Homeostasis, Exercise, and COVID-19 Isolation

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The Value of Exercise

A recent post explored human needs during COVID-19 isolation. The success of social isolation policies will depend on minimizing long-term depreciation of mental health. In this post, I explain the benefits of developing a system of daily exercise to bolster well-being.

Exercise is an under-utilised resource that is freely available to almost everyone, which can bring profound benefits if applied systematically. The impact of exercise is one of the most powerful examples of regulation created by homeostasis. Regular physical activity not only has obvious physical benefits but significant psychological benefits also. During COVID-19 isolation, exercise offers the capability to reset body and mind to a more optimum state of equilibrium.

Hawley et al. (2014) state: “Exercise represents a major challenge to whole-body homeostasis, and in an attempt to meet this challenge, myriad acute and adaptive responses take place at the cellular and systemic levels that function to minimize these widespread disruptions.”

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The Physiological Responses to Voluntary, Dynamic Exercise. Multiple organ systems are affected by exercise, initiating diverse homeostatic responses. Reproduced from ‘Integrative Biology of Exercise’ by Hawley et al. (2014).

Note of caution

Apart from its general ability to challenge homeostasis to reset the body’s biological equilibrium, exercise has a role in two domains of well-being:

(1) the immune system is strengthened through regular physical activity (Campbell and Turner, 2018; Simpson et al., 2020)

(2) psychological well-being is enhanced (Mandolesi et al., 2018).

However, exercise is no panacea.

Exercise must be applied with caution especially by people with chronic conditions. If a person has a heart condition, strenuous physical exercise may put them at risk (Keteyian et al., 2016).

In some chronic conditions such as ME/CFS, exercise tends to make many patients feel much worse (Geraghty et al., 2019).

However, if used safely and appropriately, the majority of people can quickly feel physical and mental benefits from regular exercise.

Physiological Mechanisms

Some significant effects of physical activity can be explained by physiological mechanisms (Lopresti et al., 2013). Exercise within the context of psychological health promotion has also been an active research area (Chekroud et al., 2018; Curioni and Lourenco, 2005; Mikkelsen et al., 2017; Tiggemann and Zaccardo, 2018). Some researchers have focused on neurophysiological mechanisms, which aim to identify the positive outcomes of the relationship between exercise and mental health (Eyre and Baune, 2012). Exercise is understood as a relationship between intensity and frequency, and positive outcomes are mostly based on which exercise protocol will determine a better neurophysiological response (Lopresti et al., 2013). Exercise is recognized as a mediator of primary monoamine neurotransmitters, namely, serotonin, noradrenaline and dopamine. These three neurotransmitters receive reciprocal regulation, while exercise intensity modulates the stimulation of monoamine system (Lin and Kuo, 2013). However, it is also important to recognize the affective responses of physical activities and psychological variables are likely to mediate the relationship between exercise and mental health (Rodrigues et al., 2019). There is a sound empirical basis for an integrated account of the emotional effects of exercise. A recent study with a representative US sample of 1.2 million individuals linked exercise to mental health and exercising was associated with reduced self-reported mental health burden. Furthermore, motivation and mindfulness-based techniques act as mediators for these relationships, which seem to account for the strongest effect of the exercise on fewer days of poor mental health (Chekroud et al., 2018).

Joy and Happiness

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In the context of social isolation, exercise can be an inherently rewarding activity that contributes joy, happiness and satisfaction (Ryan and Deci, 2017; Standage and Ryan, 2012). The positive outcomes also appear as a function of affective consequences of exercise or anticipation of its affective response – the hedonic principle of the law of effect (Marks, 2018). In general, the expected pleasure versus displeasure is a determining principle of the motivation to repeat behaviour (Kwasnicka et al., 2016; Williams, 2008).

Isolation and quarantine are a disagreeable experience, which may lead to sadness and even impose dramatic mental illness for those who undergo it (Brooks et al., 2020). In this context, a daily exercise routine can be crucial to modulating pleasurable situations at some point during the day. People can feel more deeply satisfied through the experience of choice and volition, reinforce their sense of autonomy and competence, and renew a sense of joy (Lubans et al., 2017; Ryan and Deci, 2017; Standage and Ryan, 2012).

The benefits of exercise depend on the degree of internalization of the behaviour. In our daily lives, exercises are normally performed in order to achieve goals, such as social aesthetic standards (Sperandei et al., 2016). These goals are separable from the purpose of the exercise (a person may not enjoy exercising, but will do it to obtain a result); and therefore, people are generally not ‘authentic’. The lack of authenticity represents a person doing an activity for contingent reward or punishment, feeling tense and pressured, lacking intentionality and being oriented to avoid guilt, angst and social judgement or to protect contingent self-worth. Contrarily, people are authentic when exercise choice is aligned with personal goals, interest and is assimilated with the individual’s characteristics, ability and identity (Deci and Flaste, 1995). Identity is associated with ongoing positive experiences attendant on the behaviour (Kwasnicka et al., 2016), such as exercising at home.

Notably, the COVID-19 pandemic causes fear and the lockdown imposes limits on people’s movement (Brooks et al., 2020; Xiang et al., 2020).

The rationale for the positive side of exercising at home is that exercise can be experienced without any strong social pressure, having a totally internal source of inspiration. The behaviour might be accompanied by higher self-esteem and lower psychological ill-being, since we are free to choose the:

  • types of exercise
  • schedule
  • frequency
  • intensity

The fulfilment of basic psychological needs appear within this context.

