularly related to exercise and nutrition, is the need to schedule meetings between the client and qualified health coaches, such as a certified personal trainer and a registered dietitian. Exercise and nutrition both influence mental health and should not be ignored when attempting to change client health behavior. Relationships with local experts in these areas should be established before referral in order to become familiar with the expert's background, skills, location, types of services rendered, and personal qualities. Sometimes clients prefer a male or female coach or can meet the consultant only on certain days at certain times. It is essential that the health care professional try to coordinate the client's needs and preferences with the coach's characteristics.
Perfectionism
Perfectionism is a trait reflecting a person's disposition toward "setting excessively high standards of performance in conjunction with a tendency to make overly critical self-evaluations" (Frost, Marten, Lahart, and Rosenblate, 1990, p. 450). It is usually studied as a trait measure—stable and cross-situational—not a state (situational) measure (Antony and Swinson, 2009).
Perfectionism has both positive and negative features. The positive aspects of perfectionism include setting and attempting to achieve high personal standards, striving to achieve lofty but realistic goals often leading to success, and being conscientious and self-confident (Flett, Hewitt, Blankstein, and Mosher, 1991). Negative features, not uncommon among people who go overboard in attempting to achieve goals, include feeling deep concern about making mistakes, which leads to heightened anxiety; having doubts about one's actions; setting excessively high standards; having difficulty recognizing success; and overemphasizing precision, neatness, order, and organization. People who fit these behavior and thought patterns are referred to by clinical psychologists as neurotic perfectionists. They have a propensity to engage in self-destructive behaviors, excessive self-criticism, failure to recognize achievement and competence, and feelings of “It's not good enough” (Antony and Swinson, 2009; Adderholdt-Elliott, 1987).
Neurotic perfectionists set unattainable goals and might engage in overtraining or exercise addiction. Their self-talk is based on messages they received when they were young, reminding themselves that “It's not good enough” and “I can do better.” Their expectations of others are also excessive. Perfectionists need to learn how to set reasonable goals and to recognize their own achievements and those of others, especially in exercise settings. They need to have indicators of success and to acknowledge when they have reached those indicators.
Implications for working with clients who reveal perfectionistic thinking include referral to a mental health professional so that its sources can be identified and treated. Perfectionism can play a role in attempts at self-improvement; however, when standards and goals are excessively high, when self-expectations for achievement are unrealistic, and when the person expects others to meet these same excessive standards, often at the expense of alienating others, then this condition becomes an obstacle to happiness, confidence, and mental health.
Another implication for working with perfectionistic clients is the need to help them set realistic but challenging goals that are measurable and observable, to help them detect times when they have met their performance expectations, and to verbally and directly recognize their accomplishments. One important strategy that validates positive feedback and gives the consultant credibility is to base feedback on numbers—perhaps fitness test results, blood test results, improved exercise performance (e.g., increased resistance in weight training, faster jogging times, reduced body-fat percentage), or some other measure that quantifies improved physical performance.
Finally, perfectionists often need to change their irrational thinking by being reminded of their accomplishments, favorably comparing their competence level with others, and being more realistic about their self-expectations. Perfectionism, particularly when excessive (also referred to by mental health professionals as irrational, maladaptive, or neurotic), has specific sources, such as parents, sport coaches, or teachers, and this may be pointed out as an issue that is nothing to be ashamed about and that might require professional consultation to address it.
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Orientations and styles can be changed to promote exercise adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two.
Orientations, Styles, and Exercise Adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two. Personality traits are permanent, stable across situations, and partly a reflection of one's genetic predisposition, and therefore they are not subject to change. Orientations and styles, on the other hand, reflect common attitudes or a person's tendency to think or act in a predictable manner. The concepts of attributional style, coping style, and win orientation reflect predictable and persistent ways of thinking and acting under certain conditions. If, for instance, a person who demonstrates success or competence has an internal attributional style, the typical way the person explains success may be internal. That is, she may typically attribute the cause of her success as due to high effort or excellent skills, both internal explanations. Not taking responsibility for success or failure and perceiving the cause as something beyond the person's control reflects an external attributional style, at least for that particular situation (e.g., maintaining high fitness, improving performance on a given task, gaining excessive weight).
Orientations and styles also predict how people perceive the importance of a healthy lifestyle and to what they attribute their good or poor health. An internal disposition could reflect taking responsibility for one's excessive weight or poor fitness as due to poor dietary choices, excessive food intake, and lack of physical activity. Someone with an external disposition will be more likely to attribute weight gain to genetics or similarity to other family members, to not acknowledge there is a weight problem, or to believe that weight gain and consequent diseases (e.g., type 2 diabetes, high blood pressure, heart disease) are normal and part of the aging process. Other types of orientations and styles related to health behavior include self-control, self-awareness, and the interchangeable concepts of self-confidence and self-efficacy.
Self-Control
Self-control refers to the extent to which a person voluntarily and consciously creates, carries out, and maintains thoughts, emotions, and behaviors toward reaching desirable goals, even after encountering obstacles (Rosenbaum, 1990). Self-control behaviors are regulated by deliberate cognitive processes that are under the person's voluntary control. A good example of self-control in exercise settings is time management. Perhaps the primary reason people offer for not exercising is not having enough time (Sternfeld et al., 2009). People with high self-control plan their day and set aside time (i.e., day of the week, hour of the day, length of time) devoted to maintaining an exercise routine.
Self-control also means that the activity itself may be planned. For example, perhaps an exerciser who prefers the company of a friend during a workout plans to meet his friend at the exercise facility. Upon entering the facility, the individual has preplanned an hour devoted to various tasks that compose the exercise workout; specific routines are planned and carried out for the duration of the session, from entering to exiting the facility. The type of aerobic and resistance training may also be predetermined and executed in attempting to reach challenging goals. Presumably, the excuse of not having enough time now becomes having more time to do other things thanks to increased energy and vigor as a function of the workout. People with a high self-control orientation are more capable of carrying out preperformance and performance routines compared with their counterparts with low self-control (Faulkner et al., 2006). People with high self-control are schedule keepers and rarely waste time.
An important situational factor in developing an exercise habit is scheduling one's exercise sessions during the week. This requires good time management skills. Rather than saying, “I'll exercise when I get the time,” restate that view with, “I will exercise at x times on the following days.” A minimum of three times a week of intense exercise that expands one's fitness capacity and has a training effect (e.g., increased heart rate, increased muscular strength) is needed. However, finding opportunities to become physically active during the day (e.g., taking the stairs instead of the elevator, walking up or down the escalator, taking an evening or lunchtime walk) is also helpful for burning calories and managing weight.
Learned Resourcefulness
The pioneer writer and researcher in the literature on learned resourcefulness is Dr. Michael Rosenbaum (1990). He defined learned resourcefulness as “an acquired repertoire of behavioral and cognitive skills with which the person is able to regulate internal events such as emotions and cognitions that might otherwise interfere with the smooth execution of a target behavior” (p. xiv). High scorers on Rosenbaum's Self-Report Scale (Rosenbaum, 1990) are better able to
• tolerate physical discomfort,
• cope effectively with stress,
• succeed in weight-reduction programs,
• prevent or overcome feelings of helplessness,
• comply with medical and other health-related regimens,
• establish and maintain a relatively healthy lifestyle, and
• delay immediate gratification (e.g., binge eating) and understand the value of delayed gratification (e.g., exercising takes time, but the person receives more energy, better health, and improved performance quality).
In general, learned resourcefulness is particularly important in controlling negative thoughts and emotions while engendering desirable cognitive processes such as positive self-talk, optimism, self-motivation, and positive mood states. People high in learned resourcefulness are more confident; more likely to adopt an active lifestyle, including regular exercise; and less likely to engage in self-destructive behaviors (e.g., smoking, taking extreme risks). It is important to note that learned resourcefulness is not viewed as a personality trait. Instead, it is an orientation—a way of thinking that can be influenced through experience, counseling, and situational conditions.
Mental Toughness
Mental toughness is a disposition that represents the ability to reach and sustain high performance under pressure by expanding one's physical, mental, and emotional capacity (Connaughton, Hanton, and Jones, 2010). Mental toughness is learned, not inherited; it's an orientation. One common but false view of many athletes and coaches is that we are born with the right competitive instincts, and people who cannot handle failure lack the genetic predisposition to be mentally tough. The belief in a mental toughness gene is tempting because it absolves the person of taking responsibility for failure. However, the reality is that mental toughness can be taught, improved, and mastered. Exercisers need mental toughness to acknowledge their poor health and the need for physical activity, to withstand the challenges of physical exertion, to overcome physical fatigue, to continue to see the benefits of an exercise program, and to maintain exercise participation as a lifelong habit.
Mentally tough people are self-motivated and self-directed (their energy comes from internal sources; it is not forced from the outside); positive but realistic about handling adversity; in control of their emotions, especially in response to frustration and disappointment; and calm and relaxed under fire (rather than avoiding pressure, they are challenged by it). Mental toughness is also characterized by high energy, physical and mental readiness for action, a strong desire to succeed, relentlessness in the pursuit of challenging goals, superb concentration skills, self-confidence in the ability to perform well, and taking full responsibility for one's actions.
Self-Awareness
Think of self-awareness as the willingness to self-reflect, to engage introspectively, and to look at oneself through the eyes of others. This is not always easy to do, but others give us signals about their expectations and evaluations of us all the time, if we just take a good look. People react to us one way if they want our friendship and we have their respect. They react to us in a completely different way if they reject or disrespect us for whatever justified or unjustified reasons.
