When Saying “No” Isn’t Enough

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Many of us are familiar, at least in passing, with the 1980s campaign against drug use called “Just Say No.” It was hailed as a way to draw attention to the war against drugs at the time. This time period coincided with the appearance of crack, a highly concentrated and addictive form of cocaine.

As you may remember, First Lady Nancy Reagan took it up as a cause, appearing on television, giving talks nationally, and visiting substance abuse recovery facilities all over the country. Apparently, Nancy Reagan, upon visiting an elementary school in Oakland, California, was asked by a young student what to do if offered drugs by her peers. Nancy replied, “Just say no,” and so it began.

School clubs and organizations soon cropped up across the country, using the catchy phrase. At times, the program was maligned, saying that “Just Say No” was too simplistic of an answer. Worse, it contributed to the belief that addicts have control over their addiction if they would only just say no.

Trying again with D.A.R.E.

The D.A.R.E. program, which was started in 1983, took it a step further. Uniformed police officers would go to classrooms to outline the dangers of drug use once a week for 10 weeks. The program was immensely popular and became implemented nationwide, with t-shirts, license plates, bumper stickers, and so forth. It is still in existence today.

However, once the program began to be studied in the 1990s and beyond, it became apparent that the program had been having virtually no effect on drug use in schools or elsewhere. In fact, by 2001, the Surgeon General of the United States, Dr. David Satcher, put D.A.R.E. in the category of “ineffective primary prevention programs.”

Looking further into it, research uncovered what they thought was missing. It was noted that educational programs such as Just Say No and D.A.R.E. do not offer enough coaching on interpersonal skills, social skills, or behavior modification.

Results began to become evident when some of the D.A.R.E. programs began to implement some of these approaches.

Making a connection to diet and exercise

We can see similarities between what works in drug prevention and programs designed to help people lose weight and exercise more (i.e., making changes to adopt a healthier lifestyle).

For starters, there are some interesting parallels between avoiding drug use and avoiding too much food, certain foods, and resisting the urge to stay on the couch:

• Peer pressure can be significant.
• Our environment now contains processed, highly palatable, and appealing foods, some of which are compared to addictive substances.
• Some cultures can embrace unhealthy eating as the norm.

Beyond that, helping people adopt healthier behaviors has a long, problematic history. Just as they have discovered by studying drug prevention programs, the more effective path is to educate, coach behavior change, empower people with ways to resist, and develop effective strategies to work around an environment that is more like a minefield than the field of dreams.

It's about behavior change.

Just educating people about the dangers of drugs or the hazards of overeating and not getting enough exercise is not going to change lives, as has been demonstrated again and again in research. Instead, research tells us that building a program around behavior change can be effective.

Here are some examples of effective behavior modification strategies:

1. Set up a structure that will push you toward success. Setting up a healthy environment will embed your surroundings with cues to make the right choices. It is not possible to always rely on yourself to “just say no” to a bad choice.
2. Having lots of choices can feel overwhelming. This is why many people turn to the structure of a diet or exercise plan. But the way to operate in the real world, where we are surrounded by options and other people trying to influence us, is to anticipate the environment and practice making good decisions in various situations.
3. Similarly, the approach is not, “I’ll do better next time,” but “What am I going to do differently next time?” “What is a reason that I think I will do it differently next time?”
4. Doing it differently requires focus, defining your purpose, and then strategic planning. You may also want to ask yourself, “What changes do I believe myself capable of making?”
5. Making change takes time and energy. There is definitely some education or learning involved, but that is just the beginning. It takes an ongoing commitment to personal growth.
6. Research tells us again and again that having process goals is more effective than relying on outcome goals. It is better to outline a path of growth, with specific smaller goals to be reached along the way, instead of hoping for a brighter future without checking in with yourself and evaluating your environment.

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Evidence

Does this work? As an example, we can check out the Look AHEAD program, which began in 2001 and ended in 2012. NIH describes this as a behavioral weight loss intervention. This program originally recruited 5,145 individuals with type 2 diabetes who were overweight or obese. Half the group was assigned to an intensive lifestyle intervention, with the other group being the controls. After eight years, the Look AHEAD research group did a thorough investigation of the results.

At the end of eight years, the intervention group lost an average of 4.7 percent of body weight, while the control group lost an average of 2.1 percent of body weight. This is the weight loss that was maintained after varying degrees of initial weight loss. Even though these results are significant, they are not spectacular. The point here is that while the article summary considered the program a success, there was an awful lot of hard work involved.

How was the program structured? The program was indeed intense. It involved cognitive behavior therapy, elements of problem-solving, motivational interviewing, and cultural and individual tailoring. Participants logged their food, were often given prepared meals, and were tracked for adherence to exercise. There were group and individual meetings, the frequency of which tapered over time.

Bottom line

The take-home message is this:

Changing lifestyle behaviors is very difficult. It requires time, patience, practice, a multi-pronged approach, and the right guidance. The parallels with drug use are evident. The challenges we face on both fronts are complex because we humans are complex. No silver bullets, no catchy phrases. But some strategies are clearly making a difference. The need is there; we have to keep trying.