Authenticity and Self-Compassion

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Another helpful process is that of self-compassion – the ability to treat oneself with the same concern and support in distressing situations; it is related to self-kindness, common humanity and mindfulness. In fact, it is associated with self-regulation when performing health-promotion behaviours (Holden et al., 2020; Semenchuk et al., 2018). Exercising at home, in a crisis situation, can be performed without self-criticism, which could hinder the process by increasing pressure and self-judgement, which in turn may provide adaptive coping, problem-solving and psychological well-being.

Research has provided empirical evidence on the positive relationship between self-compassion and exercise in providing exercise maintenance and enhancing positive emotions (Holden et al., 2020; Semenchuk et al., 2018).

Mastery and Self-control

Exercising at home can increase the individual’s sense of control. Research suggests that self-mastery is a crucial criterion for promoting positive effects on psychological outcomes (Mikkelsen et al., 2017; Ryan and Deci, 2017). In the face of this pandemic, we have seen many examples across the world showing that exercise can create a social arena in which individuals learn social skills and build social networks by adhering to exercise challenges, exercising in condominiums and encouraging others. These virtual social connections enhance feelings of autonomy and being fully alive. When autonomous forms of regulation guide behaviour, positive affective responses are expected (Ryan and Deci, 2017; Standage and Ryan, 2012). One example is the QuaranTrain launched at HAN University of Applied Sciences in the Netherlands, an online fitness programme promoting evidence-based information on exercise and resources to stay active during COVID-19 pandemic through blogs and videos (HAN University of Applied Sciences, 2020). They provide daily online support, according to World Health Organization advice on physical activity. Users post their workouts routines in social media using the trending hashtags #quarantrain and #quarantraining, with more than 5000 posts worldwide.

Self-efficacy and Self-esteem

Being engaged in exercise may result in higher levels of self-efficacy (Bandura, 1997) which can have the knock-on effect of improving one’s ability to carry out other activities (Mikkelsen et al., 2017). The relationship between changes in the ability to perform activities successfully and increased self-efficacy is fundamental, considering the observed association between depression and low self-efficacy (White et al., 2009). In the context of social isolation, physical activity may be one key to enhancing people’s feeling of competence. In addition, achievement of internal goals and satisfaction has been related to greater psychological wellness (Ryan and Deci, 2017; Standage and Ryan, 2012). This hypothesis has been confirmed by an experimental protocol in which mindfulness self-efficacy appeared to mediate the indirect effects of exercise on mental health and perceived stress (Goldstein et al., 2018), reinforcing the positive account of emotion for a better quality of life (Joseph et al., 2014).

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Mikkelsen et al. (2017) observed that exercise influences self-esteem through self-efficacy or mastery, and mood, distracting individuals from negative and worrying thoughts and rumination, improving the retrieval of positive thoughts and allowing time away from negative or stressful aspects of everyday life, and especially, the COVID-19 pandemic itself. These moderating factors might also explain the protection effect of exercise on mental health (Mikkelsen et al., 2017).

Physical activity programmes to improve self-esteem to people of all ages can be effectively delivered at home by DVD (e.g. see Awick et al., 2017) or by You Tube (e.g. PE with Joe).

Peer Support

Moreover, people in social isolation should try to create peer support through social networking services by involving friends and relatives in their exercise routines or challenges.

Resources

 

The negative impacts of COVID-19 lockdown on mental health can be ameliorated by the use of exercise, which should be as vigorously promoted as social distancing itself.

In this context, keeping moving seems to be the key.

Reference:

Thiago Matia, Fabio H Dominski and David F Marks (2020)

The ‘COMA-B’ System for Behaviour Change: Reset of the COM-B

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The COM-B System

In 2011, three psychologists, Susan Michie, Maartje M van Stralen and Robert West (MSW, 2011), proposed “a ‘behaviour system’ involving three essential conditions: capability, opportunity, and motivation…This forms the hub of a ‘behaviour change wheel’ (BCW).”

MSW mention two sources for the idea of the COM-B:

“a US consensus meeting of behavioural theorists in 1991 [see this], and a principle of US criminal law dating back many centuries…Under US criminal law, in order to prove that someone is guilty of a crime one has to show three things: means or capability, opportunity, and motive.”

They continue:

“This suggested a potentially elegant way of representing the necessary conditions for a volitional behaviour to occur…We have built on this to add nonvolitional mechanisms involved in motivation (e.g., habits) and to conceptualise causal associations between the components in an interacting system.”

A conceptual framework used by the courts to prove the innocence or guilt of accused felons may not be the most appropriate model to apply to the behavioural choices of non-criminals. The COM-B has been influential and highly cited (4220 times by 08/10/20).  However, the hub of the COM-B is incomplete and manifestly it does not work when applied to the most basic of choices in health behaviours such as smoking, drinking and the wearing of masks in a pandemic.  Here I explain why. Screen Shot 2020-04-03 at 10.34.04.png

 

In the COM-B system, Capability, Opportunity, and Motivation are said to ‘interact’ to generate Behaviour. C, O and M are claimed to be sufficient and necessary conditions for B. Before discussing the model, we need some definitions:

Definitions

MSW give the following definitions:

‘Capability’ is defined as the individual’s psychological and physical capacity to engage in the activity concerned. This includes having the necessary knowledge and skills. In plain language, ‘capability’ means ‘fit to’.

‘Motivation’ is defined as all those brain processes that energize and direct behaviour, not just goals and conscious decision-making, e.g. habitual processes, emotional responding, as well as analytical decision-making.  Thus motivation equates with ‘need to’.

‘Opportunity’ is defined as all of the factors that ‘lie outside the individual that make the behaviour possible or prompt it’.  Thus opportunity means ‘can do’.

