Chapter 12: Promoting Behavior Change PDF

Mount Saint Vincent College Access Provided by: Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e Chapter 12: Promoting Behavior Change Jennifer E. Hettema; Christopher Neumann; Bradley Samuel; Daniel S. Lessler; Christopher Dunn OBJECTIVES Objectives Describe the importance of health behavior change counseling in medical settings. Identify barriers and opportunities for promoting behavior change with vulnerable and underserved populations. Review an evidencebased and practical approach to behavior change counseling. INTRODUCTION Mr. Nguyen is a 34yearold man, Vietnamese. He lives with his girlfriend and works as a line cook. He drinks six to nine drinks several nights per week but does not meet criteria for an alcohol use disorder. The primary goal of health care is to reduce morbidity and mortality through the prevention and treatment of disease. Healthcare providers are also charged with promoting behavioral change strategies that support wellness. When thinking of causes of death, diseases such as heart disease, cancer, and respiratory disease come to mind. Underlying these causes of death, however, often lie modifiable behavioral risk factors, such as tobacco use, poor diet and physical activity, and alcohol misuse.1 Termed “actual causes of death,” these preventable behaviors account for about half of all deaths and underscore the importance of prioritizing the promotion of behavior change in healthcare settings. Furthermore, psychosocial issues, such as mental illness, substance abuse, trauma, and poverty, when left unaddressed by the healthcare system, can cause and exacerbate illness among the world’s most vulnerable populations. Two decades of behavioral research indicate that physicians can successfully promote health behavior change in their patients.2,3 Healthcare providers who understand behavior change theory and who practice a patientcentered approach to behavior change counseling achieve the best outcomes. MISPERCEPTIONS When envisioning the promotion of behavior change, it is common to picture a prototypical counseling setup, which involves a series of long intervention sessions focused on specific psychosocial stressors or mental health disorders. It is no wonder that many providers choose to avoid behavior change counseling altogether, when this is their perception of what promotion of behavior change entails. Providers in medical settings typically have neither the time nor the specialty training to operate using a counseling paradigm. However, empirical evidence suggests that relatively brief interventions can have powerful effects and that a single brief empathic discussion can promote long lasting behavior change.4 For many areas, interventions as short as 5 minutes can change important health behaviors.5 Another barrier to the promotion of behavior change in medical settings may be perceptions regarding who is appropriate for intervention. For example, when thinking about a patient who would benefit from behavior change around alcohol, many providers picture a patient with a severe alcohol use disorder, many complicating psychosocial stressors, and a history of unsuccessful quit attempts. While such patients are certainly in need of services and their medical providers should address their alcohol use, they are less likely to respond to brief interventions and more likely to benefit Downloaded 2024218 9:28 A Your IP is 63.247.225.21 from referral to more intensive specialty treatment. such patients are the first, or perhaps to come to mind when thinking aboutDunn behavior Page 1 / 18 Chapter 12: Promoting Behavior Change, Jennifer When E. Hettema; Christopher Neumann; Bradleyonly, Samuel; Daniel S. Lessler; Christopher change McGraw counseling, shy away Terms from engaging in discussions behavior change altogether. However, most of the behaviors ©2024 Hill.providers All Rightsmay Reserved. of Use patients Privacy Policy Noticeabout Accessibility our patients would benefit from changing are less intensive and more modifiable. With the case of alcohol, for example, as many as one in five patients, such as Mr. Nguyen described in the vignette earlier, may be drinking at levels that put them at risk for a range of medical and social consequences, but interventions as short as 5 minutes can change important health behaviors.5 Mount Saint Vincent College Provided by: Another barrier to the promotion of behavior change in medical settings may be perceptions regarding who is appropriateAccess for intervention. For example, when thinking about a patient who would benefit from behavior change around alcohol, many providers picture a patient with a severe alcohol use disorder, many complicating psychosocial stressors, and a history of unsuccessful quit attempts. While such patients are certainly in need of services and their medical providers should address their alcohol use, they are less likely to respond to brief interventions and more likely to benefit from referral to more intensive specialty treatment. When such patients are the first, or perhaps only, to come to mind when thinking about behavior change counseling, providers may shy away from engaging patients in discussions about behavior change altogether. However, most of the behaviors our patients would benefit from changing are less intensive and more modifiable. With the case of alcohol, for example, as many as one in five patients, such as Mr. Nguyen described in the vignette earlier, may be drinking at levels that put them at risk for a range of medical and social consequences, but do not meet criteria for an alcohol use disorder. More than half of alcoholrelated deaths and twothirds of the potential lifeyears lost because of alcohol are among such risky drinkers. This is an example of a phenomenon known as the “prevention paradox,” wherein a large number of people at small risk cause more health burden than a small number of people at greater risk.6 These patients tend to be quite responsive to brief interventions in medical settings. Shifting one’s frame of reference regarding which patients may benefit from behavior change promotion may promote implementation of such practices. VULNERABLE AND UNDERSERVED POPULATIONS Promoting behavior change is especially important with socially vulnerable populations. Behavioral health issues, such as sedentary lifestyle, obesity, and smoking, are more prevalent in people of lower socioeconomic position, and among certain racial and ethnic minorities.7,8 Moreover, physicians are less likely to initiate conversations about health behavior change with lowerincome patients.9 This is the case even though lowincome patients are more