Motivating Behavior Change What Really Works? Practice of Medicine Christine M. Peterson, M.D.
Pre-Test
Do You Know? Half of all deaths in the US are attributable to personal behavior, including: Tobacco = 400,000 deaths (one of every 5) Alcohol = 100,000 deaths Drugs = 20,000 deaths Other: Homicide, suicide, some accidents, etc.
Causes of death Though other causes get more attention Heart disease = 740,000 deaths (though at least 5-20% could be prevented or delayed with dietary and activity changes) 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?
Models of behavior change Reasoned action theory Health belief model Decisional balance model Stages of change Others
Lessons We ve Learned - I Untrained physicians have little or no effectiveness in motivating behavior change People are not always as concerned about their health as you are People often come to the doctor to try to get support for what they re already doing; not necessarily to get advice about change ** Information alone doesn t work ** ** Attempts to persuade create greater resistance **
Lessons We ve Learned - II No advice you can give will be entirely new to the patient To promote behavior change, listening is far more important and effective than giving advice To promote behavior change, asking questions is far more important and effective than giving advice Follow-up with feedback helps patients remain motivated
Behavior change = Adult learning Self-initiated and self-directed Practical, useful, applicable (problem-solving) Incorporates feedback Physician is: partner, not expert; coach, not parent; mirror, not (magic) bullet.
Evidence on effectiveness of counseling about health Risk reduction measures work, but it is unclear whether primary care counseling by untrained physicians actually promotes risk reduction. Training does improve the physician s ability to help patients initiate and sustain health behavior change.
Case Scenario AB is a 45 year old nurse who is overweight (at 5 6 and 160 lbs., her BMI = 26). Her BP is 130/85. She has a healthy low-fat diet, but she does not exercise regularly ( I don t have the time! ).
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. Not: A great day is one on which I ve exercised for half an hour ; But: I exercise every day in order to have energy and stamina to enjoy my life. Seedhouse D.1997; Health promotion: philosophy, prejudice, practice.
Why do people have negative habits? Need for stress reduction External stressors Internal factors inadequate coping skills emotional issues physiological reinforcement congruence of behavior and identity
How to help? How can behavior change be facilitated? What helps a person be ready to change their behavior?
Adult behavior change: What to do? Why to do it? (= Importance ) How to do it? ( = Confidence )
What is readiness? Ending point High Importance (Why?) Low Should, but can t Huh? Ready! Could, but why bother? Starting point Low Confidence (How?) High
What is readiness? High Importance A change in importance usually happens first. Low Low Confidence High
What is readiness? Stages of change model (Prochaskaand DiClemente) Precontemplation Contemplation Preparation Action Maintenance Relapse
Stages of Change defined
What is readiness? High Importance Relapse Action Preparation Maintenance The theory... Low Contemplation Precontemplation Low Confidence High
What is readiness? High Importance The reality! Low Low Confidence High
What is readiness? High Importance The real world! Low Low Confidence High
Goal of counseling Help patient move ahead in readiness
A method for consultation about health behavior change Patient-centered Respectful Directive (method, not message) Negotiation Non-blaming How more than What
Tasks (often simultaneous) 1. Establish Rapport 2. Elicit Agenda 3. **Assess Readiness (i.e. importance and confidence), then build on that base 4. **Avoid or reduce Resistance
1. Rapport How? Open-ended questions Non-judgmental attitude Appropriate feedback (i.e. reflection, not evaluation) What occurs? Patient sees you as an ally and not a boss to be pleased Patient works with you to consider an issue Patient feels comfortable and listened to Physician s self-esteem is not dependent on pt s change
2. Agenda The patient s! Ask directly: What aspect of your health would you like to work on? Avoid premature focus on physician s agenda Bring up as question for patient: You have... I think it might help to consider... What do you think?
3. Assessing Readiness Purpose: Elicit self-motivating statements (positive reasons for change) by patient. [Self-motivating statement = what they want to do and why.]
Assessing Readiness ❶ Ask scaling questions about importance: Rate this issue s importance to you on a scale of 0 to 10. Why so high (or so low)? What would it take for it to seem a little more important? Can you go higher?
Assessing Readiness ❷ Ask scaling questions about confidence: On a scale of 0 to 10, how confident are you that you can make this change? Why so high (or low)? What would it take for you to feel a little more confident?
Assessing Readiness ➌ Examine pros and cons - help patient identify problem area or area of concern Start with patient s ideas about the good things about current behavior, then ask about less good things Be aware of psychological reactance (to threat of loss of freedom) Avoid arguing for change Re-state their reasons for change
Assessing Readiness ➍ Explore patient s concerns about the change Open questions Key questions Real, not rhetorical To facilitate their thinking, not get a particular answer Ideally, these are freeing to patient
Key Questions for Readiness What do you think you will do? What does this mean about your (habit)? What do you think has to change? What are your options? What s the next step for you? What would be some of the good things about making a change? Where does this leave you?
Assessing Readiness ➎ Have patient develop the discrepancy between their current behavior and what they have told you is important to them Have them present the reasons for change Express empathy [ by reflection, legitimation, personal support, partnership, respect] without accepting the status quo.
Assessing Readiness ➏ Brainstorm with (not for) patient Many possible courses of action: Let s look at some of the options together. Patient s ideas supplemented by some things that you know have worked for other people You will be best judge of what works for you. Which one suits you the best? Convey optimism and willingness to re-examine
Assessing Readiness ➐ Remember successes (support selfefficacy) What made most recent successful attempt different from previous efforts? Could that difference be deliberately built into a new plan? Break into components and ask which one patient feels most confident about
Fearful Information: Who wants it? ➑ ONLY WHEN PATIENT REQUESTS, provide information Inquire about patient s interest in receiving information; pique his/her curiosity: What have you heard about.? I wonder, would you be interested in knowing more about. Avoid setting Yes, but trap for yourself Sometimes you ll need to wait till the next visit...
Roadblocks to Confidence Ordering, directing, commanding; Warning, threatening; Giving advice, suggestions, solutions; Persuading; Moralizing ( shoulds ); Disagreeing, judging, blaming;
More Roadblocks to Confidence Agreeing, approving, praising; Shaming, labeling; Interpreting, analyzing; Reassuring, consoling; Challenging with questions; Withdrawing, humoring.
4. Resistance Arises whenever there is tension or disagreement about behavior change. Traps: Taking control away Misjudging importance, confidence or readiness Meeting force with force Shows in a range of ways: ignoring, inattention, discounting, excusing, blaming, hostility, splitting, etc. Resistance from the patient is a sign that rapport needs attention.
4. Resistance It is your cue to change strategies. Strategies: Emphasize personal choice and control Reassess importance, confidence or readiness Back off and come alongside the patient Avoid by maintaining committed but curious state of mind 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
Is behavior change always beneficial? Sometimes other work needs to be done first Underlying fears Meaning of illness How behavior fits into typical day
Lessons We ve Learned - I Untrained physicians have little or no effectiveness in motivating behavior change People are not always as concerned about their health as you are People come to the doctor to try to get support for what they re already doing; not to get advice about change ** Information alone doesn t work ** ** Attempts to persuade create greater resistance **
Lessons We ve Learned - II No advice you can give will be new to the patient To promote behavior change, listening is far more important and effective than giving advice To promote behavior change, asking questions is far more important and effective than giving advice Follow-up with feedback helps patients remain motivated
Motivating Behavior Change Establish Rapport Elicit Agenda Assess Readiness Avoid Resistance [RA(Re) 2 ]
Post-Test