The model suggests that if one is fit to, needs to and can do a particular behaviour, then one will do it. Unfortunately, there is a key process missing from this scheme, as I will demonstrate below. Taking into account the original context for the COM-B model – proving guilt or innocence in the courtroom – I will use an example from the same domain.

Robbing a Bank

According to the COM-B, capability and opportunity cause changes in motivation and changes in behaviour.  I refer to that fictitious character Joe Blow (pronouns: him/her/their). 

According to the COM-B:

Joe Blow (JB) would (X rob a bank, Y kiss the queen, Z fly to the moon, whatever) if it can be shown that JB is fit to, needs to, and can do X, Y or Z. Yet this account is plainly incomplete. A key element that is missing from the COM-B is wanting: JB must want to carry out X, Y or Z if he is to actually to do it.  If JB doesn’t want to, he/she/they simply won’t do it, no matter what.

Imagine the following:

1) JB is fit to rob a bank because he/she/they is physically strong and has a jemmy and a set of tools for breaking open doors and safes – (fit to).

2)  JB is hugely in debt (to a bank, as it happens) so he/she/they need(s) money very badly, and so has a strong motive to rob a bank – (needs to).

3) JB knows there is a back alley and a door with an alarm that a friend who works in the bank will leave switched off on any night of their choosing – (can do).

Thus, JB ticks all three boxes of the COM-B but JB still chooses not to rob a bank. Why so? It could be for a million and one  possible reasons.  JB does not rob the bank because:

robbing the bank would be wrong,

it would be risky – i.e if he is found out he would go to prison,

if found out, it would look bad in front of the neighbours,

it would upset the bank manager who he knows well drinks beers with in the local pub,

it would be an unreasonable and unfair

etc

For a host of different reasons, JB may desperately need money but does not want to rob the bank to get it.

In spite of JB ticking all three of COM-B boxes, the COM-B fails to correctly predict JB’s behaviour. There is a hidden barrier. In multiple situations people do not choose to do something, something for which they could be handsomely rewarded, because they simply do not want to do it.

Another similar individual who ticks all three COM-B boxes might actually proceed to commit the bank robbery. Imagine that Joe Blow has a twin, Les Blow (LB/him/her/their) who lives on the other side of town. JB tells LB about the bank, the back alley and the dodgy security guard.  LB now meets all three criteria – LB is fit to, needs to, and can do the bank robbery. However, LB has none of the moral and social scruples held by JB and proceeds to rob the bank.

The twins act differently under essentially similar circumstances, revealing a crucial difference between the twins.

The COMA-B Reformulation

The COM-B requires reformulation because a crucial process is missing. However, the COM-B does not work because there are other problems that prohibit a good fit to real world data. The diagram of the model shows five arrows representing so-called ‘interactions’, three of which point in both directions. Four of the ‘interactions’ do not exist and none works in both directions. 

Only one ‘interaction’ in the COM-B diagram is anywhere near causal.  In order to do something, a person also has to want to do it more than they want not to do it. This is a delicate balancing act that takes place when we make decisions in our everyday lives. The COM-B is reformulated as the ‘COMA-B’ in the diagram below.

(A = ‘Aspires to’, which makes a better acronym than using W for Wants : COMW-B).

amended COM-B model.png

Adding a box for wants to and placing arrows differently converts the COM-B into the COMA-B.  In removing arrows, it is necessary to distinguish enablers from causes. Fit-to capability and can-do opportunity are both enablers of need-to motivation; wants-to is actually causal.

Conclusion

There are three necessary conditions for any action X:

  1. having the capability to do X
  2. having the opportunity to do X
  3. wanting to do X

A fourth condition, need, triggers want, but is not sufficient to produce behaviour on its own.

The above discussion shows that the original COM-B framework is incapable of predicting behaviour and behaviour change.

Recently, the authors of the COM-B produced a reformulation, which will be discussed in another post.

Changing Behaviour

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The vast majority of people change their behaviour with no external help. They just do it. ‘Change experts’ include psychologists who advocate behaviour change techniques in their interventions. A behaviour change technique (BCT) is any systematic procedure (or a category of procedures) included as an active component of an intervention designed to change behaviour. The defining characteristics of a BCT are that it is:

• Observable
• Replicable
• Irreducible
• A component of an intervention designed to change behaviour
• A postulated active ingredient within the intervention (Michie et al., 2011).

The description, classification and investigation of BCTs has become a cottage industry. Places like UCL, Aberdeen and Cambridge Universities, together with IBM, have received several millions of pounds from the Medical Research Council and Wellcome Trust to construct an ‘ontology’ of behaviour change.

According to the project website, “Behavioural Scientists are developing an ‘ontology’: a defined set of entities and their relationships” which will be used to “organise information in a form that enables efficient accumulation of knowledge and enables links to other knowledge systems.”

bs-diagramdetailedThe top level of the ‘Behaviour Change Intervention Ontology’ (project website)

An ontology is a set of concepts and categories in a subject area that shows their properties and the relations between them. An ontology can only be helpful when nothing of importance to the system as a whole is left out.

A ‘BCT Taxonomy’ has been employed to code descriptions of intervention content into BCTs (Michie et al., 2011, 2013). The taxonomy aims to code protocols in order to transparently describe the techniques used to change behaviour so that protocols could be made clearer and studies could be replicated (Michie and Abraham, 2008; Michie et al, 2011). A taxonomy also can be used to identify which techniques are most effective so that intervention effectiveness could be raised and more people would change behaviour.