likely to report acting on these physician recommendations than are middle and higherincome patients.10 Research suggests that healthcare provider’s attitudes and behavior often differ based on patient socioeconomic status (SES) and ethnic minority status. Providers tend to spend less time, use fewer rapport building statements, speak more quickly, and demonstrate more verbally dominant behavior with ethnic minority patients compared with white patients.11 When working with lower SES patients, providers are also more directive, less collaborative, are less likely to use partnership building statements, and are less likely to initiate conversations about behavior change.9,12 These differences in communication may be due to provider’s attitudes. Providers have reported less trusting attitudes toward ethnic minority patients, viewing patients of lower SES and/or ethnic minority status as less intelligent, more likely to abuse substances, lacking selfcontrol, and having less desire to be physically active.13,14 Differences in provider’s attitudes and behaviors toward ethnic minority and lower SES patients undoubtedly have an impact on engagement, which in turn can affect important patient outcomes. Compounding this issue, ethnic minority patients report less trust in physicians and the medical system compared with white patients.11,15,16 This is important because patient trust is associated with treatment adherence and improved health.17,18 MOTIVATIONAL INTERVIEWING Motivational interviewing is style of communication that can be used by healthcare providers to strengthen a patient’s own motivation and commitment to change.19 Motivational interviewing is a collaborative, goaloriented approach, which encourages providers to pay particular attention to patients’ language regarding change. It has been applied to a range of health behaviors, including medication adherence (in HIV, cardiovascular disease, diabetes, contraception), treatment engagement (continuous positive airway pressure [CPAP] use, group participation, diabetes self management, prenatal care), screening compliance (mammography, sexually transmitted disease, colorectal cancer), and lifestyle management (diet, physical activity, safe sex).20 Motivational interviewing has been found to be effective crossculturally and may even differentially benefit ethnic minority patients.21 In this chapter, we explore four processes inherent to motivational interviewing and how they may be applied to promote behavior change with vulnerable and underserved populations. The four processes include engaging, focusing, evoking, and planning for behavior change (see Box 121). We provide a brief description of each process, as it relates to the promotion of behavior change among vulnerable populations and provide practical strategies for effectively counseling patients in each process. Box 121. The Four Processes of Motivational Interviewing Motivational Interviewing Process Description Downloaded 2024218 9:28 A Your IP is 63.247.225.21 Developing a trusting, respectful, working relationship Page 2 / 18 ChapterEngaging 12: Promoting Behavior Change, Jennifer E. Hettema; Christopher Neumann; Bradley Samuel; Daniel S. Lessler; Christopher Dunn ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Focusing Collaboratively identifying an area of behavior change to explore In this chapter, we explore four processes inherent to motivational interviewing and how they may be applied to promote behavior change with Mount Saint Vincent College vulnerable and underserved populations. The four processes include engaging, focusing, evoking, and planning for behavior change (see Box 121). Access Provided by: We provide a brief description of each process, as it relates to the promotion of behavior change among vulnerable populations and provide practical strategies for effectively counseling patients in each process. Box 121. The Four Processes of Motivational Interviewing Motivational Interviewing Process Description Engaging Developing a trusting, respectful, working relationship Focusing Collaboratively identifying an area of behavior change to explore Evoking Strategically drawing out patient’s own motivations or reasons to change Planning Collaboratively outlining the details regarding how change will occur ENGAGING THE PATIENT The first step in promoting behavior change involves the development of a good patient–provider relationship. Forming a meaningful connection with patients is a necessary precursor to focused behavior change work and remains of central importance throughout the course of the working relationship. Humanistic theory asserts that people are naturally driven to seek health and happiness. Three conditions in therapeutic relationships are necessary to enhance this powerful inner drive toward health: warmth, accurate understanding of the person by the helper, and unconditional positive regard.22 Empirical research also underscores the importance of engaging the patient. A recent metaanalysis of randomized controlled trials evaluating the impact of the patient–provider relationship on validated medical outcomes found a significant positive effect across 13 trials, and the magnitude of the observed effect was nearly double the effect of aspirin in reducing myocardial infarction.23 The costs of failed engagement in promoting behavior change are high. While a range of patient and systems level factors can impact engagement, provider behavior plays a key role. Poor engagement can lead to treatment dropout, poor treatment compliance or medication nonadherence, and failure to make healthy choices for a variety of medical conditions. The issue of engagement may be particularly important for vulnerable populations, for whom both provider and patient behaviors can present barriers to a mutually trusting and respectful relationship. STRATEGIES FOR ENGAGEMENT While we are often focused on the role of the patient in the development of engagement, the provider’s communication style can significantly impact the development of engagement. A number of studies have found that patients are more likely to trust providers who are collaborative, comforting, listen carefully, and explore patient experience of disease and illness.24,25,26,27 A recent metaanalyses examining the relationship between physician communication and treatment adherence found that a communication style which included empathy and rapport building resulted in greater treatment adherence.28 In sum, a collaborative and empathic communication style is key to developing relationships that increase the likelihood of health behavior change, especially in ethnic minority and lower SES populations. In the