Learning and Conditioning

Among the oldest, most widely researched, and yet most often misunderstood models of individual behavior applied to
behavior change are those that deal with fundamental associative or classical conditioning and the related models of operant
conditioning. Classical conditioning, pioneered by Pavlov, modifies behavior by repeatedly pairing a neutral stimulus with
an unconditioned stimulus that elicits the desired response. Operant-conditioning builds on classical conditioning and
focuses on the hypothesis that the frequency of a behavior is determined by its consequences (or reinforcements; Skinner,
1938). Although learning theory has been criticized for treating behavior in simplistic and mechanistic stimulus response
terms, modern learning theory addresses complex components, including environmental cues and contexts, memory,
expectancies, and underlying neurological processes related to learning (Rescorla, 1988). As Kehoe and Macrae
(1998) note, today classical conditioning integrates cognition, brain science, associative learning, and adaptive behavior.

Classical conditioning introduced concepts that have been particularly important in the design of health-related
interventions, such as reinforcement, stimulus—response relationships, modeling, cues to action, and expectancies.
However, given the particular difficulty in maintaining behavior changes, the relapse of behaviors that have been eliminated
(or “extinguished”) by an intervention is of particular interest. Relapse of extinguished behaviors is a major problem in
health-related behavior change interventions, especially those that target alcohol use, smoking, and diet (Dimeff and
Marlatt, 1998; Marlatt and George, 1998; Perri et al., 1992; Wadden et al., 1998). Extinction initially was conceptualized as
a process in which original learning, and therefore behavior, was unlearned or destroyed. That is, it was assumed that
extinguished behavior would no longer be elicited by the environmental cues that originally evoked it. However, extensive
research shows that extinction does not involve unlearning, but rather new learning that does not overwrite the original
learning. Furthermore, the physical environment and social context in which extinction takes place, as well as such internal
states as emotions, drug-related states, and time, will influence the process of extinction (Bouton, 1998, 2000).

Those findings have important implications for health-related behavior change. Specifically, the effectiveness of an
intervention to reduce or eliminate a health risk, such as cigarette-smoking, will be limited to the extent that it is bound to
the context in which it is delivered. As noted by Bouton (2000, p. 58), “the reformed smoker who once habitually smoked in
a particular setting at work, or under the influence of a particular drug or alcohol, or in the presence of negative affect will
be ready to lapse when cigarettes are made available in one of those contexts again. We now think of extinction as
inherently context-specific, with the term ‘context' being broadly defined.”

One important implication of those findings is the importance of eliciting extinction in different contexts, including various
physical environments, times, and emotional states. For example, extinction trials that are more widely spaced and in
separate locations are more likely to be effective than core sessions that occur within short periods or in similar physical
circumstances. Behavior change efforts should recognize the possible influence of contextual cues, identify the cues that
might be involved, and help people avoid (or cope with) the contexts connected with the original health-compromising
behavior, whether physical environments, interpersonal relationships, or negative emotional states. The learning of the new
behavior (or extinction of the old) should take place in the contexts in which the person will need it the most.