The production of a structured list of BCTs provides a ‘compendium’ of behaviour change methods which helps to map the domain of behaviour change and inform practitioner decision-making. However it also risks becoming a prescriptive ‘cook-book’ of what therapeutic techniques must be applied to patients presenting with a specific behavioural problem.

Another problem with the compendium approach is that BCTs are not all optimally effective when combined in ‘pick-and-mix’ fashion. There needs to be coherence to the package that is provided by a theory that offers power and meaning and connects the components into a working set.

I can illustrate this point by considering an intervention for smoking cessation, Stop Smoking Now (Marks, 2017). This therapy is an effective method for clearing the human body of nicotine. The desire to smoke and any satisfaction from smoking are abolished using different forms of CBT and mindfulness meditation. Stop Smoking Now includes 30 BCTs integrated within a coherent theory of change based on the concept of homeostasis. In Stop Smoking Now a structured sequence of BCTs is provided that takes into account the nesting of BCTs such that guided imagery works best in combination with relaxation and both of these work best following enhancement of self-efficacy, achieved using self-recording, positive affirmations and counter-conditioning.   In addition, our field evidence shows that the outcome is enhanced by having a personable delivery from a charismatic person who builds a positive therapeutic alliance.                  

bs-diagramdetailedWith so many missing elements, this an Incomplete Model of Behaviour Change

Where is the client person in the ‘Behaviour Change Intervention Ontology’, and what about their feelings and their own striving for new balance and equilibrium?  Where is the therapist and the therapeutic alliance?  The quality of the change agent, their clinical and interpersonal skills and the quality of the therapeutic alliance can be more important than the BCTs (Hilton & Johnston, 2017) .With so many missing elements, this is beginning to appear like a top-down model of behaviour change. One may be excused for wondering whether the people designing the ‘ontology’ have any real-world hands-on experience of delivering interventions.

Hagger and Hardcastle (2014) suggest that “Interpersonal style should be included in taxonomies of behavior change techniques”. The whole point is that the therapeutic alliance is something the therapist and the client need to strive for. The alliance creates a more equal power balance between therapist and the client. It is more important than another technique, another item on the list. It is more about the ‘chemistry’ of the client-therapist relationship than about a finely polished set of BCTs. The trouble is that the advocates of the BCT compendium/ontology appear unwilling to engage with the problem. Somewhat ironically, they are resistant to change. However, the problem will not just go away, but rears its head each and every time a therapist swings into action.

Behaviour change involves a collaboration between the client wanting to make the change, with their own desires and feelings, and the change agent/therapist. The therapeutic alliance between the two parties is crucial to the project’s ‘outcome’.  Therapist’s attributes such as being flexible, honest, respectful, trustworthy, confident, warm, interested, and open contribute to that alliance. From all of this it can readily be seen that the situation is far more complex than the proposed ‘Behaviour Change Intervention Ontology’. It is never as  simplistic as an ‘Intervention’,  ‘Mechanisms of Action’ and ‘Target Behaviour’.

To use an analogy, there is so much more to baking a cake than a set of ingredients. Of course one needs a set of ingredients (the BCTs) but one also needs a baker – the behaviour change agent (BCA). The BCA/therapist must be fully trained to prepare, mix and cook the ingredients, to be fully competent to deliver the BCTs in a stylish manner. The qualities of effective therapists have been studied for at least 50 years. The stock piling of a compendium of BCT ingredients without attending to the mixing and ‘baking’ of the ingredients by the BCA on the front line is a recipe for disaster.

smart chef character cooking behind kitchen table with various o

Including therapist attributes of flexibility, authenticity, respect, trustworthiness, confidence,  warmth, interest, and openness, along with the client’s goals, desires and striving provides a more accurate and comprehensive approach to behaviour change.

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Stopping the Obesity Crisis

Health is regulated by homeostasis, a property of all living things. Homeostasis maintains equilibrium at set-points using feedback loops for optimum functioning of the organism. Long-term disruptions of homeostasis or ‘dyshomeostasis’ arise through genetic, environmental and biopsychosocial mechanisms causing illness and loss of well-being including obesity, the addictions, and chronic conditions. These and many other phenomena of Psychological Homeostasis are explained in A General Theory of Behaviour.

Obesity dyshomeostasis is associated with a self-reinforcing activity of a vicious Circle of Discontent in which hedonic reward overrides weight homeostasis in an obesogenic and chronically stressful environment. Over-consumption of processed, high-caloric, low-nutrient foods, combined with stressful living and working conditions, have caused loss of equilibrium, overweight and obesity in more than two billion people.

The prevalence of obesity is higher in women and low-income groups who are more exposed to chronic stress and low purchasing power including some ethnic minority groups.

Research on different diets suggests that a plant-based diet containing low amounts of sugar, little or no red meat and the minimum of fats promotes weight-loss and prevents obesity, diabetes, metabolic syndrome, coronary heart disease, and cancer. A vegan diet with no meat, fish or dairy is especially anti-obesogenic.

The ‘thin ideal’ pervades popular culture with narratives and images of thinness which has an entirely negative effect on youth the world over. Legislation should be enacted to ban the use of artificially enhanced images of ultra-thin models in magazines and media.

Discrimination against people who are overweight or obese causes stress and socio-economic disadvantage. Approaches to the epidemic that invoke a narrative of ‘blame-and-shame’ exacerbate the problem. There are very few people who deliberately become obese through conscious effort or who would not like to avoid it if they possibly could.

Homeostatic imbalance in obesity includes a ‘Circle of Discontent’ (COD) a system of feedback loops linking weight gain, body dissatisfaction, negative affect and over-consumption. This homeostatic COD theory is consistent with a large evidence-base of cross-sectional and prospective studies.