Self-awareness is an important component of health behavior because the ability to look inside and to be cognizant of our thoughts, emotions, and behaviors allows us to initiate steps for desirable change. If, for instance, we look in the mirror and see a person who is out of shape, overweight, and even unattractive, we can then begin the process of determining the reasons for our low energy, labored breathing, and general discomfort. Self-aware people also become more aware of the short-term costs and long-term consequences of their bad habits. They do not ignore their poor health and the negative habits that cause their current health status. This is why they are more likely to embrace support and opportunity to make lifelong changes that improve their health and happiness. They refuse to remain stuck in a self-destructive lifestyle. The challenges of self-awareness are addressed by Loehr and Schwartz (2003), who paraphrase John 32:8 from the Bible: “If the truth is to set us free, facing it cannot be a one-time event. Rather, it must become a practice. Like all of our ‘muscles,' self-awareness withers from disuse and deepens when we push past our resistance to see more of the truth” (p. 163).
Self-awareness, then, is an orientation. We differ in our willingness to become introspective about who we are and what we need to do to become better. As Loehr and Schwartz (2003) contend, “We must persistently shed light on those aspects of ourselves that we prefer not to see in order to build our mental, emotional and spiritual capacity” (p. 163). The authors also agree, however, that self-awareness can be self-defeating and overwhelming, bringing out negative thoughts, feelings, and emotions if it is absorbed in too big a dose. The right amount and frequency of self-awareness provides sufficient information to keep us on track and to be used as a source of information about what we need to become healthier and happier. As the authors conclude, “Facing the most difficult truths in our lives is challenging but also liberating” (p. 163).
Self-Efficacy
Confidence is a person's general feeling, perception, or belief that she has the capability to be successful in performing a skill and meeting task demands. Self-efficacy combines confidence with self-expectations. Self-efficacy, often associated and used interchangeably with self-confidence, is defined by Feltz and Lirgg (2001) as “the belief one has in being able to execute a specific task successfully . . .
to obtain a certain outcome” (p. 340). They further write, “Self-efficacy beliefs are not judgments about one's skills, objectively speaking, but rather are judgments of what one can accomplish with those skills” (p. 340). Thus, self-efficacy beliefs reflect a person's feelings not about what she can do but rather about what she has already done.
Self-efficacy is enormously important in an exercise setting and for changing and adhering to desirable, healthy behaviors. For example, people who experience self-doubt about their ability to join a fitness class and perform at least most of the exercises will be more likely to stop attending the class and either try some other form of exercise or return to their sedentary lifestyle. It is against human nature to continue participating in an activity in which we perceive our performance as incompetent or we fail to meet self-expectations or experience improved exercise performance and outcomes (e.g., better fitness). Therefore, building self-efficacy in an exercise setting bolsters the exercisers' perception that they are exercising properly, using correct technique, and improving performance. With respect to general health, clients will feel that following a certain set of routines will result or has resulted in superior health-related outcomes (e.g., more energy, positive mood, favorable results from medical tests). The objective of every worker in the health care industry, including fitness and nutrition coaches, is to provide instruction and positive feedback to build the person's self-efficacy about maintaining healthy habits.
Researchers have examined the link between self-efficacy and exercise behavior. Perhaps not surprising is the finding that as a person becomes more committed to an exercise habit, his self-efficacy improves. Self-efficacy is relatively low in the early stages of exercise, when a person is just beginning to develop an exercise routine or starting to make exercise a habit, and it increases dramatically as the person inserts exercise among his daily rituals. What is unknown is whether self-efficacy causes a person to adopt exercise as a lifestyle ritual or whether continued exercise increases self-efficacy. No doubt the two processes interact and self-efficacy is both the cause and the outcome of maintaining a regular exercise habit (Feltz and Lirgg, 2001; O'Leary, 1985).
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Religious institutions and spiritual leaders influence health behavior
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22).
Religious Community and Health Habits
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22). Religions, for example, promote beliefs that regulate behaviors related to alcohol, tobacco, diet, general hygiene, and medical care. Levin found that commitment to religion “may have a protective effect against subsequent illness . . . prevent or delay (illnesses), and have long-term benefits for physical and mental functioning and health” (p. 23).
The religious community is not immune from the health-related problems derived from an unhealthy lifestyle, however. The obesity epidemic still thrives in the religious and spiritual community (Cline and Ferraro, 2006). For example, the prevalence of obesity increased from 24% to 30% from 1986 to 1994 and likely has become much higher in more recent years among people of faith, that is, people who claim an affiliation with or membership in a denomination or religious institution. One potentially powerful source of health behavior change that has not been recognized in the war against obesity is the importance of religious and spiritual institutions and their leaders.
Next to physicians or other personal care providers, religious and spiritual leaders are some of the most credible people who influence the thoughts, emotions, and actions of a person of faith. People of faith often make a conscious decision to behave in a manner that is consistent with the expectations of their religious or spiritual messages.
In his book, Medicine, Religion, and Health: Where Science and Spirituality Meet (2008), Dr. Harold G. Koenig, MD, divides the benefits of religious practice or belief into six health-related areas:
1. Mental health
2. Immune function
3. Cardiovascular function
4. Stress and behavior-related diseases
5. Mortality
6. Physical disability
Based on his review of the research literature in each of these areas, Koenig (2008) concluded that religious practice or spirituality were strongly associated with superior health outcomes. He found, for example, that blood pressure and rates of stroke and cognitive impairment were each highly correlated with religious involvement (e.g., service attendance, frequency of prayer, strength of belief in a higher power). Although not always acknowledged by religious leaders, messages related to maintaining healthy habits are common throughout most religious texts.
To people of faith, arguably no one has more credibility for influencing behavior than their religious or spiritual leader. Should these leaders play a role in promoting healthy habits among congregants and the community at large? How can they address the apparent disconnect between people's religious practices, including a firm belief in religious or spiritual texts, and their lack of self-awareness about practicing healthy habits? And how can health professionals be involved in this process?
Role of Religious Leaders in Promoting and Modeling Healthy Habits
Many religious leaders contend that people who attend traditional ceremonies or services are looking for spiritual fulfillment, and that is the primary role of their institutions. Educating congregants about healthy habits is not. Perhaps this view, and the mission that propels it, needs to be reexamined. All sources of behavioral influence, including school systems, governments, corporations, the food industry, and religious institutions, need to be unified in providing information and incentives to replace self-destructive behavior patterns with healthier alternatives. One source of health behavior interventions that has received only minimal attention is the role of religious and spiritual leaders.
What should religious and spiritual leaders do to promote healthy habits, perhaps with assistance from health professionals? First, they need to look at themselves and determine if the change needs to start with them. Next, they must speak up and encourage their institution members—and other members of the community, when given the opportunity—to have discipline in all areas of their lives. One religious text, the Bible, addresses eating, indulgence, self-control, self-discipline, and gluttony. These topics need to be addressed in religious institutions and services without fear of offending attendees. Leaders of congregants who attend spiritual events and services should encourage their congregants to make lifestyle changes that will ultimately bring glory to God or some other higher power to whom they feel accountable. Religious leaders must stop being intimidated by the risk of losing members by offending them in order to acknowledge the importance of self-care as an inherent component of a religious and spiritual lifestyle (Colbert, 2002).
Perhaps the most serious obstacle to health behavior change in the religious community is persuading people of faith to take responsibility for their health and engage in the free will of healthy lifestyle choices, rather than surrender control to a higher power. Most religious texts, including the Bible, promote taking responsibility for health behavior. Philippians 2:13 states that God works within us to will his Holy Spirit and the free will to desire to create balance in our life—and the will to act on that desire.
For example, as Omartian (1996) contends, “The main reason to exercise is for your health. Without good health you cannot do all that the Lord has for you do to and you cannot be all the Lord wants you to be” (p. 117). Along these lines, Koenig (1999) asserts, “The world's religions encourage healthy living. . . .
All established religions discourage . . . any habit or activity harmful to the human body, which has traditionally been viewed as sacred, created in the image of God” (p. 72). And as Levin (2001) concludes, “All religions endorse the idea that we ought to take care of our bodies and not act in ways that are reckless and endanger our health” (p. 41).
There is an apparent need for religious institutions and their leaders to play a more prominent role in promoting community health and wellness and to serve as role models for their congregations. The credibility of pastors, priests, rabbis, imams, and other religious leaders will be further enhanced if their messages of health and wellness given in their sermons and programs are reflected in their own behavioral patterns. In other words, religious and spiritual leaders have to walk the walk, not just talk the talk.
Health Themes Addressed by Religious and Spiritual Leaders
Perhaps the strongest influence of a religious leader on the thoughts, emotions, and actions of attendees of religious services occurs when their attention is focused on the leader's words—the sermon. Health-related themes that extol the virtues of maintaining a healthy lifestyle need to be communicated more frequently and passionately, citing religious or spiritual text to reinforce main issues. For example, in the New Testament of the Christian Bible, the apostle Paul reminds his readers that their bodies are a dwelling place of the Holy Spirit, thereby bridging the gap between spiritual and physical dualism that may be keeping people of faith locked into unhealthy behavioral patterns. Paul contends that what we do with our bodies matters not only on a physical level but also on a spiritual level.
Religious leaders can also cite scripture to remind us that we are not owners but rather managers, or stewards, of our bodies. Maintaining healthy habits is a matter of personal stewardship. When we begin to perceive our bodies in a manner that is consistent with God's view, we begin to make decisions that affect our physical health that honors a higher power (i.e., God). Thus, maintaining unhealthy habits that lead to obesity and poor physical conditioning is a failure of that stewardship responsibility.
Another health theme found in religion is gluttony. The Gluttony in Religion highlight box lists examples of this theme from various religious texts that both religious leaders and health professionals may use with people of faith to address the association between healthy habits and spirituality or religion.
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Overcome mental barriers to reach exercise goals
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks.
