Addressing Outcomes Expectancies in Behavior Change

Abstract

Individuals commonly seek help for problem health behaviors, such as excessive drinking, smoking, and weight gain. Yet there is a high rate of recidivism in these behaviors because outcome expectancies are either too high, negative outcome expectancies are not considered, or outcome expectancies are not properly addressed. Health care providers are recommended to list the outcome expectancy for the problem behavior and corresponding treatment for their patient. Through the process it is important to acknowledge both the positive and negative outcomes of engaging in the problem behavior. Health care providers are then encouraged to have their patient identify the goals and objectives that will assist in achieving the desired outcome. By recognizing and addressing outcome expectancies, it is more likely that the patient will be less resistant to the health care provider’s recommendations to change problematic behavior.

‘Outcome expectancies are defined as anticipated consequences (positive or negative) as a result of engaging in a behavior.’

Problem drinking is a substantial contributor to morbidity and mortality in the United States. ¹ It has a sizeable effect on multiple conditions, including cancer, neuropsychiatric illness, and cardiovascular disease. ² Alcohol recidivism is also highly prevalent. ³ Alcohol recidivism occurs when a sober individual returns to excessive drinking after a period of time. Not surprisingly, excessive drinking is one of the most difficult behavioral changes and interventions have had a limited impact on outcomes. ⁴ Though techniques such as motivational interviewing have shown promise to facilitate behavioral change, investigators agree that excessive alcohol intake remains an extremely challenging issue.^5,6

Outcome Expectancies

Alcohol recidivism continues to be a challenging issue in large part due to outcome expectancies. In order to overcome this barrier of change outcome expectancies must be addressed. Outcome expectancies are defined as anticipated consequences (positive or negative) as a result of engaging in a behavior.^7-9 These expectations have been extensively studied in behavioral medicine and found to affect multiple health behaviors, including alcohol consumption, smoking, and weight management.^10-16 Individuals who consume excessive alcohol may have multiple positive outcome expectancies about its perceived benefits. Examples include social confidence, sexual attractiveness, and general euphoria. ¹⁷ Through the use of cognitive behavioral therapy, participants who decreased their positive alcohol-related outcome expectancies were less likely to report binge drinking recidivism. ¹² Furthermore, research has revealed that higher levels of positive outcome expectancies combined with negative personality characteristics (eg, negative urgency [the tendency to behave rashly because of one’s current emotional state]) are related to behavioral outcomes such as a greater number of alcoholic beverages per week. ¹⁰ Depending on the gravity of the health behavior, along with an individual’s personality characteristics, outcome expectancies may create a large challenge in behavior change.

Expectancies in Treatment Outcomes

Expectancies in treatment outcomes are what an individual anticipates will occur based on receiving therapy or treatment. While treatment outcome expectancies may motivate individuals to stop a behavior such as the expectancy to have better family life after alcohol cessation, treatment outcome expectancies may promote negative progress if expectations are too high or unrealistic (eg, family life is difficult to restore, time frame too short to stop behavior). Negative progress may result in feelings of frustration and failure. In the case of alcoholism, it can result in recidivism.

Treatment outcome expectancies are common in other behavioral modifications such as smoking cessation. Positive smoking cessation expectancies include improved health, relief of social pressures, and increased financial resources.^18,19 Yet individuals in smoking cessation programs who reported greater amounts of positive outcome expectancies were associated with decreased cigarette abstinence.^13,15 While the physical, mental, and financial benefits of smoking cessation may be easy to recognize, recognizing the malignant metabolic effects of smoking cessation are just as critical. These include postcessation weight gain–mediated insulin resistance, placing one at risk for diabetes and cardiovascular disease and making cessation difficult. ²⁰

Weight loss or weight management is another common treatment that can result in both positive and negative outcomes. Positive expectations for weight loss are often improved health, self-confidence, and appearance.^21,22 One study revealed that participants lost more weight when they reported higher positive outcome expectancy scores. ¹⁶ However, individuals in weight loss programs often have unrealistic expectations or are unaware of the diverse behavior changes needed to meet their goals, resulting in frustration, self-deprecation, and quitting. ²³ On the other hand, those with realistic weight loss goals are more likely to achieve and maintain their weight loss.^24-26

Steps to Address Outcome Expectancies

Suggested steps for health care providers to assist patients in recognizing and addressing outcome expectancies are as follows: List the outcome expectancies for the (a) problem behavior (eg, problem drinking) and (b) treatment/resolved behavior (eg, drinking cessation). Then discuss the validity and reality of each expectation. For example, ask an individual who suffers from problem drinking to list perceptive gains from alcohol (eg, stress relief). Also, ask to list the benefits from cessation (eg, better quality of life). Help the individual realize that though stress relief may be an immediate outcome of alcohol consumption, it is temporary and will not last without resolving underlying issues (eg, relationship stresses). Encourage the patient that alcohol cessation often leads to a better quality of life but that this may take time due to broken relationships, poor work ethic related to alcohol history, etc.

The next step requires the patient to identify reasons to stop the behavior. Instead of providing this information for the individual, allow him or her to do this. You might request in a smoking cessation counseling session, “Can you think of reasons to stop smoking?” Use these patient-identified reasons as motivators in subsequent encounters. Finally, work with individuals to set goals and objectives. A goal is a broad behavioral change outcome, whereas objectives are specific, tangible ways to meet the goal. For example, one may have a goal to lose weight. Assist patients to identify two or three items to assist with their goal that week, for example, go to grocery store to buy fruits and vegetables on Mondays after work, walk with a friend daily at 9 am, and so on. Reassess and revise objectives weekly. Provide positive reinforcement for meeting objectives, such as going to a movie if objectives are met.

Summary and Conclusions

It is critical to identify outcome expectancies for both the problem behavior and its treatment. Patients are more likely to adhere to a treatment plan if they perceive that it will bring desirable outcomes that outweigh the benefits of engaging in the problematic behavior. By recognizing and addressing outcome expectancies, it is more likely that patients will be less resistant to health care providers’ recommendations to change problematic behaviors.