A preliminary model suggests that obesity dyshomeostasis is mediated by the prefrontal cortex, amygdala and HPA axis with signalling by the peptide hormone ghrelin, which simultaneously controls feeding, affect and hedonic reward.

The totality of evidence within current knowledge suggests that obesity is a persistent, intractable condition. Prevention and treatment efforts targeting sources of dyshomeostasis provide ways of reducing adiposity, ameliorating addiction, and raising the quality of life in people suffering chronic stress.

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Vigorous and uncompromising Governmental actions are required, independent of corporate interests, at all levels of society to reduce the prevalence of obesity and related conditions. A four-armed strategy to halt the obesity epidemic is necessary.

There is an immediate need to enact anti-discrimination legislation to protect people with obesity and improve their quality of life. Anti-discrimination laws are necessary to eliminate one of the primary causes of obesity which fuels the Circle of Discontent. PLWO need legal protection from discrimination which has been shown to be detrimental to the mental health of the victims of obesity.

Legislation to enforce a mandatory code of practice is needed to resist and devalorize the thin-ideal. Precedents have been set in Israel and France to ban models with extremely low BMI, examples which should be followed in all countries. The retouching of pictures in fashion magazines to make the human subjects appear slimmer or more attractive should be controlled. Consumers should be informed when images of people have been manipulated.

Generic legislation is necessary to curb the widespread consumption of energy-dense, low nutrient foods and drinks. Mexico, France, Finland and Hungary and, most recently, the UK have set charges for a levy on sugary drinks, a step in the right direction. More generic taxation is necessary to incentivize producers and retailers to reformulate products. An ‘Unhealthy Commodities Tax’ which would yield revenue and improve the diet of a large segment of the at-risk population.

Improving the access to plant-based diets is an effective strategy for producing weight loss. The example of the WIC in the US indicates that increasing access to fruit and vegetables has a positive effect on food consumption towards a healthier diet. Following the WIC model, legislation should be considered in every state and country to improve F/V intake. Proceeds from a UCT could be used to subsidise the organic production of F/V with payments to growers and sellers to enable lower retail prices of organic F/V. Interventions to increase access and affordability of F/V would help to slow the obesity epidemic.

Huge resources have been invested on the monitoring of the epidemic and on the treatment of PLWO. The major part of future investment should be re-directed towards containment and control by legislating strategies for obesity prevention as was previously the case in tobacco control. No more kowtowing to industry. Let’s cease the “shock-horror” narrative of obesity at all levels of society and replace it by concrete actions.

We know what is required. Can our national governments show the necessary leadership and do what is necessary? The survival of the planet and the human race requires nothing less.

Stop Smoking Now

If you’re a smoker and want to give up the habit, then Stop Smoking Now is designed for you. The approach involves restoration of homeostasis without nicotine in the body or nicotine replacement, e-cigarettes or any other kind of crutch in the form of medication.

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The truth is Stop Smoking Now could not only save your life, it offers you a healthier and longer life as well. It also could save you a shed-load of money. A new car every year, fabulous holidays, and a much higher quality of life are all yours if you really want them. But it isn’t really about the money. It’s about your health and well-being.

To gain these benefits, all you need to do for the next 7-10 days is to follow the process. Yes, that’s right, it really is that simple. Hard to believe, right?

Well consider this. I have spent the last forty years fine-tuning the best possible ways for smokers to overcome the habit. My role as a Health Psychologist has brought me into contact with people from all backgrounds and cultures who have been at all the different stages of stopping smoking. In many cases, the smokers started out as desperate and hopeless cases, feeling that nothing could work for them. They had tried almost everything to stop smoking, but nothing had succeeded. Instead of blaming the faulty and futile systems they had been using to stop smoking, including most of all, their own willpower, they typically blamed themselves. They blamed themselves for being “weak”. Sounds familiar?

All a person needs to stop smoking is a system that actually works. A week or two weeks of serious application and, bingo, you will hit the jackpot, stop smoking, and remain a smoker for the rest of your life. Like many ex-smokers, you will experience feelings of joy and empowerment, hugely increased self-control and life satisfaction by achieving what previously seemed impossible – to stop smoking. Nothing can offer you a greater boost to your self-esteem than to stop smoking, absolutely nothing. It’s better than winning the lottery. Because it’s not just about the money you’ll save, it’s about a Whole New You.

Stop Smoking Now gives you the most effective method of stopping smoking. The processes described here will enable you to bring about the change.

I know – I have been there!

In my twenties virtually everybody was smoking. Smoking was the natural and normal thing to do. You could smoke almost anywhere. In shops, cafes, pubs, clubs, cinemas, theatres, absolutely everywhere. It seems crazy now, but that’s how it was. I was a pack-a-day smoker and guess what, I actually thought I was enjoying it. Sound familiar?

Cigarette advertising was everywhere. In newspapers, magazines, on TV, at the movies and on huge billboards all over the place. People would literally drive along motorways and freeways smoking cigarettes and crash their cars gawping at the billboards. It seems a different reality now, but that’s exactly how it was. All kinds of subtle and clever messages designed to get everybody to smoke a particular brand. Brands for ladies, brands for teens, brands for minorities, brands for everyone.

My brand was XXXXX. I don’t really know why. I can’t explain it. As far as I was aware, it had nothing to do with the evocative brand imagery. But at a pre-conscious level, it almost certainly had a lot to do with it. Of course, I tried other brands too, but I usually drifted back to XXXXX. I had probably been smoking for about 10-11 years when something happened that stopped me in my tracks and got me thinking. I switched to the low tar version of XXXXX, called XXXXX Ultra Lites.