Mental Barriers to Exercise Adherence
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks. However, it will not take a great deal of time to feel better and adjust to new physical demands they place on themselves. They simply need patience. Without it, they will quit. They will lack adherence, and this is exactly the problem with at least half the people who initiate exercise programs. Our high-achieving, impatient culture, made worse by personality traits such as negative perfectionism, high trait anxiety, and pessimism about the future, often does not allow us to set reasonable goals and to develop strategies to reach those goals.
Emotions, thoughts, and feelings drive behavior in one of two directions: positive, toward achieving success and developing a better, healthier, more energetic lifestyle, or negative, toward maintaining unhealthy habits, being overweight, lacking energy, and living a life inconsistent with one's values about what is important. Improving a client's lifestyle takes effort—and a plan. Health and fitness professionals need to revisit the client's values, connect each value to a new routine that will create and maintain a more active lifestyle, and improve physical and mental health. Adherence to a program of regular exercise, the theme of this chapter, is of paramount importance in doing everything in our power to take control of our destiny. In the words of former British prime minister Sir Winston Churchill, “Continuous effort—not strength or intelligence—is the key to unlocking our potential" (qtd. in Cook, 1993).
A person's decision to discontinue an exercise habit often has a psychological explanation. Here are some of the more common conditions that can lead to dropping out of an exercise program. Hopefully, health professionals can develop and apply effective responses to these excuses that will change the client's mind about quitting.
Anxiety
Anxiety consists of feelings of worry or threat about the future, as discussed in chapter 5. Anxious thoughts cause worry and distract the exerciser from the task at hand—and waste energy. Sources of exercise anxiety include worry about meeting goals, physical appearance, being accepted by others (even strangers at a fitness club), and using time to exercise instead of doing something else (“I could be watching TV or finishing a report instead of going to the gym”). Ironically, exercise actually reduces both short-term (acute) and long-term (chronic) anxiety. Exercise is what the doctor ordered for improved mental health, including reduced anxiety (deMoor et al., 2006). Health professionals should strongly consider exercise as one behavioral strategy for helping their clients manage anxiety, particularly if clients are given social support in their new exercise program.
Depression
Most people experience unhappiness and negative emotions; this is normal. Ongoing, deeply negative mood states, however, may be a more serious mood disorder referred to as clinical depression (APA, 2000). Depression is a mood disorder that ranges from mild to severe and can be due to a medical condition, substance use, or psychopathology (mental illness). A sedentary lifestyle may induce or promote depression, but exercise has been shown to reduce it in over 70 studies across various age groups and for both genders (Leith, 1998).
One factor that influences the effect of exercise on depression is whether the person has selected and is enjoying the type of physical activity. A second factor is whether the exercise is of sufficient intensity, frequency, and duration to improve fitness outcomes and lead to psychological benefits. Taking a quiet, slow walk through the park, although pleasant and relaxing, may not be sufficient to reduce depression (Brosse, Sheets, Lett, and Blumenthal, 2002). Buckworth and Dishman (2002), in support of recommendations from ACSM, suggest the following exercise guidelines for people with depression who are otherwise healthy: three to five days a week (frequency) for 20 to 60 minutes each session (duration) at 55% to 90% of maximal heart rate (intensity). Certified fitness coaches should aim to meet these standards when prescribing exercise for depressed clients.
Negativity
It is impossible to remain motivated and on task if self-talk is negative, such as, “I don't like this,” “I feel terrible,” or “I'm tired.” Replacing those thoughts with positive statements that are optimistic and enthusiastic induces more effort and energy. Examples include, “I can do this,” “I feel good,” “Just three more minutes to go,” and “Hang in there.” To quote an anonymous writer, “You cannot be unhappy and enthusiastic at the same time.
”Negative and antagonistic feelings and emotions can impair the development of an exercise habit, especially for novice performers. The problem with negative thinking is that it results in low effort and sets up the individual to fail. This process is similar to the self-fulfilling prophecy; one's performance level will be consistent with one's expectations.
Examples of negative thinking that serve as barriers to exercise success include lack of confidence (e.g., “I don't think I can do this”), intimidation (e.g., “I don't belong in this fitness facility,” “People are laughing at me”), pessimism (e.g., “I'll never lose weight,” “Exercise will never be enjoyable”), self-criticism (e.g., “I can't run even one lap of that track, so why even try?”, “Exercise is not for me; I'll always be weak”), impatience (e.g., “I've been exercising for three weeks and still run out of steam when jogging”), and irrational thinking (e.g., “I've always been heavy; why change now?”, “People just have to accept me the way I am,” “My spouse thinks my weight and appearance are just fine”).
There are several implications for health care professionals when it comes to addressing mental health. First, consultants should not attempt to diagnose or treat mental illness unless they are licensed psychologists or have other appropriate credentials related to this area. There are serious legal implications of providing treatment to a person who did not request it, was not diagnosed correctly, or did not receive the proper treatment. The key term that reflects the proper thing to do if mental illness is suspected is referral; that is, health care professionals must refer clients to a licensed mental health professional for diagnosis and treatment if mental illness, such as depression, chronic anxiety, or another condition, is suspected.
A second implication for dealing with psychological barriers to maintaining healthy habits, particularly related to exercise and nutrition, is the need to schedule meetings between the client and qualified health coaches, such as a certified personal trainer and a registered dietitian. Exercise and nutrition both influence mental health and should not be ignored when attempting to change client health behavior. Relationships with local experts in these areas should be established before referral in order to become familiar with the expert's background, skills, location, types of services rendered, and personal qualities. Sometimes clients prefer a male or female coach or can meet the consultant only on certain days at certain times. It is essential that the health care professional try to coordinate the client's needs and preferences with the coach's characteristics.
Perfectionism
Perfectionism is a trait reflecting a person's disposition toward "setting excessively high standards of performance in conjunction with a tendency to make overly critical self-evaluations" (Frost, Marten, Lahart, and Rosenblate, 1990, p. 450). It is usually studied as a trait measure—stable and cross-situational—not a state (situational) measure (Antony and Swinson, 2009).
Perfectionism has both positive and negative features. The positive aspects of perfectionism include setting and attempting to achieve high personal standards, striving to achieve lofty but realistic goals often leading to success, and being conscientious and self-confident (Flett, Hewitt, Blankstein, and Mosher, 1991). Negative features, not uncommon among people who go overboard in attempting to achieve goals, include feeling deep concern about making mistakes, which leads to heightened anxiety; having doubts about one's actions; setting excessively high standards; having difficulty recognizing success; and overemphasizing precision, neatness, order, and organization. People who fit these behavior and thought patterns are referred to by clinical psychologists as neurotic perfectionists. They have a propensity to engage in self-destructive behaviors, excessive self-criticism, failure to recognize achievement and competence, and feelings of “It's not good enough” (Antony and Swinson, 2009; Adderholdt-Elliott, 1987).
Neurotic perfectionists set unattainable goals and might engage in overtraining or exercise addiction. Their self-talk is based on messages they received when they were young, reminding themselves that “It's not good enough” and “I can do better.” Their expectations of others are also excessive. Perfectionists need to learn how to set reasonable goals and to recognize their own achievements and those of others, especially in exercise settings. They need to have indicators of success and to acknowledge when they have reached those indicators.
Implications for working with clients who reveal perfectionistic thinking include referral to a mental health professional so that its sources can be identified and treated. Perfectionism can play a role in attempts at self-improvement; however, when standards and goals are excessively high, when self-expectations for achievement are unrealistic, and when the person expects others to meet these same excessive standards, often at the expense of alienating others, then this condition becomes an obstacle to happiness, confidence, and mental health.
Another implication for working with perfectionistic clients is the need to help them set realistic but challenging goals that are measurable and observable, to help them detect times when they have met their performance expectations, and to verbally and directly recognize their accomplishments. One important strategy that validates positive feedback and gives the consultant credibility is to base feedback on numbers—perhaps fitness test results, blood test results, improved exercise performance (e.g., increased resistance in weight training, faster jogging times, reduced body-fat percentage), or some other measure that quantifies improved physical performance.
Finally, perfectionists often need to change their irrational thinking by being reminded of their accomplishments, favorably comparing their competence level with others, and being more realistic about their self-expectations. Perfectionism, particularly when excessive (also referred to by mental health professionals as irrational, maladaptive, or neurotic), has specific sources, such as parents, sport coaches, or teachers, and this may be pointed out as an issue that is nothing to be ashamed about and that might require professional consultation to address it.
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Orientations and styles can be changed to promote exercise adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two.
Orientations, Styles, and Exercise Adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two. Personality traits are permanent, stable across situations, and partly a reflection of one's genetic predisposition, and therefore they are not subject to change. Orientations and styles, on the other hand, reflect common attitudes or a person's tendency to think or act in a predictable manner. The concepts of attributional style, coping style, and win orientation reflect predictable and persistent ways of thinking and acting under certain conditions. If, for instance, a person who demonstrates success or competence has an internal attributional style, the typical way the person explains success may be internal. That is, she may typically attribute the cause of her success as due to high effort or excellent skills, both internal explanations. Not taking responsibility for success or failure and perceiving the cause as something beyond the person's control reflects an external attributional style, at least for that particular situation (e.g., maintaining high fitness, improving performance on a given task, gaining excessive weight).
Orientations and styles also predict how people perceive the importance of a healthy lifestyle and to what they attribute their good or poor health. An internal disposition could reflect taking responsibility for one's excessive weight or poor fitness as due to poor dietary choices, excessive food intake, and lack of physical activity. Someone with an external disposition will be more likely to attribute weight gain to genetics or similarity to other family members, to not acknowledge there is a weight problem, or to believe that weight gain and consequent diseases (e.g., type 2 diabetes, high blood pressure, heart disease) are normal and part of the aging process. Other types of orientations and styles related to health behavior include self-control, self-awareness, and the interchangeable concepts of self-confidence and self-efficacy.