following subsections, we focus on several concrete strategies that can be used by providers, even in busy clinic settings, to promote engagement. Being Present and Mindful In busy clinic settings, it can be a challenge to be present and mindful with each patient. When working with vulnerable populations, it can be hard to avoid ruminative thinking about challenging patients or barriers to effective care. When pressed with the daunting task of caring for those who are in such great need, it can be easy to neglect important selfcare activities. In medicine, mindfulness is the purposeful and nonjudgmental attention to one’s own experiences, thoughts, and feelings.29 Physician mindfulness has been found to improve patient care and is associated with better rapport building, increased discussion of psychosocial issues, and higher patient satisfaction. Mindfulness has also been found to improve practitioner’s well being, stress levels, and burnout.30,31 Several simple strategies may be used to promote mindfulness with patients (see Box 122). Downloaded 2024218 9:28 A Your IP is 63.247.225.21 Page 3 / 18 Chapter 12: Promoting Behavior Change, Jennifer E. Hettema; Christopher Neumann; Bradley Samuel; Daniel S. Lessler; Christopher Dunn Box 122. Strategies toRights Promote Mindfulness ©2024 McGraw Hill. All Reserved. Terms of Use Privacy Policy Notice Accessibility Taking a moment before each patient to examine thoughts and feelings (e.g., “It’s late in the day; I don’t know if I have any energy left”) In busy clinic settings, it can be a challenge to be present and mindful with each patient. When working with vulnerable populations, it can be hard to avoid ruminative thinking about challenging patients or barriers to effective care. When pressed with the daunting task of Mount caring for those who are in Saint Vincent College such great need, it can be easy to neglect important selfcare activities. In medicine, mindfulness is the purposeful and nonjudgmental attention to Access Provided by: one’s own experiences, thoughts, and feelings.29 Physician mindfulness has been found to improve patient care and is associated with better rapport building, increased discussion of psychosocial issues, and higher patient satisfaction. Mindfulness has also been found to improve practitioner’s well being, stress levels, and burnout.30,31 Several simple strategies may be used to promote mindfulness with patients (see Box 122). Box 122. Strategies to Promote Mindfulness Taking a moment before each patient to examine thoughts and feelings (e.g., “It’s late in the day; I don’t know if I have any energy left”) Maintaining a healthy work–life balance Seeking formal or informal support from professional mentors and peers Purposefully seeking to identify explicit and implicit biases that may impact care. One interesting way of exploring implicit biases can be found at https://implicit.harvard.edu/implicit/ Empathy and Reflective Listening Empathy is a construct that is often discussed as a critical clinical skill for healthcare providers to promote client engagement. Some ambiguity surrounds the term “empathy,” with interpretations ranging from the ability to share the feelings of another to general warm or caring personality traits. In healthcare communication, one helpful way to think of empathy is the extent to which the clinician makes an effort to understand the unique perspective of the patient.19 Frequent and accurate use of reflections, or statements that paraphrase or infer the underlying meaning of what a client has said, is the primary means by which we operationalize empathy. In healthcare settings, provider’s empathy has been found to be predictive of patient outcome across a range of issues. For example, in one correlational study of patients with diabetes treated by family physicians, physicians’ scores on a selfreport scale of empathy were highly predictive of patient control of hemoglobin A1c and lowdensity lipoprotein.32 Provider’s empathy has also been found to be related to outcomes in depression,33 cancer,34 and the common cold.35 Motivational interviewing provides us with guidance on how to empathically listen to our patients using the skill of reflection. During the engagement process, we should rely heavily on the use of reflective listening. Taking the time to understand our patients’ unique situations and perspectives promotes trust and alliance. Reflective listening can also help us ensure accurate understanding, which may be particularly important for vulnerable populations whose cultural and experiential background may differ significantly from the provider, leading to misinterpretation. With reflective listening, providers are essentially making guesses about what patients mean by what they say. However, instead of stating the guess in the form of a question, communication is streamlined by transforming the hypothesis into a declarative statement with a downward inflection at the end. Box 123 provides several examples. As can be seen, there are often multiple possible meanings underlying what a patient has said, and a provider will use his or her understanding of the patient’s individual circumstances and strategic aims to determine what aspect of what the patient has said might be most helpful to reflect. When conducting motivational interviewing, providers are encouraged to use at least two reflections for every question that they ask. Box 123. Examples of Reflective Listening Mrs. Fernandez is a 62yearold woman. She does not work and lives with her adult nephew. She is conversant in English and has poorly controlled Type 2 diabetes Patient Statement “My sugars are probably off the charts.” Provider Guess About Meaning Reflection Do you mean that you are concerned about what you ate for breakfast? You are concerned about what you ate for breakfast. Downloaded 2024218 9:28 A Your IP is 63.247.225.21 you mean that Behavior you haven’tChange, been checking yourE. sugars lately?Christopher Neumann; YouBradley haven’t been checking yourS. sugars lately.Christopher Dunn Page 4 / 18 ChapterDo 12: Promoting Jennifer Hettema; Samuel; Daniel Lessler; ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Mr. Jones is a 55yearold man. He lives with his partner and receives disability. He is HIV+ and struggles with medication adherence and depression. end. Box 123 provides several examples. As can be seen, there are often multiple possible meanings underlying what a patient has said, and a provider Mount Saint Vincent College will use his or her understanding of the patient’s individual circumstances and strategic aims to determine what aspect of what the patient has said Access Provided by: might be most