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I was living in the US when I switched to this ‘sleek’ low-tar brand, a supposedly ‘safer’ method of smoking – ‘safer’ according to the the big tobacco companies, that is. My grey-and-white pack of XXXXX looked smooth and on-trend, the perfect thing for a ‘Man-about-Town’. Like millions of others all over the world, I was one ‘cool dude’ making the switch to ‘low tar’. Until I discovered the truth, that is…

Little did I realize at first what a complete sham these ‘lights’ really were. The tobacco companies had discovered the sneaky idea of making tiny holes in the sides of the filters so when you inhaled you got extra air mixed in with the smoke. This fooled the machines used for measuring cigarette tar levels into assigning lower tar levels inside the cigarettes. Millions of ‘cool dudes’ all over the world were being taken for a ride because the cigarettes contained the exact same chemical concoction of tobacco as the regular, high tar brands. And you paid extra for the privilege! When the government scientists finally figured out what was going on, the terms “light,” “low,” and “mild” in product labeling and advertisements were banned in the USA.

A week or two after I had made the switch I woke up one morning with an unexplained headache and began to notice I was having to inhale ever more deeply to get any real ‘satisfaction’ from my Ultra Lites. This was in 1976 when I was working at the University of Oregon with Professor Ray Hyman. Ray Hyman remains one of the tiny number of people to have one of Psychology’s few real ‘laws’ named after him: the ‘Hick-Hyman Law’.

One evening over dinner Ray gave me a penetrating stare and said: Given all you know about the ill-effects of smoking, why the heck are you still smoking? He stopped me dead, so to speak. I really couldn’t give a rational answer. It was at that very moment that I decided to give up smoking. Within a few days of preparation, I did it. I destroyed my remaining cigarettes and never smoked again.

As I sit at my laptop, forty years later, I can honestly say that I gave up smoking thanks to the headaches from my XXXXX Ultra Lites and the pep talk from my friend. My thanks go out to them both. This was the best health-related decision that I took in the whole of my life. Thanks Ray! Thanks XXXXX Ultra Lites! It’s now forty short years since I quit smoking.

Once I took the decision to quit smoking, however, it was far from plain sailing. I discovered how very difficult it can be. I was crotchety with the whole world. I couldn’t sleep properly. I was sharing my woes with the inside of a beer bottle. There was an inexplicable gap in my life. A vacuum of nothingness that was difficult to fill.

This was how it all started, the main reason I decided to write books and run programmes and campaigns to help other people to stop smoking. After I returned from my visit to the US, a very smart PhD student called Paul Sulzberger came to me with the idea. He and I started running Stop Smoking courses. We put together a course of five sessions that groups of people attended over a period of eight days. The sessions started on a Tuesday and finished the following Wednesday. It was highly successful. Eighty-five percent of smokers had given up by the end of the eight days. The remaining 15 percent had all reduced their consumption significantly.

News of our Stop Smoking programme spread like wildfire and we took the programme all over New Zealand and into Australia. We must have helped 20,000-plus smokers give up the habit. Our research and an independent research organisation told us that we were producing some very exciting results, the highest cessation rates ever recorded. We did ads on TV and in the major papers and franchised the system internationally and it is still running under various umbrellas to this day.

In the mid-80s I returned to London as Head and the first Professor of Psychology at the School of Psychology at Middlesex Polytechnic. The busy London lifestyle felt a bit different to more laid-back New Zealand. In my efforts to continue the march against smoking, I needed a more efficient approach so I converted the method into a self-help pack I called the QUIT FOR LIFE Programme, which was published by the British Psychological Society.

The BPS QFL Book Cover

In 2005, the first edition of the version you are now reading was published. In its current edition, Stop Smoking Now has proved to be the most successful stop smoking method ever invented. Yes, that’s right, ever invented.

I have the results of scientific trials prove this. One of my most memorable moments was when I returned on a visit to the beautiful South Island of New Zealand on holiday with my son, Michael. While in Dunedin we visited a friend who lived in the suburb of St Clair. It was a warm and sunny afternoon. A person who, at first I did not remember, had taken my smoking cessation programme many years before came over, looked me straight in the eye, and said: “You saved my life. You helped me stop smoking 25 years ago. Now I’m 75 and fit as a fiddle, thanks to you, I wouldn’t still be here if you hadn’t helped me stop smoking.” This is not the only time I have received the heart-warming announcement: “You saved my life”. Many others have said exactly the same thing.

I too probably wouldn’t still be alive today if I hadn’t stopped smoking. I know from bitter experience. I watched my one-and-only brother Jon die from throat cancer caused by smoking. Jon had only just reached his sixtieth birthday.

But that’s all history now. Let’s return to the present…You are on a different path, a path that can lead to health, increased quality of life, and happiness.

What You Need To Stop Smoking Now
You have taken the first precious step on the path to changing your smoking habit. You have within your hands a powerful and unique system designed to enable you to reach this important goal to stop smoking. You have the desire. You have the motivation. You have the ability. In this book, you have the strategies, the know-how you need to do it, to Stop Smoking Now. Follow the guidance in this book, and you will stop smoking in just a few days, and, think about it, you will never need to smoke again!

This will be the most important step to improve your health that you can take in the whole of your life. Experiencing the process from beginning to end is something you will never forget. You will be a changed person, a New You.