Self-Control
Self-control refers to the extent to which a person voluntarily and consciously creates, carries out, and maintains thoughts, emotions, and behaviors toward reaching desirable goals, even after encountering obstacles (Rosenbaum, 1990). Self-control behaviors are regulated by deliberate cognitive processes that are under the person's voluntary control. A good example of self-control in exercise settings is time management. Perhaps the primary reason people offer for not exercising is not having enough time (Sternfeld et al., 2009). People with high self-control plan their day and set aside time (i.e., day of the week, hour of the day, length of time) devoted to maintaining an exercise routine.
Self-control also means that the activity itself may be planned. For example, perhaps an exerciser who prefers the company of a friend during a workout plans to meet his friend at the exercise facility. Upon entering the facility, the individual has preplanned an hour devoted to various tasks that compose the exercise workout; specific routines are planned and carried out for the duration of the session, from entering to exiting the facility. The type of aerobic and resistance training may also be predetermined and executed in attempting to reach challenging goals. Presumably, the excuse of not having enough time now becomes having more time to do other things thanks to increased energy and vigor as a function of the workout. People with a high self-control orientation are more capable of carrying out preperformance and performance routines compared with their counterparts with low self-control (Faulkner et al., 2006). People with high self-control are schedule keepers and rarely waste time.
An important situational factor in developing an exercise habit is scheduling one's exercise sessions during the week. This requires good time management skills. Rather than saying, “I'll exercise when I get the time,” restate that view with, “I will exercise at x times on the following days.” A minimum of three times a week of intense exercise that expands one's fitness capacity and has a training effect (e.g., increased heart rate, increased muscular strength) is needed. However, finding opportunities to become physically active during the day (e.g., taking the stairs instead of the elevator, walking up or down the escalator, taking an evening or lunchtime walk) is also helpful for burning calories and managing weight.
Learned Resourcefulness
The pioneer writer and researcher in the literature on learned resourcefulness is Dr. Michael Rosenbaum (1990). He defined learned resourcefulness as “an acquired repertoire of behavioral and cognitive skills with which the person is able to regulate internal events such as emotions and cognitions that might otherwise interfere with the smooth execution of a target behavior” (p. xiv). High scorers on Rosenbaum's Self-Report Scale (Rosenbaum, 1990) are better able to
• tolerate physical discomfort,
• cope effectively with stress,
• succeed in weight-reduction programs,
• prevent or overcome feelings of helplessness,
• comply with medical and other health-related regimens,
• establish and maintain a relatively healthy lifestyle, and
• delay immediate gratification (e.g., binge eating) and understand the value of delayed gratification (e.g., exercising takes time, but the person receives more energy, better health, and improved performance quality).
In general, learned resourcefulness is particularly important in controlling negative thoughts and emotions while engendering desirable cognitive processes such as positive self-talk, optimism, self-motivation, and positive mood states. People high in learned resourcefulness are more confident; more likely to adopt an active lifestyle, including regular exercise; and less likely to engage in self-destructive behaviors (e.g., smoking, taking extreme risks). It is important to note that learned resourcefulness is not viewed as a personality trait. Instead, it is an orientation—a way of thinking that can be influenced through experience, counseling, and situational conditions.
Mental Toughness
Mental toughness is a disposition that represents the ability to reach and sustain high performance under pressure by expanding one's physical, mental, and emotional capacity (Connaughton, Hanton, and Jones, 2010). Mental toughness is learned, not inherited; it's an orientation. One common but false view of many athletes and coaches is that we are born with the right competitive instincts, and people who cannot handle failure lack the genetic predisposition to be mentally tough. The belief in a mental toughness gene is tempting because it absolves the person of taking responsibility for failure. However, the reality is that mental toughness can be taught, improved, and mastered. Exercisers need mental toughness to acknowledge their poor health and the need for physical activity, to withstand the challenges of physical exertion, to overcome physical fatigue, to continue to see the benefits of an exercise program, and to maintain exercise participation as a lifelong habit.
Mentally tough people are self-motivated and self-directed (their energy comes from internal sources; it is not forced from the outside); positive but realistic about handling adversity; in control of their emotions, especially in response to frustration and disappointment; and calm and relaxed under fire (rather than avoiding pressure, they are challenged by it). Mental toughness is also characterized by high energy, physical and mental readiness for action, a strong desire to succeed, relentlessness in the pursuit of challenging goals, superb concentration skills, self-confidence in the ability to perform well, and taking full responsibility for one's actions.
Self-Awareness
Think of self-awareness as the willingness to self-reflect, to engage introspectively, and to look at oneself through the eyes of others. This is not always easy to do, but others give us signals about their expectations and evaluations of us all the time, if we just take a good look. People react to us one way if they want our friendship and we have their respect. They react to us in a completely different way if they reject or disrespect us for whatever justified or unjustified reasons.
Self-awareness is an important component of health behavior because the ability to look inside and to be cognizant of our thoughts, emotions, and behaviors allows us to initiate steps for desirable change. If, for instance, we look in the mirror and see a person who is out of shape, overweight, and even unattractive, we can then begin the process of determining the reasons for our low energy, labored breathing, and general discomfort. Self-aware people also become more aware of the short-term costs and long-term consequences of their bad habits. They do not ignore their poor health and the negative habits that cause their current health status. This is why they are more likely to embrace support and opportunity to make lifelong changes that improve their health and happiness. They refuse to remain stuck in a self-destructive lifestyle. The challenges of self-awareness are addressed by Loehr and Schwartz (2003), who paraphrase John 32:8 from the Bible: “If the truth is to set us free, facing it cannot be a one-time event. Rather, it must become a practice. Like all of our ‘muscles,' self-awareness withers from disuse and deepens when we push past our resistance to see more of the truth” (p. 163).
Self-awareness, then, is an orientation. We differ in our willingness to become introspective about who we are and what we need to do to become better. As Loehr and Schwartz (2003) contend, “We must persistently shed light on those aspects of ourselves that we prefer not to see in order to build our mental, emotional and spiritual capacity” (p. 163). The authors also agree, however, that self-awareness can be self-defeating and overwhelming, bringing out negative thoughts, feelings, and emotions if it is absorbed in too big a dose. The right amount and frequency of self-awareness provides sufficient information to keep us on track and to be used as a source of information about what we need to become healthier and happier. As the authors conclude, “Facing the most difficult truths in our lives is challenging but also liberating” (p. 163).
Self-Efficacy
Confidence is a person's general feeling, perception, or belief that she has the capability to be successful in performing a skill and meeting task demands. Self-efficacy combines confidence with self-expectations. Self-efficacy, often associated and used interchangeably with self-confidence, is defined by Feltz and Lirgg (2001) as “the belief one has in being able to execute a specific task successfully . . .
to obtain a certain outcome” (p. 340). They further write, “Self-efficacy beliefs are not judgments about one's skills, objectively speaking, but rather are judgments of what one can accomplish with those skills” (p. 340). Thus, self-efficacy beliefs reflect a person's feelings not about what she can do but rather about what she has already done.
Self-efficacy is enormously important in an exercise setting and for changing and adhering to desirable, healthy behaviors. For example, people who experience self-doubt about their ability to join a fitness class and perform at least most of the exercises will be more likely to stop attending the class and either try some other form of exercise or return to their sedentary lifestyle. It is against human nature to continue participating in an activity in which we perceive our performance as incompetent or we fail to meet self-expectations or experience improved exercise performance and outcomes (e.g., better fitness). Therefore, building self-efficacy in an exercise setting bolsters the exercisers' perception that they are exercising properly, using correct technique, and improving performance. With respect to general health, clients will feel that following a certain set of routines will result or has resulted in superior health-related outcomes (e.g., more energy, positive mood, favorable results from medical tests). The objective of every worker in the health care industry, including fitness and nutrition coaches, is to provide instruction and positive feedback to build the person's self-efficacy about maintaining healthy habits.
Researchers have examined the link between self-efficacy and exercise behavior. Perhaps not surprising is the finding that as a person becomes more committed to an exercise habit, his self-efficacy improves. Self-efficacy is relatively low in the early stages of exercise, when a person is just beginning to develop an exercise routine or starting to make exercise a habit, and it increases dramatically as the person inserts exercise among his daily rituals. What is unknown is whether self-efficacy causes a person to adopt exercise as a lifestyle ritual or whether continued exercise increases self-efficacy. No doubt the two processes interact and self-efficacy is both the cause and the outcome of maintaining a regular exercise habit (Feltz and Lirgg, 2001; O'Leary, 1985).
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Religious institutions and spiritual leaders influence health behavior
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22).
Religious Community and Health Habits
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22). Religions, for example, promote beliefs that regulate behaviors related to alcohol, tobacco, diet, general hygiene, and medical care. Levin found that commitment to religion “may have a protective effect against subsequent illness . . . prevent or delay (illnesses), and have long-term benefits for physical and mental functioning and health” (p. 23).
The religious community is not immune from the health-related problems derived from an unhealthy lifestyle, however. The obesity epidemic still thrives in the religious and spiritual community (Cline and Ferraro, 2006). For example, the prevalence of obesity increased from 24% to 30% from 1986 to 1994 and likely has become much higher in more recent years among people of faith, that is, people who claim an affiliation with or membership in a denomination or religious institution. One potentially powerful source of health behavior change that has not been recognized in the war against obesity is the importance of religious and spiritual institutions and their leaders.