helpful to reflect. When conducting motivational interviewing, providers are encouraged to use at least two reflections for every question that they ask. Box 123. Examples of Reflective Listening Mrs. Fernandez is a 62yearold woman. She does not work and lives with her adult nephew. She is conversant in English and has poorly controlled Type 2 diabetes Patient Statement “My sugars are probably off the charts.” Provider Guess About Meaning Reflection Do you mean that you are concerned about what you ate for breakfast? You are concerned about what you ate for breakfast. Do you mean that you haven’t been checking your sugars lately? You haven’t been checking your sugars lately. Mr. Jones is a 55yearold man. He lives with his partner and receives disability. He is HIV+ and struggles with medication adherence and depression. Patient Statement “I haven’t missed one single dose since our last visit.” Provider Guess About Meaning Reflection Do you mean you’ve been using some of the strategies we discussed? You’ve been using some of the strategies we discussed Do you mean your labs last month really scared you? Your labs last month really scared you. Values Exploration Another strategy for promoting engagement involves taking time to ask about and understand the patients’ goals and values.19 This may involve briefly talking about life activities and relationships important to the patient. Not only do such conversations build rapport, they simultaneously increase patients’ motivation to change by giving them a chance to verbalize the healthy ideals that are important to them. One simple method for understanding the motivators that drive your patients is by asking them openended questions and then listening empathically using the skills of reflection. Examples of values questions adapted from Miller and Rollnick19 can be found in Box 124. Box 124. Examples of Values Exploration Questions to Promote Engagement “Tell me what matters most to you in life?” “What are some of the most important values that guide your life?” “How do you hope your life will look a few a years from now?” “Tell me about your family? How old are your children? What are they doing right now?” Responding to Discord Even when we invest in efforts to engage with patients, discord or disharmony in the collaborative relationship may still arise.19 Discord often takes the form of a “fight or flight” response on the part of the patient. This may involve taking an oppositional stance (“You’d never be able to understand what this is like.”) or2024218 disengagement the Discord can often be perceived as wrestling with the patient, versus the perception of dancing that Downloaded 9:28 Afrom Your IPinteraction. is 63.247.225.21 Page 5 / 18 Chapter 12: Promoting Behavior Change, Jennifer E. Hettema; Christopher Neumann; Bradley Samuel; Daniel S. Lessler; Christopher Dunn is often experienced when collaboration is high. ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility In motivational interviewing, relationship discord is distinguished from the expression of reasons not to change or barriers to change (e.g., “Drinking helps to ease my anxiety.”). Such counterchange talk is more indicative of underlying ambivalence about change versus problems with the Responding to Discord Mount Saint Vincent College Access Provided by: Even when we invest in efforts to engage with patients, discord or disharmony in the collaborative relationship may still arise.19 Discord often takes the form of a “fight or flight” response on the part of the patient. This may involve taking an oppositional stance (“You’d never be able to understand what this is like.”) or disengagement from the interaction. Discord can often be perceived as wrestling with the patient, versus the perception of dancing that is often experienced when collaboration is high. In motivational interviewing, relationship discord is distinguished from the expression of reasons not to change or barriers to change (e.g., “Drinking helps to ease my anxiety.”). Such counterchange talk is more indicative of underlying ambivalence about change versus problems with the interpersonal relationship. The section “Evoking from the Patient” provides guidance on responding to language about reasons or barriers to change. When it comes to discord, however, several strategies are available. First, engaging in active listening using reflection to understand and explore patient discord is often sufficient to extinguish it. Similarly, clinicians could validate and apologize for any missteps perceived by the patient, shift focus to another topic, emphasize the patient’s choice or autonomy, or return to earlier processes to determine whether they inadvertently or prematurely moved into a later process, such as focusing, evoking, or planning. FOCUSING WITH THE PATIENT A good working relationship leaves providers and patients with the groundwork they need to identify and pursue a specific direction. This focusing is the second process in motivational interviewing. Developing clear and collaboratively generated goals or areas for exploration allows for purposeful interactions aimed at promoting behavioral change. Interactions without focus are less likely to lead to behavioral change. There are several potential sources of focus in medical interactions.19 In many circumstances, the patient will present with a problem or concern that becomes the area of focus (e.g., “I’d like to quit smoking.”). Other times, the setting itself will determine the direction of an interaction (e.g., an HIV testing and counseling center). Finally, the medical provider may be a source of focus (e.g., a physician is concerned about the diabetes self management practices of a patient with poorly controlled blood sugar). In motivational interviewing and other patientcentered approaches, providers are encouraged to find direction collaboratively by using a guiding style that actively integrates all potential sources of focus. In situations in which direction is clear, focusing may simply involve confirming the goal of one’s work with a patient. However, in other cases, direction may be unclear or there may be many competing priorities to choose from, in which case specific focusing skills will be called into play. Focusing skills become even more important with vulnerable populations as providers seek to efficiently identify areas of greatest need. Even with an average patient panel, a provider could easily spend all of his or her time with a patient assessing and intervening to promote behavioral change.36 This problem may be magnified with vulnerable populations in which prevalence of behavioral risk factors is increased. Good focusing skills