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Theory-based Journal of Health Psychology

Copyright © 2005 SAGE Publications
London, Thousand Oaks and New Delhi,
Behavior Change www.sagepublications.com
Vol 10(1) 27–31

Interventions: DOI: 10.1177/1359105305048552

Comments on Hobbis
and Sutton
Abstract
Hobbis and Sutton (this issue)
suggest that Cognitive Behavior
Therapy (CBT) techniques can
be used in interventions based
MARTIN FISHBEIN on the Theory of Planned
University of Pennsylvania, USA Behavior (TPB). Although this
suggestion has merit, CBT is
ICEK AJZEN only one of many applicable
University of Massachusetts – Amherst, USA methods for producing belief
and behavior change.
Moreover, CBT’s primary
purpose is to help people carry
M A RT I N F I S H B E I N is Distinguished Professor of out intended behaviors, not to
Communications and Director, Health influence intentions, and that it
Communications Area, Annenberg Public Policy is more useful in face-to-face
Center. He introduced an expectancy-value model of than in community-level
attitudes and the theory of reasoned action. interventions. Contrary to
Hobbis and Sutton’s critique,
I C E K A J Z E N is Professor of Psychology. He developed TPB can accommodate core
the Theory of Planned Behavior and is the author of beliefs or fundamental
numerous scholarly articles and books concerning assumptions, but the theory
attitudes and the prediction of behavior. suggests that interventions
targeted at such beliefs are less
effective than interventions
targeted at behavior specific
beliefs.

COMPETING INTERESTS: None declared.