Next to physicians or other personal care providers, religious and spiritual leaders are some of the most credible people who influence the thoughts, emotions, and actions of a person of faith. People of faith often make a conscious decision to behave in a manner that is consistent with the expectations of their religious or spiritual messages.
In his book, Medicine, Religion, and Health: Where Science and Spirituality Meet (2008), Dr. Harold G. Koenig, MD, divides the benefits of religious practice or belief into six health-related areas:
1. Mental health
2. Immune function
3. Cardiovascular function
4. Stress and behavior-related diseases
5. Mortality
6. Physical disability
Based on his review of the research literature in each of these areas, Koenig (2008) concluded that religious practice or spirituality were strongly associated with superior health outcomes. He found, for example, that blood pressure and rates of stroke and cognitive impairment were each highly correlated with religious involvement (e.g., service attendance, frequency of prayer, strength of belief in a higher power). Although not always acknowledged by religious leaders, messages related to maintaining healthy habits are common throughout most religious texts.
To people of faith, arguably no one has more credibility for influencing behavior than their religious or spiritual leader. Should these leaders play a role in promoting healthy habits among congregants and the community at large? How can they address the apparent disconnect between people's religious practices, including a firm belief in religious or spiritual texts, and their lack of self-awareness about practicing healthy habits? And how can health professionals be involved in this process?
Role of Religious Leaders in Promoting and Modeling Healthy Habits
Many religious leaders contend that people who attend traditional ceremonies or services are looking for spiritual fulfillment, and that is the primary role of their institutions. Educating congregants about healthy habits is not. Perhaps this view, and the mission that propels it, needs to be reexamined. All sources of behavioral influence, including school systems, governments, corporations, the food industry, and religious institutions, need to be unified in providing information and incentives to replace self-destructive behavior patterns with healthier alternatives. One source of health behavior interventions that has received only minimal attention is the role of religious and spiritual leaders.
What should religious and spiritual leaders do to promote healthy habits, perhaps with assistance from health professionals? First, they need to look at themselves and determine if the change needs to start with them. Next, they must speak up and encourage their institution members—and other members of the community, when given the opportunity—to have discipline in all areas of their lives. One religious text, the Bible, addresses eating, indulgence, self-control, self-discipline, and gluttony. These topics need to be addressed in religious institutions and services without fear of offending attendees. Leaders of congregants who attend spiritual events and services should encourage their congregants to make lifestyle changes that will ultimately bring glory to God or some other higher power to whom they feel accountable. Religious leaders must stop being intimidated by the risk of losing members by offending them in order to acknowledge the importance of self-care as an inherent component of a religious and spiritual lifestyle (Colbert, 2002).
Perhaps the most serious obstacle to health behavior change in the religious community is persuading people of faith to take responsibility for their health and engage in the free will of healthy lifestyle choices, rather than surrender control to a higher power. Most religious texts, including the Bible, promote taking responsibility for health behavior. Philippians 2:13 states that God works within us to will his Holy Spirit and the free will to desire to create balance in our life—and the will to act on that desire.
For example, as Omartian (1996) contends, “The main reason to exercise is for your health. Without good health you cannot do all that the Lord has for you do to and you cannot be all the Lord wants you to be” (p. 117). Along these lines, Koenig (1999) asserts, “The world's religions encourage healthy living. . . .
All established religions discourage . . . any habit or activity harmful to the human body, which has traditionally been viewed as sacred, created in the image of God” (p. 72). And as Levin (2001) concludes, “All religions endorse the idea that we ought to take care of our bodies and not act in ways that are reckless and endanger our health” (p. 41).
There is an apparent need for religious institutions and their leaders to play a more prominent role in promoting community health and wellness and to serve as role models for their congregations. The credibility of pastors, priests, rabbis, imams, and other religious leaders will be further enhanced if their messages of health and wellness given in their sermons and programs are reflected in their own behavioral patterns. In other words, religious and spiritual leaders have to walk the walk, not just talk the talk.
Health Themes Addressed by Religious and Spiritual Leaders
Perhaps the strongest influence of a religious leader on the thoughts, emotions, and actions of attendees of religious services occurs when their attention is focused on the leader's words—the sermon. Health-related themes that extol the virtues of maintaining a healthy lifestyle need to be communicated more frequently and passionately, citing religious or spiritual text to reinforce main issues. For example, in the New Testament of the Christian Bible, the apostle Paul reminds his readers that their bodies are a dwelling place of the Holy Spirit, thereby bridging the gap between spiritual and physical dualism that may be keeping people of faith locked into unhealthy behavioral patterns. Paul contends that what we do with our bodies matters not only on a physical level but also on a spiritual level.
Religious leaders can also cite scripture to remind us that we are not owners but rather managers, or stewards, of our bodies. Maintaining healthy habits is a matter of personal stewardship. When we begin to perceive our bodies in a manner that is consistent with God's view, we begin to make decisions that affect our physical health that honors a higher power (i.e., God). Thus, maintaining unhealthy habits that lead to obesity and poor physical conditioning is a failure of that stewardship responsibility.
Another health theme found in religion is gluttony. The Gluttony in Religion highlight box lists examples of this theme from various religious texts that both religious leaders and health professionals may use with people of faith to address the association between healthy habits and spirituality or religion.
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Overcome mental barriers to reach exercise goals
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks.
Mental Barriers to Exercise Adherence
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks. However, it will not take a great deal of time to feel better and adjust to new physical demands they place on themselves. They simply need patience. Without it, they will quit. They will lack adherence, and this is exactly the problem with at least half the people who initiate exercise programs. Our high-achieving, impatient culture, made worse by personality traits such as negative perfectionism, high trait anxiety, and pessimism about the future, often does not allow us to set reasonable goals and to develop strategies to reach those goals.
Emotions, thoughts, and feelings drive behavior in one of two directions: positive, toward achieving success and developing a better, healthier, more energetic lifestyle, or negative, toward maintaining unhealthy habits, being overweight, lacking energy, and living a life inconsistent with one's values about what is important. Improving a client's lifestyle takes effort—and a plan. Health and fitness professionals need to revisit the client's values, connect each value to a new routine that will create and maintain a more active lifestyle, and improve physical and mental health. Adherence to a program of regular exercise, the theme of this chapter, is of paramount importance in doing everything in our power to take control of our destiny. In the words of former British prime minister Sir Winston Churchill, “Continuous effort—not strength or intelligence—is the key to unlocking our potential" (qtd. in Cook, 1993).
A person's decision to discontinue an exercise habit often has a psychological explanation. Here are some of the more common conditions that can lead to dropping out of an exercise program. Hopefully, health professionals can develop and apply effective responses to these excuses that will change the client's mind about quitting.
Anxiety
Anxiety consists of feelings of worry or threat about the future, as discussed in chapter 5. Anxious thoughts cause worry and distract the exerciser from the task at hand—and waste energy. Sources of exercise anxiety include worry about meeting goals, physical appearance, being accepted by others (even strangers at a fitness club), and using time to exercise instead of doing something else (“I could be watching TV or finishing a report instead of going to the gym”). Ironically, exercise actually reduces both short-term (acute) and long-term (chronic) anxiety. Exercise is what the doctor ordered for improved mental health, including reduced anxiety (deMoor et al., 2006). Health professionals should strongly consider exercise as one behavioral strategy for helping their clients manage anxiety, particularly if clients are given social support in their new exercise program.
Depression
Most people experience unhappiness and negative emotions; this is normal. Ongoing, deeply negative mood states, however, may be a more serious mood disorder referred to as clinical depression (APA, 2000). Depression is a mood disorder that ranges from mild to severe and can be due to a medical condition, substance use, or psychopathology (mental illness). A sedentary lifestyle may induce or promote depression, but exercise has been shown to reduce it in over 70 studies across various age groups and for both genders (Leith, 1998).
One factor that influences the effect of exercise on depression is whether the person has selected and is enjoying the type of physical activity. A second factor is whether the exercise is of sufficient intensity, frequency, and duration to improve fitness outcomes and lead to psychological benefits. Taking a quiet, slow walk through the park, although pleasant and relaxing, may not be sufficient to reduce depression (Brosse, Sheets, Lett, and Blumenthal, 2002). Buckworth and Dishman (2002), in support of recommendations from ACSM, suggest the following exercise guidelines for people with depression who are otherwise healthy: three to five days a week (frequency) for 20 to 60 minutes each session (duration) at 55% to 90% of maximal heart rate (intensity). Certified fitness coaches should aim to meet these standards when prescribing exercise for depressed clients.
Negativity
It is impossible to remain motivated and on task if self-talk is negative, such as, “I don't like this,” “I feel terrible,” or “I'm tired.” Replacing those thoughts with positive statements that are optimistic and enthusiastic induces more effort and energy. Examples include, “I can do this,” “I feel good,” “Just three more minutes to go,” and “Hang in there.” To quote an anonymous writer, “You cannot be unhappy and enthusiastic at the same time.
”Negative and antagonistic feelings and emotions can impair the development of an exercise habit, especially for novice performers. The problem with negative thinking is that it results in low effort and sets up the individual to fail. This process is similar to the self-fulfilling prophecy; one's performance level will be consistent with one's expectations.
Examples of negative thinking that serve as barriers to exercise success include lack of confidence (e.g., “I don't think I can do this”), intimidation (e.g., “I don't belong in this fitness facility,” “People are laughing at me”), pessimism (e.g., “I'll never lose weight,” “Exercise will never be enjoyable”), self-criticism (e.g., “I can't run even one lap of that track, so why even try?”, “Exercise is not for me; I'll always be weak”), impatience (e.g., “I've been exercising for three weeks and still run out of steam when jogging”), and irrational thinking (e.g., “I've always been heavy; why change now?”, “People just have to accept me the way I am,” “My spouse thinks my weight and appearance are just fine”).