You already realize that smoking is the most stupid, addictive and harmful habit known to humankind. It is predicted that one billion people will die in the 21st Century as a consequence of smoking. One way of solving the world’s population explosion, I suppose… But a smoking-related death it’s not normally a quick death. Smoking-related illnesses are nasty, protracted and painful and require thousands of health care dollars. Having watched my brother slowly die in great pain, it’s something I wouldn’t wish on anybody.

Stop Smoking Now offers you the best chance to overcome your smoking habit without any help from Big Pharma. It offers you a way to extinguish the habit, once and for all. And that’s without taking a shed load of gut-busting drugs. The methods in this book have been evaluated with hundreds of smokers in randomized controlled trials. Tens of thousands of people like you have successfully overcome their smoking habit using these methods.

If you use all of the procedures with commitment and perseverance, you will overcome your smoking habit for ever. You twill be a Calm and Confident Non-Smoker.

Stop Smoking Now is in three stages.

Part One is all about Theory. I discuss the psychology of smoking and quitting. I introduce Cognitive Behaviour Therapy (CBT) and its cousin, ‘Mindfulness’, explain how they work, and how they can help you to give up smoking once and for all. It will help you to think about and become acutely aware of what you do when you smoke, why you do it, and what smoking really means to you.

If you’re not much interested in Theory and want to cut straight to the nitty-gritty, you can skip Part One and move directly to Part Two. Part Two is the Practical stuff, the guts of the whole system. It guides you, step by step, from the addicted smoker you are now to a new healthful life as a non-smoker. The process takes 7 to 10 days. This will be your new beginning, a brand new life, the most dramatic way to improve your quality of life, extend your lifespan and make you better off financially in one smart move.

Part Three is also Practical. It’s about Regaining your Life as a Non-smoker. It guides you over the pitfalls of being a recent quitter and helps you to prevent relapse and maintain your non-smoking permanently.

Why You Should Stop Smoking Now
Stopping smoking is, without any doubt, the most important thing you can do to improve your health. If you stop smoking:

• You will live longer and live a healthier life.
• You will significantly reduce your chance of having a heart attack, stroke, or cancer.
• Your skin, hair, body and clothes will no longer reek of tobacco.
• Your fingers will stop turning yellow.
• Your sex life will show a significant improvement.
• If you are pregnant, you will improve your chances of having a healthy baby.
• The people you live with, your loved ones and your children, will have a healthier, less polluted environment.
• You will save a lot of extra money to spend on luxuries and holidays.

How This Method Can Help You
There are thirty different procedures that have helped thousands of smokers give up the habit. Nobody can predict which particular procedures will work best for you – everybody is different. However, by trying this wide range of different procedures, you are giving yourself your best chance of success. Please try them all.

Believe it or not, you can possibly enjoy certain aspects of the process of stopping smoking. It is part of the design to make this method as an enjoyable and fun experience as possible. You will learn a lot about yourself and the potential you have to change yourself for the better. Yes, to actually make yourself a better and more aware and fully functioning person. But I would not be telling you the whole truth, if I didn’t tell you that it can be very, very difficult. You already know that.

An addicted smoker is always, to a degree, dysfunctional. The changes that make you will make will help you to be a fully functional human being again. Like you used to be before you took up the habit, or rather, before the habit took over you.

Drinking, eating, Internet surfing, shopping, chilling, watching TV, gaming, gambling – anything to excess can quickly turn into an addiction. Smoking is a habit which seems extremely difficult to change. As an ex-smoker I know. But smoking can be brought under control easily and permanently by applying this systematic programme.

The book can be used as a stand-alone, self-help, how-to method of quitting or it can be combined with the treatment offered by your local health service providers. Two or more smokers can also Stop Smoking Now together to generate an element of cooperation, or even competition. Who gets there first, is always an interesting challenge, as is Who stays there the longest?

I wish you absolute and complete success in becoming a happy and successful non-smoker.

Homeostasis, Balance, Stability

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The fixity of the milieu supposes a perfection of the organism such that the external variations are at each instant compensated for and equilibrated…. All of the vital mechanisms, however varied they may be, have always one goal, to maintain the uniformity of the conditions of life in the internal environment…. The stability of the internal environment is the condition for the free and independent life.

Claude Bernard

The central principle of the General Theory in the construct of ‘Psychological Homeostasis’. Sixty-one years after Bernard (1865) wrote about the ‘internal milieu’, Walter B. Cannon (1926) coined the term ‘homeostasis’. Then, 16 years later, psychobiologist Curt Richter (1942) expanded homeostasis to include behavioural or ‘ total organism regulators’ in the context of feeding. From this viewpoint, ‘external’ behaviours that are responses to environmental stimuli lie on a continuum with ‘internal’ physiological events. For Richter, behaviour includes all aspects of feeding necessary to maintain the internal environment. Bernard, Cannon and Richter all focused on a purely physiological form of homeostasis, ‘H[Φ]’. I wish to convince the reader that the hypothesis of the ‘external milieu’, the proximal world of socio-physical action, is equally important.

The General Theory extends homeostasis to all forms of behaviour. Psychological homeostasis can be explained in two stages, starting with the classic version of homeostasis in Physiology, H[Φ], followed by the operating features of its psychological sister, H[Ψ]. The essential features are illustrated in Figure 2.1.

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Figure 2.1 Upper panel: A representation of Physiological (Type I) Homeostasis (H[Φ]). Adapted from Modell et al. (2015). Lower panel: A representation of Psychological (Type II) Homeostasis (H[Ψ]).