Keywords
ADDRESS. Correspondence should be directed to:
M A RT I N F I S H B E I N , Annenberg Public Policy Center, Annenberg
Cognitive Behavioral Therapy,
School for Communication, 3620 Walnut Street, Philadelphia, PA Interventions, Planned Behavior,
19104, USA. [email: mfishbein@asc.upenn.edu] Reasoned Action
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05 048552_fishb_(jr/t) 11/11/04 2:14 pm
JOURNAL OF HEALTH PSYCHOLOGY 10(1)
THE T H E O RY of Planned Behavior (TPB;
Ajzen, 1991) is frequently used to identify the
determinants of health-related behavior, but it
provides little guidance on how these determi-
nants can be changed. To remedy this situation,
Hobbis and Sutton (this issue) propose that
techniques developed for Cognitive Behavior
Therapy (CBT) can gainfully be applied to
interventions based on the Theory of Planned
Behavior (TPB). Their discussion raises a
number of important issues.
Hobbis and Sutton note that the methods of
CBT are ‘primarily used with people who are
actively seeking help to support behaviour
change’, whereas ‘health behaviour change
programmes based on the TPB are generally
instigated by others who consider such
programmes to be of benefit to populations
they deem to be at risk’ (p. 13). The authors
apparently fail to realize a crucial implication of
this observation, namely, that the two
approaches are focused on different stages of
the behavior-change process. Interventions
based on the TPB are mostly directed at indi-
viduals who do not currently intend to perform
the desired target behavior: to get individuals
who have no intention to do so to perform
testicular self-examinations (Brubaker &
Fowler, 1990), to ride the bus instead of driving
the car (Bamberg, Ajzen, & Schmidt, 2003), to
wear a bicycle safety helmet (Quine, Rutter, &
Arnold, 2001), to increase regular condom use
(Fishbein et al., 2001) and so forth. The inter-
vention targets behavioral, normative, and/or
control beliefs in an effort to produce positive
intentions among participants who, prior to the
intervention, either did not contemplate
performing the behavior or were disinclined to
do so.
In marked contrast, Cognitive Behavior
Therapy generally tries to help people carry out
their previously formed intentions or to attain
their existing behavioral goals, such as over-
coming eating disorders (Goebel-Fabbri,
Fikkan, & Franko, 2003), panic reactions
(Kenardy et al., 2003) or pathological gambling
(Wulfert, Blanchard, & Martell, 2003). It is not
at all clear that some of the strategies developed
in CBT would be effective or even relevant for
interventions designed to influence behavioral
intentions. For example, encouraging indi-
viduals to ‘test out and experience new ways of
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Page 28
thinking and behaving through the application
of out-of-session homework “experiments” ’
(p. 10) may encounter resistance when these
individuals have no intention to change their
current behavior (Prochaska & DiClemente,
1983). Other methods, such as engaging indi-
viduals in a reasoned discussion of their
erroneous or biased beliefs, can perhaps be
adopted in attempts to change behavioral,
normative or control beliefs regarding the target
behavior and could thus be used to produce the
desired intention.
Many different intervention methods can
and have been used successfully in the context
of the TPB. Among other strategies, investi-
gators have, for example, been able to change
intentions and behavior by enrolling indi-
viduals in an intensive two-week workshop
designed to change job-search strategies (Van
Ryn & Vinokur, 1992), challenging misconcep-
tions about testicular self-examination
(Brubaker & Fowler, 1990) and modifying situ-
ational factors by introducing a pre-paid bus
ticket to encourage bus use (Bamberg et al.,
2003). In fact, investigators utilizing the TPB or
other ‘reasoned action’ approaches have
borrowed techniques and strategies from
various sources, including CBT and social
learning or social cognitive theory (SCT;
Bandura, 1986). To illustrate, consider some of
the techniques that were used to bring about
behavioral change in two intervention studies
based on a reasoned action approach. Both
were concerned with increasing condom use
with main and occasional partners. One (the
CDC AIDS Community Demonstration
Projects Research Group, 1999; Fishbein et al.,
1997) was a community level intervention
where volunteers from the community distrib-
uted newsletters that contained the inter-
vention materials (the AIDS Community
Demonstration Projects; ACDP) while the
other (Fishbein et al., 2001; Kamb et al., 1998)
was conducted in STD clinics and the inter-
vention was delivered one-on-one by trained
counselors (Project RESPECT).
In the ACDP, the main intervention
materials were role model stories designed to
influence outcome expectancies, perceived
norms or self-efficacy. The stories were
provided by members of the community who
related how they had changed their beliefs or
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FISHBEIN & AJZEN: THEORY-BASED BEHAVIOR CHANGE INTERVENTIONS
behaviors regarding condom use. The stories
were targeted at variables relevant to the
community and were designed for a given stage
in the change process. Specifically, formative
research was conducted to elicit accessible
behavioral, normative and control beliefs; to
classify the population along a stage of change
continuum; and to identify the accessible beliefs
that discriminated between people at different
stages. Because each community newsletter
contained two or three role model stories, it was
possible to target different stories to subpopu-
lations at different stages of change. Clearly,
the intervention used a mixture of techniques:
it relied on a reasoned action approach to
identify the critical variables or beliefs to be
changed, it borrowed from the transtheoretical
stages of change model (Prochaska &
DiClemente, 1983) to segment the target popu-
lation and it drew from social cognitive theory
for the use of modeling.
Very different intervention methods were
employed in Project RESPECT. The inter-
vention was delivered by trained counselors
who, through a series of cued and uncued
open-ended questions, identified the behav-
ioral, normative or control beliefs that seemed
to be preventing a given client from using
condoms. For example, based on formative
research, a set of salient advantages and
disadvantages of consistent condom use were
identified. These perceived outcomes were
then put on cards and the clients were asked to
indicate their agreement or disagreement that
each outcome would occur, as well as to specify
any other advantages or disadvantages they
could think of. Clients were verbally reinforced
for endorsing or mentioning outcomes
supportive of condom use. Beliefs that
opposed condom use were challenged and
discussed. In addition, participants received
skill training in both condom use and condom
negotiation, and were asked to set short-term
goals to be carried out between intervention
sessions. Thus once again we find that the
intervention used a number of different
strategies (e.g. role-playing, interactive ques-
tioning, learned mastery experiences) to bring
about changes in behavioral, normative and
control beliefs, changes that were found to be
reflected in intended and actual condom use.
It should be clear that many different