There are several implications for health care professionals when it comes to addressing mental health. First, consultants should not attempt to diagnose or treat mental illness unless they are licensed psychologists or have other appropriate credentials related to this area. There are serious legal implications of providing treatment to a person who did not request it, was not diagnosed correctly, or did not receive the proper treatment. The key term that reflects the proper thing to do if mental illness is suspected is referral; that is, health care professionals must refer clients to a licensed mental health professional for diagnosis and treatment if mental illness, such as depression, chronic anxiety, or another condition, is suspected.
A second implication for dealing with psychological barriers to maintaining healthy habits, particularly related to exercise and nutrition, is the need to schedule meetings between the client and qualified health coaches, such as a certified personal trainer and a registered dietitian. Exercise and nutrition both influence mental health and should not be ignored when attempting to change client health behavior. Relationships with local experts in these areas should be established before referral in order to become familiar with the expert's background, skills, location, types of services rendered, and personal qualities. Sometimes clients prefer a male or female coach or can meet the consultant only on certain days at certain times. It is essential that the health care professional try to coordinate the client's needs and preferences with the coach's characteristics.
Perfectionism
Perfectionism is a trait reflecting a person's disposition toward "setting excessively high standards of performance in conjunction with a tendency to make overly critical self-evaluations" (Frost, Marten, Lahart, and Rosenblate, 1990, p. 450). It is usually studied as a trait measure—stable and cross-situational—not a state (situational) measure (Antony and Swinson, 2009).
Perfectionism has both positive and negative features. The positive aspects of perfectionism include setting and attempting to achieve high personal standards, striving to achieve lofty but realistic goals often leading to success, and being conscientious and self-confident (Flett, Hewitt, Blankstein, and Mosher, 1991). Negative features, not uncommon among people who go overboard in attempting to achieve goals, include feeling deep concern about making mistakes, which leads to heightened anxiety; having doubts about one's actions; setting excessively high standards; having difficulty recognizing success; and overemphasizing precision, neatness, order, and organization. People who fit these behavior and thought patterns are referred to by clinical psychologists as neurotic perfectionists. They have a propensity to engage in self-destructive behaviors, excessive self-criticism, failure to recognize achievement and competence, and feelings of “It's not good enough” (Antony and Swinson, 2009; Adderholdt-Elliott, 1987).
Neurotic perfectionists set unattainable goals and might engage in overtraining or exercise addiction. Their self-talk is based on messages they received when they were young, reminding themselves that “It's not good enough” and “I can do better.” Their expectations of others are also excessive. Perfectionists need to learn how to set reasonable goals and to recognize their own achievements and those of others, especially in exercise settings. They need to have indicators of success and to acknowledge when they have reached those indicators.
Implications for working with clients who reveal perfectionistic thinking include referral to a mental health professional so that its sources can be identified and treated. Perfectionism can play a role in attempts at self-improvement; however, when standards and goals are excessively high, when self-expectations for achievement are unrealistic, and when the person expects others to meet these same excessive standards, often at the expense of alienating others, then this condition becomes an obstacle to happiness, confidence, and mental health.
Another implication for working with perfectionistic clients is the need to help them set realistic but challenging goals that are measurable and observable, to help them detect times when they have met their performance expectations, and to verbally and directly recognize their accomplishments. One important strategy that validates positive feedback and gives the consultant credibility is to base feedback on numbers—perhaps fitness test results, blood test results, improved exercise performance (e.g., increased resistance in weight training, faster jogging times, reduced body-fat percentage), or some other measure that quantifies improved physical performance.
Finally, perfectionists often need to change their irrational thinking by being reminded of their accomplishments, favorably comparing their competence level with others, and being more realistic about their self-expectations. Perfectionism, particularly when excessive (also referred to by mental health professionals as irrational, maladaptive, or neurotic), has specific sources, such as parents, sport coaches, or teachers, and this may be pointed out as an issue that is nothing to be ashamed about and that might require professional consultation to address it.
Learn more about Applied Health Fitness Psychology.
Orientations and styles can be changed to promote exercise adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two.
Orientations, Styles, and Exercise Adherence
Most authors in the health and exercise psychology literature do not differentiate between personality traits and other personal characteristics called orientations and styles (terms that are used interchangeably), but there are stark differences between the two. Personality traits are permanent, stable across situations, and partly a reflection of one's genetic predisposition, and therefore they are not subject to change. Orientations and styles, on the other hand, reflect common attitudes or a person's tendency to think or act in a predictable manner. The concepts of attributional style, coping style, and win orientation reflect predictable and persistent ways of thinking and acting under certain conditions. If, for instance, a person who demonstrates success or competence has an internal attributional style, the typical way the person explains success may be internal. That is, she may typically attribute the cause of her success as due to high effort or excellent skills, both internal explanations. Not taking responsibility for success or failure and perceiving the cause as something beyond the person's control reflects an external attributional style, at least for that particular situation (e.g., maintaining high fitness, improving performance on a given task, gaining excessive weight).
Orientations and styles also predict how people perceive the importance of a healthy lifestyle and to what they attribute their good or poor health. An internal disposition could reflect taking responsibility for one's excessive weight or poor fitness as due to poor dietary choices, excessive food intake, and lack of physical activity. Someone with an external disposition will be more likely to attribute weight gain to genetics or similarity to other family members, to not acknowledge there is a weight problem, or to believe that weight gain and consequent diseases (e.g., type 2 diabetes, high blood pressure, heart disease) are normal and part of the aging process. Other types of orientations and styles related to health behavior include self-control, self-awareness, and the interchangeable concepts of self-confidence and self-efficacy.
Self-Control
Self-control refers to the extent to which a person voluntarily and consciously creates, carries out, and maintains thoughts, emotions, and behaviors toward reaching desirable goals, even after encountering obstacles (Rosenbaum, 1990). Self-control behaviors are regulated by deliberate cognitive processes that are under the person's voluntary control. A good example of self-control in exercise settings is time management. Perhaps the primary reason people offer for not exercising is not having enough time (Sternfeld et al., 2009). People with high self-control plan their day and set aside time (i.e., day of the week, hour of the day, length of time) devoted to maintaining an exercise routine.
Self-control also means that the activity itself may be planned. For example, perhaps an exerciser who prefers the company of a friend during a workout plans to meet his friend at the exercise facility. Upon entering the facility, the individual has preplanned an hour devoted to various tasks that compose the exercise workout; specific routines are planned and carried out for the duration of the session, from entering to exiting the facility. The type of aerobic and resistance training may also be predetermined and executed in attempting to reach challenging goals. Presumably, the excuse of not having enough time now becomes having more time to do other things thanks to increased energy and vigor as a function of the workout. People with a high self-control orientation are more capable of carrying out preperformance and performance routines compared with their counterparts with low self-control (Faulkner et al., 2006). People with high self-control are schedule keepers and rarely waste time.
An important situational factor in developing an exercise habit is scheduling one's exercise sessions during the week. This requires good time management skills. Rather than saying, “I'll exercise when I get the time,” restate that view with, “I will exercise at x times on the following days.” A minimum of three times a week of intense exercise that expands one's fitness capacity and has a training effect (e.g., increased heart rate, increased muscular strength) is needed. However, finding opportunities to become physically active during the day (e.g., taking the stairs instead of the elevator, walking up or down the escalator, taking an evening or lunchtime walk) is also helpful for burning calories and managing weight.
Learned Resourcefulness
The pioneer writer and researcher in the literature on learned resourcefulness is Dr. Michael Rosenbaum (1990). He defined learned resourcefulness as “an acquired repertoire of behavioral and cognitive skills with which the person is able to regulate internal events such as emotions and cognitions that might otherwise interfere with the smooth execution of a target behavior” (p. xiv). High scorers on Rosenbaum's Self-Report Scale (Rosenbaum, 1990) are better able to
• tolerate physical discomfort,
• cope effectively with stress,
• succeed in weight-reduction programs,
• prevent or overcome feelings of helplessness,
• comply with medical and other health-related regimens,
• establish and maintain a relatively healthy lifestyle, and
• delay immediate gratification (e.g., binge eating) and understand the value of delayed gratification (e.g., exercising takes time, but the person receives more energy, better health, and improved performance quality).
In general, learned resourcefulness is particularly important in controlling negative thoughts and emotions while engendering desirable cognitive processes such as positive self-talk, optimism, self-motivation, and positive mood states. People high in learned resourcefulness are more confident; more likely to adopt an active lifestyle, including regular exercise; and less likely to engage in self-destructive behaviors (e.g., smoking, taking extreme risks). It is important to note that learned resourcefulness is not viewed as a personality trait. Instead, it is an orientation—a way of thinking that can be influenced through experience, counseling, and situational conditions.
Mental Toughness
Mental toughness is a disposition that represents the ability to reach and sustain high performance under pressure by expanding one's physical, mental, and emotional capacity (Connaughton, Hanton, and Jones, 2010). Mental toughness is learned, not inherited; it's an orientation. One common but false view of many athletes and coaches is that we are born with the right competitive instincts, and people who cannot handle failure lack the genetic predisposition to be mentally tough. The belief in a mental toughness gene is tempting because it absolves the person of taking responsibility for failure. However, the reality is that mental toughness can be taught, improved, and mastered. Exercisers need mental toughness to acknowledge their poor health and the need for physical activity, to withstand the challenges of physical exertion, to overcome physical fatigue, to continue to see the benefits of an exercise program, and to maintain exercise participation as a lifelong habit.
