Motivating Behavior Change What Really Works? Practice of Medicine I Christine M. Peterson, M.D. Terry Saunders, Ph.D. Pre-Test Among deaths in the U.S. that occur prematurely, the per cent attributable to personal behavior is 1. 1 2. 2 3. 5 4. 7 1 2 5 7 1
Which of the following unhealthy behaviors ranks first in contributing to deaths in the U.S.? 1. Alcohol abuse 2. Drug abuse 3. Tobacco use Alcohol abuse Drug abuse Tobacco use You can increase the patient s confidence in his/her ability to change when you give him/her a wide variety of suggestions. 1. True 2. False True False If your patients resists change, you can help them by pointing out their resistance and maintaining a strong position for change. 1. True 2. False True False 2
For the following 3 questions, label each statement as a facilitator or deterrent for motivating a patient to change an unhealthy behavior. Letting the patient indicate interest in information before providing it E.g., Would you like to learn more about exercise and its effects on your condition? 1. Facilitator 2. Deterrent Facilitator Deterrent Giving praise for following the physician's recommendations E.g., I m so pleased that you followed my advice and lost ten pounds. 1. Facilitator 2. Deterrent Facilitator Deterrent 3
Soliciting the patient s s ideas about negative aspects of the potential change E.g., Can you tell me what you ve heard about how people feel when they first stop smoking? 1. Facilitator 2. Deterrent Facilitator Deterrent Do You Know? Half of all deaths in the US are attributable to personal behavior, including: Tobacco = 435,000 deaths (one of every 5) Poor diet and physical inactivity = 365,000 deaths Alcohol = 85,000 deaths Drugs = 17,000 deaths Other: Homicide, suicide, some accidents, etc. Mokdad et al., JAMA 2004;291(10)1238-1245. Do You Know? Half of all patient visits require a behavior change on the part of the patient as part of treatment Meds Diet Exercise Safer sex practices Substance avoidance Etc., etc., etc. 4
Life experience In observing others who have changed a health-related behavior, what seemed to work? Motivational Interviewing A directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. - Rollnick and Miller, 1995 Goals of this section of PoM To gain a better understanding of the difficulty and complexity of behavior change To practice approaching a patient in an open and non-judgmental manner 5
Behavioral objectives for students To maintain an open and curious approach To learn about techniques useful in motivating behavior change, esp. exploring ambivalence and limiting resistance To learn about own attitudes and beliefs about changing behavior THESE WILL BE ASSESSED IN YOUR PoM GROUP THIS WEEK. Research findings: Behavior change = Adult learning Self-initiated and self-directed Practical, useful, applicable to real life (problem-solving) Incorporates feedback about efforts The power to change is in the patient. In clinical settings, physician should be: partner, not expert; coach, not parent; mirror, not magic bullet. 6
How do people actually change? Stages of change model (Prochaska and DiClemente) Precontemplation Contemplation Preparation / Planning Action Maintenance Relapse Readiness for change: What to do? Why to do it? (= Importance ) How to do it? ( = Confidence ) What is readiness? High Importance (Why?) Low I should, but I can t. Huh? I m ready! I could, but why should I bother? Ending point Starting point Low Confidence (How?) High 7
What is readiness? High Importance A change in importance usually happens first. Low Low High Confidence What is readiness? High Relapse Action Maintenance Importance Preparation Contemplation The theory... Low Precontemplation Low Confidence High What is readiness? High Importance The reality! Low Low High Confidence 8
Behavior Change Job Descriptions Facts: physician s job Personal meaning: patient s job 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 ( double DARES ) Our patient A 55 year old woman who is 5 7 tall and weighs 190 lbs (BMI = 32). Her BP is 148/96. She has Type 2 diabetes. You know that losing weight is almost certain to lower her BP and improve her glucose tolerance perhaps to normal levels. 9
Assessment: Precontemplation Patient Denial Reluctance Other-defined Reactance Argument O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care" Assessment: Contemplation Patient Openness Weighs pros and cons Dabbles in action Can be obsessive O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care" Assessment: Preparation / Planning Patient Understands need for change (= IMPORTANCE) Begins to commit Can picture overcoming obstacles (= CONFIDENCE) May procrastinate O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care" 10
