Motivating Behavior Change What Really Works?

Transcription

1 Motivating Behavior Change What Really Works? Pre-Test Practice of Medicine 1 Christine M. Peterson, M.D. David Waters, Ph.D. Do You Know? Half of all deaths in the US are attributable to personal behavior, including: Tobacco = 400,000 deaths (one of every 5) Overweight and obesity = 300,000 deaths Alcohol = 100,000 deaths Drugs = 20,000 deaths Other: Homicide, suicide, some accidents, etc. Causes of death Though other causes get a lot of attention: Breast cancer = 46,000 deaths Prostate cancer = 40,000 deaths How to help? How can we help our patients to change their behavior in healthpromoting ways? Lessons We Have Learned ** Information alone doesn t work ** ** Attempts to persuade create resistance ** Why is that? 1

2 Why do people have negative habits? For patients and physicians, it is not objective health concerns which shape their account of the good life, it is their understanding of the good life which shapes what they see as health concerns. People are more motivated by what they want, than by what they know. Seedhouse D.1997; Health promotion: philosophy, prejudice, practice. Why do people have negative habits? External factors: life stresses Internal factors: inadequate coping skills emotional issues physiological reinforcement congruence of behavior and identity Attempts at persuasion just increase the stress! Behavior change = Adult learning Self-initiated and self-directed Practical, useful, applicable to real life (problem-solving) Incorporates feedback about efforts In clinical setting, physician is: partner, not expert; coach, not parent; mirror, not (magic) bullet. How to help? How can behavior change be facilitated by physicians? What helps a person be ready to change their behavior? The answers are in the patient! How do people actually change? Stages of change model (Prochaska and DiClemente) Precontemplation Contemplation Preparation Action Maintenance Relapse Physician s role in behavior change Goal = Help patient move ahead to the next stage First, accurately assess patient s current stage Then, facilitate movement to next stage 2

3 Assessment: Precontemplation Denial Reluctance Other-defined Reactance Argument I have some concern, but if you don t, I ll accept that. [Strategy: When the patient is ready, I ll be here.] Assessment: Contemplation Openness Weighs pros and cons Dabbles in action Can be obsessive Would you like to work on this with my help? ] [Strategy: Go slow, reflect, don t rush, nurture the idea.] O'Connell D., Ch. 16 Behavior Change in Feldman, Christensen "Behavioral Medicine in Primary Care" Assessment: Preparation Understands need for change Begins to commit Can picture overcoming obstacles May procrastinate How can I help as you get ready? [Strategy: Don t jump too fast, don t assume too much; don t take over.] Assessment: Action Describes plan Follows a plan Shows commitment Resists slips Remains vulnerable What do you need from me to keep this going? [Strategy: Stay positive and supportive, help with weak spots.] Assessment: Maintenance Has accomplished Notes improvement Aware of need for vigilance May lose ground Lifestyle may preclude relapse I m rooting for you. [Strategy: Look for lessons from past for future use.] Assessment: Relapse Returns to problem behavior Begins as slips Cycles back to earlier stage Needs help to shorten relapse I m not discouraged; let s talk about when not if. [Strategy: Do you want to stay on it and start again?] O'Connell D., Ch. 16 Bahavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care" 3

4 Roadblocks to Behavior Change Moralizing ( shoulds ); Persuading; Disagreeing, judging, blaming; Warning, threatening; Ordering, directing, commanding; Shaming, labeling; Challenging with questions; Withdrawing, humoring. More Roadblocks to Behavior Change Giving advice, suggestions, solutions; Agreeing, approving, praising; Reassuring, consoling; Interpreting, analyzing. Fearful Information: No one wants it! ONLY WHEN PATIENT REQUESTS, provide information s interest : What have you heard about.? I wonder, would you be interested in knowing more about. Avoid the Yes, but trap. Link Behavior with Outcome; Establish Agenda The patient s agenda! Ask directly about patient s goals. Link patient s desired health outcome to a specific patient behavior: You have [condition]...and that is causing your [symptom or problem]. I think it might help to consider [behavior change]... Establish patient s agenda: What do you think? Avoid assigning physician s agenda. Stages of change model (Prochaska and DiClemente) Precontemplation Contemplation Preparation Action Maintenance Relapse 4