Mentally tough people are self-motivated and self-directed (their energy comes from internal sources; it is not forced from the outside); positive but realistic about handling adversity; in control of their emotions, especially in response to frustration and disappointment; and calm and relaxed under fire (rather than avoiding pressure, they are challenged by it). Mental toughness is also characterized by high energy, physical and mental readiness for action, a strong desire to succeed, relentlessness in the pursuit of challenging goals, superb concentration skills, self-confidence in the ability to perform well, and taking full responsibility for one's actions.
Self-Awareness
Think of self-awareness as the willingness to self-reflect, to engage introspectively, and to look at oneself through the eyes of others. This is not always easy to do, but others give us signals about their expectations and evaluations of us all the time, if we just take a good look. People react to us one way if they want our friendship and we have their respect. They react to us in a completely different way if they reject or disrespect us for whatever justified or unjustified reasons.
Self-awareness is an important component of health behavior because the ability to look inside and to be cognizant of our thoughts, emotions, and behaviors allows us to initiate steps for desirable change. If, for instance, we look in the mirror and see a person who is out of shape, overweight, and even unattractive, we can then begin the process of determining the reasons for our low energy, labored breathing, and general discomfort. Self-aware people also become more aware of the short-term costs and long-term consequences of their bad habits. They do not ignore their poor health and the negative habits that cause their current health status. This is why they are more likely to embrace support and opportunity to make lifelong changes that improve their health and happiness. They refuse to remain stuck in a self-destructive lifestyle. The challenges of self-awareness are addressed by Loehr and Schwartz (2003), who paraphrase John 32:8 from the Bible: “If the truth is to set us free, facing it cannot be a one-time event. Rather, it must become a practice. Like all of our ‘muscles,' self-awareness withers from disuse and deepens when we push past our resistance to see more of the truth” (p. 163).
Self-awareness, then, is an orientation. We differ in our willingness to become introspective about who we are and what we need to do to become better. As Loehr and Schwartz (2003) contend, “We must persistently shed light on those aspects of ourselves that we prefer not to see in order to build our mental, emotional and spiritual capacity” (p. 163). The authors also agree, however, that self-awareness can be self-defeating and overwhelming, bringing out negative thoughts, feelings, and emotions if it is absorbed in too big a dose. The right amount and frequency of self-awareness provides sufficient information to keep us on track and to be used as a source of information about what we need to become healthier and happier. As the authors conclude, “Facing the most difficult truths in our lives is challenging but also liberating” (p. 163).
Self-Efficacy
Confidence is a person's general feeling, perception, or belief that she has the capability to be successful in performing a skill and meeting task demands. Self-efficacy combines confidence with self-expectations. Self-efficacy, often associated and used interchangeably with self-confidence, is defined by Feltz and Lirgg (2001) as “the belief one has in being able to execute a specific task successfully . . .
to obtain a certain outcome” (p. 340). They further write, “Self-efficacy beliefs are not judgments about one's skills, objectively speaking, but rather are judgments of what one can accomplish with those skills” (p. 340). Thus, self-efficacy beliefs reflect a person's feelings not about what she can do but rather about what she has already done.
Self-efficacy is enormously important in an exercise setting and for changing and adhering to desirable, healthy behaviors. For example, people who experience self-doubt about their ability to join a fitness class and perform at least most of the exercises will be more likely to stop attending the class and either try some other form of exercise or return to their sedentary lifestyle. It is against human nature to continue participating in an activity in which we perceive our performance as incompetent or we fail to meet self-expectations or experience improved exercise performance and outcomes (e.g., better fitness). Therefore, building self-efficacy in an exercise setting bolsters the exercisers' perception that they are exercising properly, using correct technique, and improving performance. With respect to general health, clients will feel that following a certain set of routines will result or has resulted in superior health-related outcomes (e.g., more energy, positive mood, favorable results from medical tests). The objective of every worker in the health care industry, including fitness and nutrition coaches, is to provide instruction and positive feedback to build the person's self-efficacy about maintaining healthy habits.
Researchers have examined the link between self-efficacy and exercise behavior. Perhaps not surprising is the finding that as a person becomes more committed to an exercise habit, his self-efficacy improves. Self-efficacy is relatively low in the early stages of exercise, when a person is just beginning to develop an exercise routine or starting to make exercise a habit, and it increases dramatically as the person inserts exercise among his daily rituals. What is unknown is whether self-efficacy causes a person to adopt exercise as a lifestyle ritual or whether continued exercise increases self-efficacy. No doubt the two processes interact and self-efficacy is both the cause and the outcome of maintaining a regular exercise habit (Feltz and Lirgg, 2001; O'Leary, 1985).
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Religious institutions and spiritual leaders influence health behavior
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22).
Religious Community and Health Habits
Levin (2001) concluded from his review of the religion and health literature that “nearly every religion espouses beliefs that govern behavior regarding health, disease, and death [and] some religions require behaviors related to health while others forbid behaviors related to health or medical care” (p. 22). Religions, for example, promote beliefs that regulate behaviors related to alcohol, tobacco, diet, general hygiene, and medical care. Levin found that commitment to religion “may have a protective effect against subsequent illness . . . prevent or delay (illnesses), and have long-term benefits for physical and mental functioning and health” (p. 23).
The religious community is not immune from the health-related problems derived from an unhealthy lifestyle, however. The obesity epidemic still thrives in the religious and spiritual community (Cline and Ferraro, 2006). For example, the prevalence of obesity increased from 24% to 30% from 1986 to 1994 and likely has become much higher in more recent years among people of faith, that is, people who claim an affiliation with or membership in a denomination or religious institution. One potentially powerful source of health behavior change that has not been recognized in the war against obesity is the importance of religious and spiritual institutions and their leaders.
Next to physicians or other personal care providers, religious and spiritual leaders are some of the most credible people who influence the thoughts, emotions, and actions of a person of faith. People of faith often make a conscious decision to behave in a manner that is consistent with the expectations of their religious or spiritual messages.
In his book, Medicine, Religion, and Health: Where Science and Spirituality Meet (2008), Dr. Harold G. Koenig, MD, divides the benefits of religious practice or belief into six health-related areas:
1. Mental health
2. Immune function
3. Cardiovascular function
4. Stress and behavior-related diseases
5. Mortality
6. Physical disability
Based on his review of the research literature in each of these areas, Koenig (2008) concluded that religious practice or spirituality were strongly associated with superior health outcomes. He found, for example, that blood pressure and rates of stroke and cognitive impairment were each highly correlated with religious involvement (e.g., service attendance, frequency of prayer, strength of belief in a higher power). Although not always acknowledged by religious leaders, messages related to maintaining healthy habits are common throughout most religious texts.
To people of faith, arguably no one has more credibility for influencing behavior than their religious or spiritual leader. Should these leaders play a role in promoting healthy habits among congregants and the community at large? How can they address the apparent disconnect between people's religious practices, including a firm belief in religious or spiritual texts, and their lack of self-awareness about practicing healthy habits? And how can health professionals be involved in this process?
Role of Religious Leaders in Promoting and Modeling Healthy Habits
Many religious leaders contend that people who attend traditional ceremonies or services are looking for spiritual fulfillment, and that is the primary role of their institutions. Educating congregants about healthy habits is not. Perhaps this view, and the mission that propels it, needs to be reexamined. All sources of behavioral influence, including school systems, governments, corporations, the food industry, and religious institutions, need to be unified in providing information and incentives to replace self-destructive behavior patterns with healthier alternatives. One source of health behavior interventions that has received only minimal attention is the role of religious and spiritual leaders.
What should religious and spiritual leaders do to promote healthy habits, perhaps with assistance from health professionals? First, they need to look at themselves and determine if the change needs to start with them. Next, they must speak up and encourage their institution members—and other members of the community, when given the opportunity—to have discipline in all areas of their lives. One religious text, the Bible, addresses eating, indulgence, self-control, self-discipline, and gluttony. These topics need to be addressed in religious institutions and services without fear of offending attendees. Leaders of congregants who attend spiritual events and services should encourage their congregants to make lifestyle changes that will ultimately bring glory to God or some other higher power to whom they feel accountable. Religious leaders must stop being intimidated by the risk of losing members by offending them in order to acknowledge the importance of self-care as an inherent component of a religious and spiritual lifestyle (Colbert, 2002).
Perhaps the most serious obstacle to health behavior change in the religious community is persuading people of faith to take responsibility for their health and engage in the free will of healthy lifestyle choices, rather than surrender control to a higher power. Most religious texts, including the Bible, promote taking responsibility for health behavior. Philippians 2:13 states that God works within us to will his Holy Spirit and the free will to desire to create balance in our life—and the will to act on that desire.
For example, as Omartian (1996) contends, “The main reason to exercise is for your health. Without good health you cannot do all that the Lord has for you do to and you cannot be all the Lord wants you to be” (p. 117). Along these lines, Koenig (1999) asserts, “The world's religions encourage healthy living. . . .
All established religions discourage . . . any habit or activity harmful to the human body, which has traditionally been viewed as sacred, created in the image of God” (p. 72). And as Levin (2001) concludes, “All religions endorse the idea that we ought to take care of our bodies and not act in ways that are reckless and endanger our health” (p. 41).
There is an apparent need for religious institutions and their leaders to play a more prominent role in promoting community health and wellness and to serve as role models for their congregations. The credibility of pastors, priests, rabbis, imams, and other religious leaders will be further enhanced if their messages of health and wellness given in their sermons and programs are reflected in their own behavioral patterns. In other words, religious and spiritual leaders have to walk the walk, not just talk the talk.