will help the provider to collaboratively identify potential areas of behavioral change that can be manageably addressed in their specific context. In addition, as Maslow described, human needs can be thought of existing in a hierarchy, and our motivation to achieve a given need is contingent on satisfaction of more basic needs.37 Providers working with patients whose physiological and safety needs are not being met because of hunger, poverty, violence, or other factors should be mindful of these larger contextual issues in their patients’ lives. If available, teaming up with allied health professionals, such as social workers, to help patients address structural barriers in their lives, may help increase their chances of successfully focusing on other behavioral health issues. STRATEGIES FOR FOCUSING The goal of focusing is, for the clinician and patient to agree on a behavioral topic for discussion. Medical providers have the difficult task of balancing the many medical and behavioral needs of the patient within a small time window. On the provider’s part, some clinical judgment is required to triage presenting issues and delegate time accordingly. With some acute issues, it may not be feasible or appropriate to address behavioral issues at all, and all of the provider’s efforts may be spent on medical procedures. In contrast, with some highrisk behaviors (e.g., needle sharing), it may be appropriate to minimally address medical issues, and focus primarily on the pressing behavioral health issue. For most patients, though, particularly in outpatient continuity settings, it will be clinically appropriate to address both. Asking Permission One strategy that sets a respectful tone for focusing is asking permission. Asking permission implicitly communicates support of the patient’s autonomy and may increase buyin and active participation in the interaction. For example, a provider might ask: “Would it be alright if we spend a few minutes talking about contraception?” Of course, providers should not ask permission if they are not able or willing to accept no for an answer. Downloaded 2024218 9:28 A Your IP is 63.247.225.21 Normalizing Page 6 / 18 Chapter 12: Promoting Behavior Change, Jennifer E. Hettema; Christopher Neumann; Bradley Samuel; Daniel S. Lessler; Christopher Dunn ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility In circumstances in which an area of focus involves a stigmatized behavior, normalizing the focus may increase patients’ willingness to disclose. For example, “I like to check in with all of my patients about safety. Do you feel safe at home?” Asking Permission Mount Saint Vincent College Access Provided by: One strategy that sets a respectful tone for focusing is asking permission. Asking permission implicitly communicates support of the patient’s autonomy and may increase buyin and active participation in the interaction. For example, a provider might ask: “Would it be alright if we spend a few minutes talking about contraception?” Of course, providers should not ask permission if they are not able or willing to accept no for an answer. Normalizing In circumstances in which an area of focus involves a stigmatized behavior, normalizing the focus may increase patients’ willingness to disclose. For example, “I like to check in with all of my patients about safety. Do you feel safe at home?” Agenda Setting Agenda setting is a strategy for collaboratively and explicitly mapping out what will occur during an interaction. For example, a provider might ask a patient for permission to spend the last few minutes of a visit discussing lifestyle changes that the patient is contemplating. Training providers in agenda setting techniques has been shown to improve patient satisfaction.38 Providing a Menu of Options Another strategy for focusing involves providing patients with a menu of potential health behavior topics to discuss. The menu could be sought from the patient himself (e.g., “What behavior changes have you thought about making?”) or it can be generated by the provider. Menus of options could be presented verbally, or using a visual aid. A menu gives patients the freedom to identify those lifestyle topics of greatest importance to them: “If you were to pick one issue to discuss today, which would it be?” The menu also may help patients not yet contemplating health behavior change to choose a topic they can at least discuss in a hypothetical way (“If you were to some day make a healthy change, in which area might that be?”). Collaboratively Sharing Information or Feedback Providing patients with information and feedback is an effective tool to promote focusing. For example, educating a patient about safe drinking limits may lead to a focus on risky drinking behavior. Similarly, providing a patient with feedback about her HbA1c level may lead to a focus on diabetes self management practices. The Elicit–Provide–Elicit technique is one strategy for sharing information and feedback in a collaborative style.39 Using this technique, the provider first elicits what the patient knows or thinks about a topic. If necessary, information can then be provided in a way that is tailored to what the patient already knows. Finally, the provider can elicit what the patient thinks of the information or how, if at all, it impacts her thinking about her health behavior. Consider the example in Box 125. Box 125. Collaboratively Sharing Using Elicit–Provide–Elicit Mrs. Dodd is a 63yearold woman with poorly controlled asthma. She has presented to the emergency department three times in the past year and has had poor adherence to preventive medication. Provider(elicits what patient knows): “What’s your understanding of how things have been going in terms of controlling your asthma?” Patient: “I know things have been pretty out of control. My rescue inhaler doesn’t seem to be enough anymore. But I’ve heard that steroids are dangerous to take all the time.” Provider(provides): “Your recent visit to the emergency room and what you’ve reported about your ability to control your breathing are concerning to me. It’s true that for a very small number of people, steroids can have harmful side effects. But the risk of damaging your lungs from repeated asthma attacks is much larger than the risk of potential side effects from the steroid.” Provider(elicits reaction): “What do you make of that?” Patient: “Really? I didn’t know that. I thought it was just discomfort. I think I’m ready to discuss some of the steroid options.” EVOKING FROM THE PATIENT Once a trusting working relationship has been established and a collaborative focus has been achieved, providers should draw out and strengthen the Downloaded 