To be counted as homeostasis, H[Φ], a system is required to have five features:
1. It must contain a sensor that measures the value of the regulated variable.
2. It must contain a mechanism for establishing the “normal range” of values for the regulated variable. In the model shown in Figure 2.1, this mechanism is represented by the “Set point Y”.
3. It must contain an “error detector” that compares the signal being transmitted by the sensor (representing the actual value of the regulated variable) with the set range. The result of this comparison is an error signal that is interpreted by the controller.
4. The controller interprets the error signal and determines the value of the outputs of the effectors.
5. The effectors are those elements that determine the value of the regulated variable. The effectors may not be the same for upward and downward changes in the regulated variable.

Identical principles apply to Psychological (Type II) Homeostasis (H[Ψ] with two notable differences (Figure 2.1, lower panel). In Psychological Homeostasis, there are two sets of effectors, inward and outward, and the conceptual boundary between the internal and external environments lies between the controller and the outward effectors of the somatic nervous system, i.e. the muscles that control speech and action. Furthermore, Psychological Homeostasis operates with intention, purpose, and desire.

The individual organism extends its ability to thrive in nature with Type II homeostasis. Self-extension by niche construction creates zones of safety, one of the primary goals of Type II homeostasis. Niche construction amplifies the organism’s ability to occupy and control the environment proximally and distally. The use of tools for hunting, weapons for aggression, fire for cooking, domestication of animals, the use of language, money, goods for trade and commodification, agriculture, science, technology, engineering, medicine, culture, music literature and social media are all methods of expanding and projecting niches of safety, well-being and control. Individual ownership of assets such as land, buildings, companies, stocks and shares reflect a universal need to extend occupation, power and control but these possessions do not necessarily increase the subjective well-being of the owner [AP 007].

Initiated by the brain and other organs, homeostasis of either type can often act in anticipatory or predictive mode. One principal function of any conscious system is prediction of rewards and dangers. A simple example is the pre-prandial secretion of insulin, ghrelin and other hormones that enable the consumption of a larger nutrient load with minimal postprandial homeostatic consequences. When a meal containing carbohydrates is to be consumed, a variety of hormones is secreted by the gut that elicit the secretion of insulin from the pancreas before the blood sugar level has actually started to rise. The blood sugar level starts lowering in anticipation of the influx of glucose from the gut into the blood. This has the effect of blunting the blood glucose concentration spike that would otherwise occur. Daily variations in dietary potassium intake are compensated by anticipative adjustments of renal potassium excretion capacity. That urinary potassium excretion is rhythmic and largely independent on feeding and activity patterns indicates that this homeostatic mechanism behaves predictively.

Similar principles operate in Type II homeostasis acting together with the brain as a “prediction machine”. When we anticipate a pleasant event such as a birthday party, there is a preparatory ‘glow’ which can change one’s mood in a positive direction, or thinking about an impending visit to the dentist may be likely to produce feelings of anxiety, or the receipt of a prescription of medicines from one’s physician may lead to improvements in symptoms, even before the medicines are taken.

At societal level, anticipation enables rational mitigation, e.g. anticipation of demographic changes influences policy, threat from hostile countries influences expenditure on defence, and the threat of a new epidemic influences programmes of prevention. [AP 008].

Homeostasis involves several interacting processes in a causal network. A homeostatic adjustment in one process necessitates a compensatory adjustment in one or more of the other interacting processes. To illustrate this situation, consider what happens in phosphate homeostasis (Figure 2.3). Many REF-behaviours that we shall refer to are isomorphic with the 4-process structure in Figure 2.2. However, in nature there is no restriction on the number of interconnected processes and any process can belong to multiple homeostatic networks.

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Figure 2.2 Phosphate homeostasis. A decrease in the serum phosphorus level causes a decrease in FGF23 and parathyroid hormone (PTH) levels. Increase in serum phosphorus leads to opposite changes. Calcitriol increases serum phosphorus and FGF23, while it decreases PTH. Increase in FGF23 leads to decrease in PTH and calcitriol levels. PTH increases calcitriol and FGF23 levels. Reproduced from Jagtap et al. (2012) with permission.

Homeostasis never rests. It is continuous, comprehensive and thorough. With each round of the REF, all of the major processes in a network are reset to maintain stability of the whole system. The REF process goes through a continuous series of ‘reset’ cycles each of which stabilizes the system until the next occasion one of the processes falls outside its set range and another reset is required.
Processes in Type II homeostasis may vary along quantitative axes or they can have discrete categorical values. For example, values, beliefs, preferences and goals can have discrete values, as does the state of sleep or waking.

Any change in a categorical process involves change throughout the network to which is belongs. [AP 009].

Such changes may be rapid, in the millisecond range, e.g. a changed preference from chocolate chip cookie flavoured ice cream to Madagascar vanilla that may occurs an instant after arriving at the ice-cream kiosk. At the other end of the spectrum of importance, in buying a new apartment, the final choice might also occur in the instant the preferred option is first sighted. Or the decision could take months or years even though it is of precious little consequence, e.g. deciding that one is a republican rather than a monarchist, or it may never occur because we simply do not care one way or the other. These considerations lead to a surprising proposition that:

The speed of a decision is independent of its subjective utility [AP 010].

One objective of A General Theory of Behaviour is to explain the relevance of the REF system to Psychology. We know already that the regulation of action is guided by three fundamental systems: (i) the brain and central nervous system (CNS), (ii) the endocrine system (ES) and (iii) the immune system (IS). It is proposed that, as a ‘meta-system’ of homeostatic control, these systems collectively govern both physiology and behaviour using two types of homeostasis, H[Φ] and H[Ψ], respectively. We can understand how this might be possible in light of a recently discovered ‘central homeostatic network’.

An extract from: A General Theory of Behaviour.