expect to benefit if they change their behavior. Self-regulation is a concept that derives from cognitive social learning theory (see Bandura. p.. and it includes what many people call “will power. the most important prerequisite for behavior change is a person's sense of self-efficacy or the conviction that one is able successfully to execute the behavior required to produce the desired outcome. and managing stress. It is as if the learning and memory system is organized with a default assumption that the first-learned thing is correct. behaviors. and perceive their social environment as encouraging the change. 2000.. Ewart. not the second things. A growing body of literature supports the importance of self-efficacy in initiation and maintenance of behavioral change (Bandura. but if they lack a belief that they can indeed change. engaging in regular exercise. Kaplan et al. Self-regulation can be critical in such health-protective and health-maintaining behaviors as eating a healthy diet. 61): [F]irst-learned things seem much more likely to generalize over place and time. 1987. 1986. Baumeister et al. Substantial empirical evidence suggests that self-efficacy beliefs (and the related concept of optimism) are reliable predictors of behavior. their efforts are not likely to succeed. 1990). Bandura et al. that original learning of a behavior readily generalizes across contexts.. including a number of health-related behaviors (e. 1986.. 1998. 1999.. 1986. Scheier et al.. Carver and Scheier. Strecher et al. but that behavior changes with observations of others. namely. The evidence that extinction depends on context is but one of several important results from basic research on learning and conditioning with important implications for explaining health-related behavior change. Cognitive Social Learning Cognitive social-learning theory (e.. 1997).g. Compas et al. One way of thinking about research on behavior change is that the organism seems to treat the second thing learned about a stimulus as a kind of exception to a rule. 1997) proposes that reinforcements are not the sole determinants of behavior. 1977. and that they mediate the effects of intervention on behavior change. 1999). According to cognitive social-learning theory. Eisenberg et al. 1994. modulation. or redirection of a person's emotions.. modification. place.” behavioral interventions that are informed by recent developments in learning theory and other fields of basic behavioral science.” Self-regulation includes cognitive and behavioral processes that involve the initiation. That perspective provides support for the importance of preventive interventions that promote health-enhancing behaviors.. Wiedenfeld et al. People can feel susceptible to an illness.Marlatt and Gordon. 1998. 1985. One implication of this is that if we really want to reduce cardiovascular risk. the failure or breakdown . or environment (Compas et al. physiological responses. Closer ties between intervention research and basic learning theory and research could contribute to what O'Donohue (1998) called “third-generation behavior therapy.There is another important difference between original learning and extinction. 1989. whereas extinction does not (Bouton. 1986).. Bandura.. or time. Conversely. 1977. and everything else is conditional on the current context. thoughts. we should arrange a world in which healthy behaviors are the first things.g. learned. delay. as opposed to interventions designed to treat or change health-compromising behaviors. termination. 1995.

the desire to avoid becoming ill is a value. 1990). An important contribution of the model is the recognition that prevention requires people to take action in the absence of illness. limitations have been noted. the perceived severity of a risk does not reliably predict protective health behaviors (Rimer. People are thought to weigh an action's effectiveness in reducing a health threat against possible negative outcomes associated with that action. poor dietary management. and emotional arousal. Operant-conditioning theory focused on the hypothesis that the frequency of a behavior is determined by its consequences while Cognitive Theory gave more emphasis to expectations to explain behavior. 1974). and a sedentary lifestyle. influence of observational learning. 1958). among other things. Perceived susceptibility is the perception of personal risk of developing a particular condition. The theory was intended to explain virtually all behaviors over which people have the ability to exert self-control. and belief that a specific health behavior can prevent an illness is an expectancy. For example. in explaining women's reluctance to perform breast self-examination or obtain mammograms (Rimer. for example. 1990). The HBM has been applied. Although much research supports the utility of Social Learning Theory. or by integrating it with other models. The predictive utility of the HBM and its applicability to behavior change can be improved by adding variables. The type of action taken depends on perceived benefits (beliefs about the effectiveness of different actions) and perceived barriers (potential negative aspects of particular actions). The model was developed in the 1950s to explain why people did not engage in behaviors to prevent or detect disease early. such as smoking. such as self-efficacy. Factors that influence behavioral choices are mediated through the variable of behavioral intent. screening for Tay-Sachs disease. perceived susceptibility and perceived severity provide motivation for reducing or eliminating such threats.of self-regulatory efforts can be crucial in some risky behaviors. or social consequences to being diagnosed with an illness. Perhaps the most critical of these is the lack of predictive value for some of its central tenets. In order to maximize the predictive ability of an intention to perform a specific behavior. and it involves a subjective evaluation of risk rather than a rigorously derived level of risk. For example. exercise programs. In addition it is difficult to quantify and measure the conceptual elements of Social Learning Theory: self-efficacy. it is critical that . This continues to be useful. The limitations of the HBM are reviewed by Janz and Becker (1984). Together.Hochbaum. Perceived severity is the degree to which the person attributes negative medical. and smoking cessation (Strecher and Rosenstock. Moreover. It integrates elements of operant-conditioning and Cognitive Theory. It is difficult to evaluate the efficacy of theory-based interventions because the studies have involved only small numbers of subjects and the intervention designs have been very complex. 1997). Theory of Reasoned Action The Theory of Reasoned Action was first proposed by Ajzen and Fishbein (1980) to predict an individual's intention to engage in a behavior at a specific time and place. nutrition programs. to influenza inoculation. clinical. the HBM is more descriptive than explanatory and does not presuppose or imply a strategy for change (Rosenstock and Kirscht. Health Belief Model One of the earliest theoretical models developed for understanding health behaviors was the health belief model (HBM.