2024218 9:28 A Your IP is 63.247.225.21 19 Evoking Page 7 / 18 Chapter Behavior Change, Jennifer E. Hettema; Christopher Neumann; Bradley Samuel; Daniel S. Lessler; Christopher patient’s12: ownPromoting motivations to change through the process of evoking. is a strategic response to patient ambivalence. For example,Dunn a patient ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility considering colorectal cancer screening may, on the one hand, have a fear of developing cancer, want to live a long and healthy life, and value what his medical providers recommend. On the other hand, he may feel very uncomfortable about receiving a colonoscopy, fear that it will be painful or embarrassing, and at times discount the probability that he himself could get cancer. Patient: “Really? I didn’t know that. I thought it was just discomfort. I think I’m ready to discuss some of the steroid options.” Mount Saint Vincent College Access Provided by: EVOKING FROM THE PATIENT Once a trusting working relationship has been established and a collaborative focus has been achieved, providers should draw out and strengthen the patient’s own motivations to change through the process of evoking.19 Evoking is a strategic response to patient ambivalence. For example, a patient considering colorectal cancer screening may, on the one hand, have a fear of developing cancer, want to live a long and healthy life, and value what his medical providers recommend. On the other hand, he may feel very uncomfortable about receiving a colonoscopy, fear that it will be painful or embarrassing, and at times discount the probability that he himself could get cancer. While providers are encouraged to acknowledge and accept the side of the patient’s ambivalence that does not favor change, when evoking, providers are called upon to differentially focus their clinical efforts on the side of the patient’s ambivalence that favors change. Process research suggests that provider behaviors consistent with a motivational interviewing approach increase the amount that patients talk about reasons for change, and that this patient language in turn predicts outcomes.40 It should be noted that the evoking process is only appropriate in situations in which there is clearly a healthy behavior change to be made (e.g., substance misuse, treatment noncompliance, unprotected sex).19 For other issues that do not have a clear direction in which to seek resolution of ambivalence (e.g., organ donation, divorce), providers may seek to maintain neutrality and not influence the direction of change. Some issues (breastfeeding, resuscitation orders) are more nuanced and will require consideration of contextual and other factors to make a determination regarding the appropriateness of evoking. STRATEGIES FOR EVOKING RECOGNIZING CHANGE TALK “Change talk” is a term that refers to patient statements made in favor of change. Categories of change talk include a desire to change, readiness to change, and the ability to change. However, the ultimate in change talk is “commitment language,” which is a strong signal that behavior change will soon occur.41 It is often easy to miss “change talk” in the midst of “counterchange” talk (Box 126). Box 126. Change Talk Mr. Jones, the aforementioned 55yearold man living with HIV. Mr. Jones: “Taking my medications just reminds me that I’m sick. I want to suppress the virus, but sometimes I think the pills are worse than the disease.” Provider: As providers, it is easy to focus on the counterchange talk in the statement above. However, there is an element of change talk in this statement: “I want to suppress the virus…” Recognizing change talk when it happens will allow providers to respond to it in an evoking fashion. Responding to Change Talk When change talk does occur, providers seeking to promote behavior change through evocation should seek to differentially respond the change talk. Providers can use core communications skills such as openended questions, affirmation, and reflections to highlight the change talk that the patient has said. Box 127 provides examples based on the aforementioned change talk from John. Box 127. Responding to Change Talk Mr. Jones:“I want to suppress the virus…” Openended question “Why do you want to suppress the virus?” “What would it be like for you to have an undetectable viral load again?” Downloaded 2024218 9:28 A Your IP is 63.247.225.21 Affirmation “You’re a real fighter when it comes to your health.” Page 8 / 18 Chapter 12: Promoting Behavior Change, Jennifer E. Hettema; Christopher Neumann; Bradley Samuel; Daniel S. Lessler; Christopher Dunn ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Reflection “You want to see your viral load start going back down again.” Mount Saint Vincent College When change talk does occur, providers seeking to promote behavior change through evocation should seek to differentially respond the change talk. Access Provided by: Providers can use core communications skills such as openended questions, affirmation, and reflections to highlight the change talk that the patient has said. Box 127 provides examples based on the aforementioned change talk from John. Box 127. Responding to Change Talk Mr. Jones:“I want to suppress the virus…” Openended question “Why do you want to suppress the virus?” “What would it be like for you to have an undetectable viral load again?” Affirmation “You’re a real fighter when it comes to your health.” Reflection “You want to see your viral load start going back down again.” Evoking Change Talk Providers can explicitly draw out change talk from a patient by implementing several strategies. One obvious strategy is to ask openended question, the answer to which is change talk. Such questions allow patients to develop their own arguments for change, which is more powerful than having providers tell them why they should change. Several examples of evocative questions can be found in Box 128 below. Box 128. Evocative Questions to Evoke Change Talk “What are some good things that could happen if you cut down on your drinking?” “What are some strengths and resources you could draw on if you decided to exercise more?” “Why wouldn’t you want to have to go on insulin?” “What scares you about your blood pressure?” “What strategies helped you to quit before?” “What would it be like to not have to smoke to manage your anxiety … to be free of cigarettes … to really know that you know how to quit and stay quit.” “How would you like your viral load to look in 6 months?” Ruler Exercises There are also several structured activities specifically designed to draw out change talk. One such activity is the use of a scaling ruler, which can be implemented in very brief interactions to elicit change talk. The purpose of the ruler exercise is not actually to assess readiness to change, but to give patients an opportunity to make their own arguments for change. Box 129 provides examples of how to use ruler exercises in the evocation process. Box 129. Using Rulers to Explore Importance and Confidence 1. “I’d like to understand how important it is to you personally to change your ___________ (make the change under discussion). If 0 is not important and 10 is very important, what number would you give yourself today?” 