Health Themes Addressed by Religious and Spiritual Leaders
Perhaps the strongest influence of a religious leader on the thoughts, emotions, and actions of attendees of religious services occurs when their attention is focused on the leader's words—the sermon. Health-related themes that extol the virtues of maintaining a healthy lifestyle need to be communicated more frequently and passionately, citing religious or spiritual text to reinforce main issues. For example, in the New Testament of the Christian Bible, the apostle Paul reminds his readers that their bodies are a dwelling place of the Holy Spirit, thereby bridging the gap between spiritual and physical dualism that may be keeping people of faith locked into unhealthy behavioral patterns. Paul contends that what we do with our bodies matters not only on a physical level but also on a spiritual level.
Religious leaders can also cite scripture to remind us that we are not owners but rather managers, or stewards, of our bodies. Maintaining healthy habits is a matter of personal stewardship. When we begin to perceive our bodies in a manner that is consistent with God's view, we begin to make decisions that affect our physical health that honors a higher power (i.e., God). Thus, maintaining unhealthy habits that lead to obesity and poor physical conditioning is a failure of that stewardship responsibility.
Another health theme found in religion is gluttony. The Gluttony in Religion highlight box lists examples of this theme from various religious texts that both religious leaders and health professionals may use with people of faith to address the association between healthy habits and spirituality or religion.
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Overcome mental barriers to reach exercise goals
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks.
Mental Barriers to Exercise Adherence
Exercise is challenging, no question about it. People who have spent years leading a sedentary lifestyle cannot expect to strengthen muscles, make new demands on the heart and lungs, lose weight, and reach performance goals in just a few weeks. However, it will not take a great deal of time to feel better and adjust to new physical demands they place on themselves. They simply need patience. Without it, they will quit. They will lack adherence, and this is exactly the problem with at least half the people who initiate exercise programs. Our high-achieving, impatient culture, made worse by personality traits such as negative perfectionism, high trait anxiety, and pessimism about the future, often does not allow us to set reasonable goals and to develop strategies to reach those goals.
Emotions, thoughts, and feelings drive behavior in one of two directions: positive, toward achieving success and developing a better, healthier, more energetic lifestyle, or negative, toward maintaining unhealthy habits, being overweight, lacking energy, and living a life inconsistent with one's values about what is important. Improving a client's lifestyle takes effort—and a plan. Health and fitness professionals need to revisit the client's values, connect each value to a new routine that will create and maintain a more active lifestyle, and improve physical and mental health. Adherence to a program of regular exercise, the theme of this chapter, is of paramount importance in doing everything in our power to take control of our destiny. In the words of former British prime minister Sir Winston Churchill, “Continuous effort—not strength or intelligence—is the key to unlocking our potential" (qtd. in Cook, 1993).
A person's decision to discontinue an exercise habit often has a psychological explanation. Here are some of the more common conditions that can lead to dropping out of an exercise program. Hopefully, health professionals can develop and apply effective responses to these excuses that will change the client's mind about quitting.
Anxiety
Anxiety consists of feelings of worry or threat about the future, as discussed in chapter 5. Anxious thoughts cause worry and distract the exerciser from the task at hand—and waste energy. Sources of exercise anxiety include worry about meeting goals, physical appearance, being accepted by others (even strangers at a fitness club), and using time to exercise instead of doing something else (“I could be watching TV or finishing a report instead of going to the gym”). Ironically, exercise actually reduces both short-term (acute) and long-term (chronic) anxiety. Exercise is what the doctor ordered for improved mental health, including reduced anxiety (deMoor et al., 2006). Health professionals should strongly consider exercise as one behavioral strategy for helping their clients manage anxiety, particularly if clients are given social support in their new exercise program.
Depression
Most people experience unhappiness and negative emotions; this is normal. Ongoing, deeply negative mood states, however, may be a more serious mood disorder referred to as clinical depression (APA, 2000). Depression is a mood disorder that ranges from mild to severe and can be due to a medical condition, substance use, or psychopathology (mental illness). A sedentary lifestyle may induce or promote depression, but exercise has been shown to reduce it in over 70 studies across various age groups and for both genders (Leith, 1998).
One factor that influences the effect of exercise on depression is whether the person has selected and is enjoying the type of physical activity. A second factor is whether the exercise is of sufficient intensity, frequency, and duration to improve fitness outcomes and lead to psychological benefits. Taking a quiet, slow walk through the park, although pleasant and relaxing, may not be sufficient to reduce depression (Brosse, Sheets, Lett, and Blumenthal, 2002). Buckworth and Dishman (2002), in support of recommendations from ACSM, suggest the following exercise guidelines for people with depression who are otherwise healthy: three to five days a week (frequency) for 20 to 60 minutes each session (duration) at 55% to 90% of maximal heart rate (intensity). Certified fitness coaches should aim to meet these standards when prescribing exercise for depressed clients.
Negativity
It is impossible to remain motivated and on task if self-talk is negative, such as, “I don't like this,” “I feel terrible,” or “I'm tired.” Replacing those thoughts with positive statements that are optimistic and enthusiastic induces more effort and energy. Examples include, “I can do this,” “I feel good,” “Just three more minutes to go,” and “Hang in there.” To quote an anonymous writer, “You cannot be unhappy and enthusiastic at the same time.
”Negative and antagonistic feelings and emotions can impair the development of an exercise habit, especially for novice performers. The problem with negative thinking is that it results in low effort and sets up the individual to fail. This process is similar to the self-fulfilling prophecy; one's performance level will be consistent with one's expectations.
Examples of negative thinking that serve as barriers to exercise success include lack of confidence (e.g., “I don't think I can do this”), intimidation (e.g., “I don't belong in this fitness facility,” “People are laughing at me”), pessimism (e.g., “I'll never lose weight,” “Exercise will never be enjoyable”), self-criticism (e.g., “I can't run even one lap of that track, so why even try?”, “Exercise is not for me; I'll always be weak”), impatience (e.g., “I've been exercising for three weeks and still run out of steam when jogging”), and irrational thinking (e.g., “I've always been heavy; why change now?”, “People just have to accept me the way I am,” “My spouse thinks my weight and appearance are just fine”).
There are several implications for health care professionals when it comes to addressing mental health. First, consultants should not attempt to diagnose or treat mental illness unless they are licensed psychologists or have other appropriate credentials related to this area. There are serious legal implications of providing treatment to a person who did not request it, was not diagnosed correctly, or did not receive the proper treatment. The key term that reflects the proper thing to do if mental illness is suspected is referral; that is, health care professionals must refer clients to a licensed mental health professional for diagnosis and treatment if mental illness, such as depression, chronic anxiety, or another condition, is suspected.
A second implication for dealing with psychological barriers to maintaining healthy habits, particularly related to exercise and nutrition, is the need to schedule meetings between the client and qualified health coaches, such as a certified personal trainer and a registered dietitian. Exercise and nutrition both influence mental health and should not be ignored when attempting to change client health behavior. Relationships with local experts in these areas should be established before referral in order to become familiar with the expert's background, skills, location, types of services rendered, and personal qualities. Sometimes clients prefer a male or female coach or can meet the consultant only on certain days at certain times. It is essential that the health care professional try to coordinate the client's needs and preferences with the coach's characteristics.
Perfectionism
Perfectionism is a trait reflecting a person's disposition toward "setting excessively high standards of performance in conjunction with a tendency to make overly critical self-evaluations" (Frost, Marten, Lahart, and Rosenblate, 1990, p. 450). It is usually studied as a trait measure—stable and cross-situational—not a state (situational) measure (Antony and Swinson, 2009).
Perfectionism has both positive and negative features. The positive aspects of perfectionism include setting and attempting to achieve high personal standards, striving to achieve lofty but realistic goals often leading to success, and being conscientious and self-confident (Flett, Hewitt, Blankstein, and Mosher, 1991). Negative features, not uncommon among people who go overboard in attempting to achieve goals, include feeling deep concern about making mistakes, which leads to heightened anxiety; having doubts about one's actions; setting excessively high standards; having difficulty recognizing success; and overemphasizing precision, neatness, order, and organization. People who fit these behavior and thought patterns are referred to by clinical psychologists as neurotic perfectionists. They have a propensity to engage in self-destructive behaviors, excessive self-criticism, failure to recognize achievement and competence, and feelings of “It's not good enough” (Antony and Swinson, 2009; Adderholdt-Elliott, 1987).
Neurotic perfectionists set unattainable goals and might engage in overtraining or exercise addiction. Their self-talk is based on messages they received when they were young, reminding themselves that “It's not good enough” and “I can do better.” Their expectations of others are also excessive. Perfectionists need to learn how to set reasonable goals and to recognize their own achievements and those of others, especially in exercise settings. They need to have indicators of success and to acknowledge when they have reached those indicators.
Implications for working with clients who reveal perfectionistic thinking include referral to a mental health professional so that its sources can be identified and treated. Perfectionism can play a role in attempts at self-improvement; however, when standards and goals are excessively high, when self-expectations for achievement are unrealistic, and when the person expects others to meet these same excessive standards, often at the expense of alienating others, then this condition becomes an obstacle to happiness, confidence, and mental health.
Another implication for working with perfectionistic clients is the need to help them set realistic but challenging goals that are measurable and observable, to help them detect times when they have met their performance expectations, and to verbally and directly recognize their accomplishments. One important strategy that validates positive feedback and gives the consultant credibility is to base feedback on numbers—perhaps fitness test results, blood test results, improved exercise performance (e.g., increased resistance in weight training, faster jogging times, reduced body-fat percentage), or some other measure that quantifies improved physical performance.
Finally, perfectionists often need to change their irrational thinking by being reminded of their accomplishments, favorably comparing their competence level with others, and being more realistic about their self-expectations. Perfectionism, particularly when excessive (also referred to by mental health professionals as irrational, maladaptive, or neurotic), has specific sources, such as parents, sport coaches, or teachers, and this may be pointed out as an issue that is nothing to be ashamed about and that might require professional consultation to address it.
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