the Transtheoretical Model encompassed the concepts of decision criteria. the model has contributed to the recognition that most potential recipients of health-related behavior change efforts are not motivated to change. 1996). Although early cross-sectional studies provided support for the theory (DiClemente et al.g. self-efficacy. Population surveys show 80% of the target group in the “precontemplation” or “contemplation” stages. 1997. 1991. Pierce et al. Despite questions about its theoretical validity. self-efficacy. 1994). and time. The development of innovative motivational programs to encourage less interested people to consider healthier lifestyles represents a new direction in health and behavior change (e. Behavioral intentions are influenced by the attitude about the likelihood that the behavior will have the expected outcome and the subjective evaluation of the risks and benefits of that outcome. This is followed by the decision to take action (preparation) and the first steps toward the behavioral change (action). unaware. 1997. 1999. The Transtheoretical Model has been influential in research on smoking and was recently extended to other health risk behaviors (Prochaska et al. The predictive power of the model depends significantly on the identification of most or all of the salient outcomes associated with a given behavior for any particular target population. In addition to these temporal stages. The earliest stage of behavior change starts with moving from being uninterested. substituting healthier alternative behaviors. Variables from cognitive social learning—such as outcome expectancy. 1996. 1997). the requirement for maintenance and relapses are recognized as part of the process. Miller and Rollnick.. 1999). The theoretical validity of the Stages-of-Change Model for behavior change is a matter of controversy (Budd and Rollnick. multivariate analyses of several behavioral predictors demonstrate that the stages are weak predictors of cessation (Farkas et al. Herzog et al. and recognizing supportive social norms. Hochbaum (1958) assessed the “readiness” of adults to participate in screening.measures of the intent closely reflect the measures of the behavior.. such as the Transtheoretical Model (also known as the Stages-of-Change Model) first proposed by Prochaska and DiClemente (1983). The inclusion of beliefs about susceptibility to illness and the personal benefits of screening was seen as an essential element in “readiness.. self-reevaluation..Sutton. and behavioral self-control—appear to be better predictors of change than are the stages and associated processes (Bandura. corresponding in terms of action. or unwilling to change (precontemplation) to considering a change (contemplation). contingency management. committing to change.. and change processes (consciousness-raising. target. 1995).” The concept was expanded into more elaborate models. seeking support. Fava et al. stimulus control. This model characterizes the continuum of steps that people take toward change and includes the activities or processes to move people from one stage to another. environmental reevaluation. 1996). Furthermore. context.. With determined action. relief from negative emotions associated with unhealthy behavior. Stages-of-Change Model/Transtheoretical Model Beginning with the first formulation of the HBM.. Sutton. Prochaska et al.. That result draws attention to the potential of approaches that increase motivation for health promotion and illness prevention. . recent longitudinal studies did not support the Transtheoretical Model (Herzog et al.. 1995). 1998).

social. Social-Action Theory fosters interdisciplinary collaborations by incorporating and coordinating the perspectives of the biological. processes of social interdependence and social interaction. Social-Action Theory provides a framework for multilevel approaches to health promotion and illness prevention. It views the person as influenced by environmental contexts or settings to which he or she brings a particular temperament and biological context. 1990).Social Action Theory One important example of a model that attempts to integrate individual psychological processes with social contextual factors is Social-Action Theory (Ewart. self-efficacy beliefs. and underlying biological processes to predict health- protective behaviors and outcomes (Ewart. epidemiologic. Social-Action Theory specifies mediating mechanisms that link organizational structures to personal health and incorporates key concepts from the earlier theoretical models. however. Thus. 1991). has focused on individual strategies to facilitate desired changes. and problem-solving skills. again placing the focus on the influence of context on individual behavior. which builds on Social Cognitive-Learning Theory. 1991). . In Social-Action Theory. Most behavioral research. Some applications of social-action theory focus on the mechanisms and maintenance of behavior change (Ewart. It provides an approach for defining public health goals and modifiable social and personal influences that can be used to encourage individual health-related behavior change. including self-efficacy and outcome expectancies. a person's capacity to practice healthy eating habits and to exercise is influenced by access to health-enhancing foods and safe places to exercise and by internal goal structures. biology and social and environmental contexts determine the success of interventions to promote individual behavior change (Ewart. and less is known about how social and other contextual factors can be mobilized to promote behavior change. models of self- regulation. 1991). and behavioral sciences. It offers a theoretical rationale for intervening in health policy and for creating environments that are conducive to self-protective choices.