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Page 29
strategies can and have been used to influence
intentions and actions in the context of the TPB,
and perhaps more importantly, that different
techniques may be needed in different contexts.
Thus, many strategies that can effectively be
used in face-to-face situations are often not
applicable in community level interventions. In
fact, as Hobbis and Sutton themselves note,
CBT strategies such as mastery exercises (both
within and outside of the intervention session),
‘Socratic questioning’, skills training and role-
playing lend themselves more easily to face-
to-face than to broad-based community
interventions. Moreover, different strategies
may have to be used at different stages of behav-
ior change.
These considerations bring us back to the
distinction between changing intentions (the
primary goal of TPB interventions) and helping
people to carry out their intentions (the
primary goal of CBT). It may be argued that
producing favorable intentions is, for certain
behaviors and for some individuals, not enough
to produce a change in the target behavior. In
these instances, two interventions may be
required, one to produce the desired intention
and another, very different intervention to
facilitate performance of the intended behav-
ior. A simple procedure to accomplish the latter
task is to ask participants to formulate an
implementation intention (Gollwitzer, 1999),
i.e. to specify when, where, and how they plan
to perform the intended behavior (see Higgins
& Conner, 2003 for an example application in
the context of the TPB). The techniques devel-
oped for Cognitive Behavior Therapy can simi-
larly be used to help participants carry out a
previously formed intended behavior or reach
an existing goal.
The question of interest, then, is not whether
techniques developed for Cognitive Behavior
Therapy can be used in TPB interventions,
because clearly they can. In fact, in the context
of the TPB, it is possible to use virtually any
available intervention method irrespective of its
theoretical origin. Hobbis and Sutton, however,
suggest that cognitive behavior theory offers
guidelines for effective behavioral interventions
that go beyond methods and procedures.
Whereas the TPB focuses on accessible
behavior-specific beliefs, CBT ‘postulates
different kinds of beliefs at different levels of
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JOURNAL OF HEALTH PSYCHOLOGY 10(1)
consciousness, from core beliefs at the deepest
level to automatic thoughts at the most
conscious level’ (p. xx). However, as Hobbis and
Sutton point out, automatic thoughts at the
most conscious level are similar to accessible
behavioral, normative, or control beliefs in the
TPB. Nevertheless, even at the level of auto-
matic thoughts, CBT suggests that there are
other beliefs that are not behavior-specific,
beliefs that may be important determinants of
behavior.
Thus, Hobbis and Sutton’s discussion implies
that the TPB is incomplete because it fails to
deal with beliefs at different levels of conscious
awareness, that are not behavior-specific. More-
over, they suggest that interventions could be
made more effective by considering beliefs at
different levels (e.g. ‘rules for living’ and core
beliefs) as potential targets. However, they also
note that addressing core beliefs may be appro-
priate only when trying to change dysfunctional
behaviors related to enduring mental health
problems, and that attempts to change core
beliefs in a normal population may have damag-
ing consequences for the participants and is thus
fraught with ethical concerns. These problems
can be avoided, according to Hobbis and Sutton,
by working at the level of less deep-seated auto-
matic thoughts (i.e. at the level of TPB’s behav-
ior-specific beliefs), an approach they deem
sufficient for most behavior change inter-
ventions based on CBT.
The basic argument, then, seems to be that,
although behavioral interventions should
perhaps avoid core beliefs, they could benefit
from targeting beliefs that are more funda-
mental and less behavior-specific than the
behavioral, normative and control beliefs
contained in the Theory of Planned Behavior.
From our perspective, this suggestion is
misguided. In the context of the TPB, core
beliefs and other fundamental assumptions
about the self are considered to be background
factors comparable to personality traits, values,
level of education, social status, etc. These types
of factors can influence intentions and actions
indirectly by their impact on behavioral, norma-
tive and control beliefs. Although the funda-
mental beliefs about the self-considered in CBT
may provide insight into the origins of currently
accessible behavioral, normative or control
beliefs, interventions in the context of the TPB
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Page 30
are directed at the behavior-specific beliefs
themselves. We are not aware of any empirical
research to date to support the proposition that
behavior-specific beliefs cannot be changed
without first addressing fundamental assump-
tions about the self or without going back even
further to underlying core beliefs.
The role of core or fundamental beliefs and
the need to change them in order to influence
behavior is in many ways analogous to the role
of prejudice toward an ethnic, religious or
other group and its effect on behavior with
respect to members of that group. If we were
interested in increasing the probability that
African Americans will be hired, would we be
better off trying to make employers’ attitudes
toward African Americans more favorable (i.e.
decrease their prejudice), or should we try to
change their behavioral, normative and control
beliefs concerning the behavior of interest, i.e.
hiring African Americans? A reasoned action
approach suggests that changing behavior-
specific beliefs is a much more effective strat-
egy than targeting a background factor, such as
general prejudice. For one, as in the case of
core beliefs, it is much more difficult to change
deep-seated prejudice than it is to change
behavior-specific beliefs. Moreover, even if we
succeeded in reducing prejudice, there is no
assurance that this change in general attitudes
will find expression in a particular behavior of
interest, such as hiring decisions (Ajzen &
Fishbein, in press). It is of course conceivable
that, after modifying some of their behavioral,
normative or control beliefs, strongly preju-
diced individuals may simply find other beliefs
(or reasons) not to hire African Americans.
Fortunately, at least in the health domain,
TPB-based intervention studies have not found
this to be a major problem. As noted earlier,
these studies have shown that TPB-based
interventions have been very successful.
Changes in behavior-specific beliefs are found
to produce corresponding changes in attitudes,
subjective norms and perceived behavioral
control, and that these changes, in turn, influ-
ence intentions and actions (see, for example,
Fishbein et al., 2001).
In conclusion, we agree that the techniques
and strategies developed for Cognitive Behav-
ior Therapy can be usefully applied to behavior
change interventions based on the Theory of
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FISHBEIN & AJZEN: THEORY-BASED BEHAVIOR CHANGE INTERVENTIONS

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