Are your clients being defensive? If so, self-affirmation may help.

Peter Harris and Ian Hadden, The Self-Affirmation Research Group, School of Psychology, University of Sussex, UK

Have you ever been reluctant to face up to something you’d rather ignore? Maybe your fondness for something bad for you that you eat too often or your tendency to avoid health check-ups? Well, you’re not alone. Most of us think we are generally quite sensible and competent people. So, being told that something we do is not really sensible or competent can be quite challenging. As a result, we can be pretty skilled at resisting messages we’d prefer not to hear.

Unfortunately, resisting messages about risks to our health – such as the effects of being overweight or of smoking or of not adhering to a medication regimen – can have serious consequences for both quality and length of life. So, how can you as a health practitioner help clients take on board health messages that they’d prefer to ignore? A technique known as self-affirmation might help.

A self-affirmation is an act that helps someone reassure themselves that they are a good and competent person. This reduces their need to protect themselves from a health message that implies they are not, which helps them to treat the message more objectively and to focus on its relevance and implications for them personally. This, in turn, may encourage them to take steps to address it. You find out more about the theory underlying self-affirmation here.

Almost anything qualifies as a self-affirmation, including reminders of one’s good deeds, special talents, character strengths, or important social relationships. Currently the most-researched technique for inducing self-affirmation is a values affirmation in which people answer questions or write about their most important values, such as being generous or honest.

The evidence that self-affirmation can work comes from experimental studies. Participants who have been prompted to self-affirm (often on only one occasion) tend to believe health messages more and feel readier to change compared to those who have not. Self-affirmations have also resulted in changes in behaviour several months later. Benefits of self-affirmation have been found for a wide range of health behaviours including alcohol consumption, cigarette smoking, unsafe sex, the consumption of mercury in oily fish, doping in sport, fruit and vegetable consumption, physical activity, dental flossing, and sun protection. Some studies have found that the effects can even be strongest among those who are hardest to engage, such as people who drink or smoke most or are keen to tan.

Work has mainly been prevention research in young, non-patient samples, but there have been some studies with patient groups too. For example, haemodialysis patients who were asked to recall past acts of kindness showed improved phosphate control and greater adherence to fluid intake guidance over the following 12 months than those who were not. Hypertensive African American patients showed improved medication adherence after receiving an intervention that included a self-affirmation component.

So how might you use self-affirmation in practice? Let’s consider a consultation in which you want to deliver a health message that might challenge your client e.g., about the harmful effects of their smoking or of not taking their medication as prescribed. If you have 5-15 minutes available and literacy is not an issue, you could try a simple values affirmation exercise at the start of the consultation. You could ask your client to write or talk privately about their most important value and why it is important to them, or to complete some scales designed to remind them of their values. Once they have done this, you could then deliver the health message about the risks of smoking or non-adherence.

If time or literacy are issues, a brief kindness questionnaire has been widely used to induce self-affirmation. Some other brief techniques have also been recently developed. These include attempts to reduce the values affirmation to a few key sentences, to use value questionnaires , to integrate the affirmation with the message, or to help people form the intention to self-affirm when threatened. However, at best these have been used in only a few studies so far and we know little about how well they work.

You can find some of these manipulations on the resources page of our Self-Affirmation Research Group (SARG) Website at the University of Sussex. (They are in English.) We are happy to advise on these and or other self-affirmation techniques you might be considering.

Points for practice

1) When should I consider using self-affirmation?

Consider using self-affirmation when you need to give a client an important message about their health that you think they might be inclined to ignore or reject. In these cases, self-affirmation may increase the likelihood that they will accept the message and take appropriate action.

2) How can I best use self-affirmation in practice?

It may be best to use self-affirmation when working one-to-one or in small groups and with time at your disposal. In these cases, you could precede delivery of a health message by one of the values affirmation methods that have been tried and tested before. See the resources page on the SARG website for examples in English of materials that you could use.

Discuss with your client whether they’d prefer to do the affirmation privately or with you present. Try to encourage them to choose to do the self-affirmation exercise rather than requiring them to do it. There is some evidence that freedom to choose may be important in helping the intervention to work.

3) What should I be cautious of?

Make sure your health message is persuasive. Self-affirmation should encourage your clients to be more open-minded, which means they are more likely to accept a strong message, but may also be more likely to reject a weak message.

Use self-affirmation with those clients you are confident will otherwise resist your message. There is some evidence that self-affirmation may not work or even be counterproductive if participants are not being defensive in the first place.

If in doubt, seek advice – we are here to help.