Assessment: Action Patient Describes plan Follows a plan Shows commitment Resists slips Remains vulnerable O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care" Assessment: Maintenance Patient Has accomplished Notes improvement Aware of need for vigilance May lose ground New lifestyle may help make relapse less likely O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care" Assessment: Relapse Patient Returns to problem behavior Begins as slips Cycles back to earlier stage Needs help to shorten relapse O'Connell D., Ch. 16 Behavior Change in Feldman and Christensen "Behavioral Medicine in Primary Care" 11
Assessing readiness High Relapse Action Maintenance Importance Preparation Contemplation Low Precontemplation Low Confidence High After assessment, how to help? How can behavior change be facilitated by physicians? The answer is in the patient! Establish the Patient s Agenda The patient s agenda! Ask directly about patient s goals. Avoid assigning physician s agenda. 12
Link Behavior with Outcome 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]... Reinforce the Patient s Agenda Emphasize the patient s agenda: What do you think? What would you like to do? 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 ( double DARES ) 13
Yet another mnemonic: Double DARES Develop Discrepancy Avoid Argument Roll with Resistance Express Empathy Support Self-efficacy Develop Discrepancy; (Establish Ambivalence) 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 Establish Ambivalence; Pros and Cons Examine pros and cons of the current vs. the desired behavior Good things less good things about current behavior Re-state their reasoning for and against change 14
Avoid Arguing Be aware of threat of loss of freedom It should never be you against the patient; it should be the part of the patient that wants to change against the part that doesn t. Roll with Resistance Arises whenever there is tension or disagreement Results from traps: Taking control away Misjudging importance, confidence or readiness Meeting force with force Roll with Resistance Manifests in: Yes, but or in subtler ways ignoring, inattention, discounting, excusing, non-compliance blaming, hostility, splitting, etc. It is a sign that rapport needs attention. 15
Roll with Resistance Resistance is your cue to change 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. Express Empathy Express empathy without unmindfully accepting the status quo. I can understand that you might feel that way. Yes, it sounds pretty difficult, doesn t it? Support Self-efficacy Fearful Information: No one wants it! Provide information ONLY WHEN PATIENT REQUESTS IT. Patient s interest : What have you heard about.? I wonder, would you be interested in knowing more about. Avoid having the patient put you in the Yes, but trap. 16
Roadblocks to Behavior Change Disagreeing, judging, blaming; Warning, threatening; Shaming, labeling. More Roadblocks to Behavior Change Moralizing ( shoulds ); Persuading; Challenging with questions; Directing, ordering, commanding. More Roadblocks to Behavior Change Giving advice, suggestions, solutions; Agreeing, approving, praising based on physician s agenda. 17
More Roadblocks to Behavior Change Reassuring, consoling; Interpreting, analyzing; Withdrawing, humoring. 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 18
Among deaths in the U.S. that occur prematurely, the per cent attributable to personal behavior is 1. 1 2. 2 3. 5 4. 7 1 2 5 7 Which of the following unhealthy behaviors ranks first in contributing to deaths in the U.S.? 1. Alcohol abuse 2. Drug abuse 3. Tobacco use Alcohol abuse Drug abuse Tobacco use You can increase the patient s confidence in his/her ability to change when you give him/her a wide variety of suggestions.. 1. True 2. False True False 19
If your patients resists change, you can help them by pointing out their resistance and maintaining a strong position for change. 1. True 2. False True False For the following 3 questions, label each statement as a facilitator or deterrent for motivating a patient to change an unhealthy behavior. Letting the patient indicate interest in information before providing it E.g., Would you like to learn more about exercise and its effects? 1. Facilitator 2. Deterrent Facilitator Deterrent 20
Giving praise for following the physician's recommendations E.g., I m so pleased that you followed my advice and lost ten pounds. 1. Facilitator 2. Deterrent Facilitator Deterrent Soliciting the patient s s ideas about negative aspects of the potential change E.g., Can you tell me what you ve heard about how people feel when they first stop smoking? 1. Facilitator 2. Deterrent Facilitator Deterrent Lessons We Have Learned Information alone doesn t work. Attempts to persuade create resistance. Exploring the patient s agenda and relating empathically to their ambivalence about change has been shown to be effective in promoting health behavior change. 21