5 Adult behavior change: What to do? Why to do it? (= ) How to do it? ( = ) (Why?) Starting point I should, but I can t. Huh? I m ready! I could, but why should I bother? (How?) Ending point A change in importance usually happens first. Relapse Action Preparation Contemplation Maintenance The theory... Precontemplation The reality! The real reality! 5

6 Key Questions for Readiness - 1 What do you think has to change? What does this mean for you about your (habit)? What are your options? What do you think you will do? Key Questions for Readiness - 2 What s the next step for you? What would be some of the good things about making a change? Where does this leave you? Link Behavior with Outcome; Establish Agenda The patient s agenda! Ask directly about patient s goals. Link patient s desired health outcome to a specific patient behavior: You have [condition]...and that is causing your [symptom or problem]. I think it might help to consider [behavior change]... Establish patient s agenda: What do you think? Avoid assigning physician s agenda. Establish Ambivalence; Pros and Cons Examine pros and cons - help patient identify problem area or area of concern Good things less good things about current behavior Be aware of threat of loss of freedom Avoid arguing Re-state their reasoning for and against change Establish Ambivalence; Develop Discrepancy Have patient describe the discrepancy between their current behavior and what they have told you is important to them ambivalence. Have them present the reasons for change in terms of their desired outcome Express empathy without accepting the status quo. Moving Beyond Precontemplation Denial Reluctance Other-defined Reactance Argument Permission Inquiry Discrepancies Concern Asks pt. to think between visits O'Connell D., Ch. 16 Behavior Change in Feldman, Christensen "Behavioral Medicine in Primary Care" 6

7 Moving Beyond Contemplation Openness Weighs pros and cons Dabbles in action Can be obsessive Elicits pt s perspective Helps with pros and cons Asks about promoters Suggests trials Moving Beyond Preparation Understands need for change Begins to commit Can picture overcoming obstacles May procrastinate Summarizes pt s reasons Negotiates a start date Encourages public statement Arranges followup Moving Beyond Action Describes plan Follows a plan Shows commitment Resists slips Remains vulnerable Shows interest Supports pros Slip vs relapse Anticipates handling slip Helps to modify Arranges follow-up Staying with Maintenance Has accomplished Notes improvement Aware of need for vigilance May lose ground Lifestyle may preclude relapse Physician Shows support Inquires re feelings Asks about slips Helps plan for intensifying effort Supports lifestyle Reflects on permanence of change Recovering from Relapse Returns to problem behavior Begins as slips Cycles back to earlier stage Needs help to shorten relapse Frames as learning opportunity Asks for specifics Reminds reasons are valid When not if pt. changes again Normalizes O'Connell D., Ch. 16 Bahavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care" Roadblocks to Moralizing ( shoulds ); Persuading; Disagreeing, judging, blaming; Warning, threatening; Ordering, directing, commanding; Shaming, labeling; Challenging with questions; Withdrawing, humoring. 7

8 More Roadblocks to Giving advice, suggestions, solutions; Agreeing, approving, praising; Reassuring, consoling; Interpreting, analyzing. Resistance (description) Arises whenever there is tension or disagreement Results from traps: Taking control away Misjudging importance, confidence or readiness Meeting force with force Manifests in: ignoring, inattention, discounting, excusing, blaming, hostility, splitting, etc. It is a sign that rapport needs attention. Resistance (management) It is your cue to change strategies. Strategies: Emphasize personal choice and control Reassess stage and/or readiness (importance, confidence) Back off and come alongside the patient Stay committed but curious. It s like dancing - you have to stay relaxed. Maintaining Behavior Change: The 3 F s Timely follow-up by physician (or team member) Feedback Non-judgmental When you, then occurred. Focused on patient s agenda Post-Test 8