2. “Why did you give it a ___________ (number the patient gave) of a ___________ (lower number than the patient gave)?” This elicits change talk. (“I gave it a 7 and not a 3, because I’m afraid of cancer.”) 3. “What would it take for you to give it a ___________ (higher number than the patient gave)?” The answer to this question tells the provider what Downloaded 2024218 9:28 A Your IP is 63.247.225.21 specific medical information might serve to increase the patient’s importance, eitherBradley by increasing herDaniel or his concern or removing barriers. Page 9 / 18 Chapter 12: Promoting Behavior Change, Jennifer E. Hettema; Christopher Neumann; Samuel; S. Lessler; Christopher Dunn ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility 1. “If you were to decide to (make the change under discussion), how confident are you that you would be successful, if 0 is not at all confident and 10 is very confident?” This tells the provider the patient’s confidence level relative to importance. Some providers then try to raise whichever Mount Saint Vincent College There are also several structured activities specifically designed to draw out change talk. One such activity is the use of a scaling ruler, which can be Access Provided by: implemented in very brief interactions to elicit change talk. The purpose of the ruler exercise is not actually to assess readiness to change, but to give patients an opportunity to make their own arguments for change. Box 129 provides examples of how to use ruler exercises in the evocation process. Box 129. Using Rulers to Explore Importance and Confidence 1. “I’d like to understand how important it is to you personally to change your ___________ (make the change under discussion). If 0 is not important and 10 is very important, what number would you give yourself today?” 2. “Why did you give it a ___________ (number the patient gave) of a ___________ (lower number than the patient gave)?” This elicits change talk. (“I gave it a 7 and not a 3, because I’m afraid of cancer.”) 3. “What would it take for you to give it a ___________ (higher number than the patient gave)?” The answer to this question tells the provider what specific medical information might serve to increase the patient’s importance, either by increasing her or his concern or removing barriers. 1. “If you were to decide to (make the change under discussion), how confident are you that you would be successful, if 0 is not at all confident and 10 is very confident?” This tells the provider the patient’s confidence level relative to importance. Some providers then try to raise whichever metric is lower. 2. “Why did you give it a (number the patient gave it) and not a (lower number than the patient gave)?” The answer to this question promotes “change talk” and may help identify the patient’s strengths. (“I know I can quit drinking if I put my mind to it, because I have already quit smoking.”) 3. “What would it take for you to give it a (higher n umber than the patient gave)?” This identifies barriers to change that both provider and patient can now collaboratively address. PLANNING WITH THE PATIENT When readiness to change is sufficiently high, moving into the planning process is appropriate. During planning, providers and patients collaboratively generate the details regarding how change will occur. Effective planning usually addresses the “who, what, where, when, and hows” of change. In some cases, planning may involve patients committing to making small lifestyle changes on their own, and in other circumstances it may involve referral to services to more fully address a problem. STRATEGIES FOR PLANNING The first step in the planning process involves accurately judging whether a transition to this process is appropriate in the first place. As providers, it can feel uncomfortable to leave an interaction without developing a plan for change. While this desire for planning comes from a good place on the part of the provider, prematurely planning can provoke resistance. The flavor of this resistance varies with patients’ cultures (e.g., arguing against the need for change, passive smiling, silence, changing the topic, passive compliance), but is universally unpleasant: rapport is damaged and patients resist. It takes time for patients to navigate the earlier stages of the change process. Many providers have experienced patients who finally take action after years of thinking and talking about change. Their thinking and talking represent indispensable preparation and premature planning could, in fact, have prevented such progress. Readiness to plan can be assessed by listening for the amount and strength of patient change talk in relation to counterchange talk. Providers who believe that a transition to planning is appropriate may choose to test the waters by explicitly asking patients. As with any process in promoting behavior change, be prepared to revisit earlier processes if readiness changes during an interaction. Know Available Resources Once readiness to plan has occurred, it is helpful as a provider to know what resources are available to patients. It can be helpful to identify and catalog of communitybased and Internet resources that can help patients to achieve their behavioral goals.42 Examples of communitybased resources include tollfree “quit smoking” lines; exercise programs sponsored by departments of public parks and recreation; and other programs sponsored by nonprofit organizations such as the YMCA and diseasespecific advocacy groups (e.g., local chapters of the American Diabetes Association). Similarly, many evidencebased materials are available that include selfhelp strategies for a variety of health behaviors. In addition, with an increased emphasis on behavioral health in medical settings, many programs offer colocated or fully integrated behavioral health services. Downloaded 2024218 9:28 A Your IP is 63.247.225.21 Chapter 12: Promoting Behavior Change, Jennifer Dunn10 / 18 Understanding the Basics of Specialty Care E. Hettema; Christopher Neumann; Bradley Samuel; Daniel S. Lessler; ChristopherPage ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility For patients with more extensive behavioral health issues, specialty treatment may be appropriate. Knowing which behavioral health issues are appropriate for brief intervention in medical settings and which likely necessitate more extensive clinician contact is paramount. For example, while Once readiness to plan has occurred, it is helpful as a provider to know what resources are available to patients. It can be helpful to identify and catalog Mount Saintresources Vincent College of communitybased and Internet resources that can help patients to achieve their behavioral goals.42 Examples of communitybased Access programs Provided by: sponsored by include tollfree “quit smoking” lines; exercise programs sponsored by departments of public parks and recreation; and other nonprofit organizations such as the YMCA and diseasespecific advocacy groups (e.g., local chapters of the American Diabetes Association). Similarly, many evidencebased materials are available that include selfhelp strategies for a variety of health behaviors. In addition, with an increased emphasis on behavioral health in medical settings, many programs offer colocated or fully integrated behavioral health services. Understanding the Basics of Specialty Care For patients with more extensive behavioral health issues, specialty treatment may be appropriate. Knowing which behavioral health issues are appropriate for brief intervention in medical settings and which likely necessitate more extensive clinician contact is paramount. For example, while there is good evidence to suggest that risky alcohol use is often responsive to brief intervention in primary care,5 risky drug use is less responsive and likely requires specialty treatment.43 Specialty intervention skills can be learned and applied by medical providers themselves in certain circumstances. However, trained behavioral health providers can often spend more time with patients and have received extensive training on promoting behavioral change. Either way, a basic level of familiarity with commonly used approaches can be helpful in presenting patients with treatment options. Many behavioral health specialists use an approach similar to the four motivational interviewing processes described in this chapter. However, behavioral health specialists have typically also received extensive training in skillsbased approaches that allow them to help patients tackle behaviors for which basic planning is not enough. For example, Mr. Jones, the AfricanAmerican patient living with HIV and depression, may be sufficiently ready to address his depression, but collaborative planning between him and his medical provider has not proven sufficient to increase his medical adherence and help him engage in other strategies to reduce his feelings of depression. In this case, specialty care may be appropriate. One commonly used form of specialty care that patients in medical settings are referred to in the planning process is cognitive behavioral therapy (CBT). CBT is based on learning theory and emphasizes the relationships between thoughts, feelings, and behaviors. CBT teaches patients to identify and challenge negative thoughts that influence maladaptive or unhealthy behaviors. For example, Mr. Jones may have negative beliefs such as “I’ll always be depressed so why bother taking my medications” or “I don’t deserve to get any pleasure out of life.” These beliefs could influence Mr. John’s engagement in behaviors that lead to a poorer quality of life (i.e., poor medication adherence, increasing social isolation). By learning to recognize and challenge these types of beliefs, patients are less likely to engage in behaviors that could decrease quality of life. CBT also helps patients to set small, realistic goals to improve behavioral health and encourages using small rewards for meeting goals. For example, Mr. Jones could seek to take and record his medication for a weeklong period, and plan to reward himself with his favorite ice cream if he succeeds. The primary function of CBT is to help patients change their thoughts and behaviors surrounding a particular behavioral health problem. CBT has been useful in managing myriad behavioral health concerns. It is particularly helpful during the planning process, when patients have high levels of readiness to address an issue. A recent review of CBT for chronic pain found that patients who received a CBT intervention reported improvements in pain, disability, and mood.44 Similarly, CBT studies on patients with diabetes resulted in improvements in HbA1c levels, diabetes related distress, blood glucose testing, and problemsolving skills.45 Current clinical practice guidelines include CBT to aid in smoking cessation.46 Finally, several reviews on weight management have emphasized the importance of cognitive behavioral approaches to weight loss.47,48 Acceptance and commitment therapy (ACT) is another skillsbased approach that is frequently implemented with patients who are managing behavioral health concerns. ACT is based on the idea that experiencing a wide range of thoughts and emotions is normal. However, problems occur when we are unwilling to experience unpleasant thoughts and emotions, and then engage in behaviors to avoid such experiences, often at the expense of one’s values. ACT teaches patients to be mindful and accepting of such experiences, reduce the control that distressing thoughts and feelings can have on one’s behavior, and increase valueconsistent behaviors. This process, known as psychological flexibility, is defined as “being able to be present in the moment, fully aware and open to our experience, and to take action consistent with our values.”49 ACT has been used to address a number of health concerns such as chronic pain, diabetes, weight loss, and smoking cessation. ACT has been most thoroughly studied with chronic pain patients. Six randomized controlled trials have demonstrated improvement in chronic pain management when using ACT. Patients receiving ACT report decreased pain, related medical appointments, and improvements in functioning.50 ACT has also been shown to be useful with patients with diabetes. A randomized controlled trial demonstrated improvements in diabetes selfcare and HbA1c levels when patients received an ACT intervention.51 Finally, a number of smaller pilot studies lend support to an ACT model of care for improving diet, increasing physical activity, and smoking cessation.52,53,54,55,56 COLLABORATIVE REFERRAL AND SKILL EXCHANGE When sharing referral information or skills with patients, it is helpful to continue using collaborative processes, and avoid taking a topdown stance (Box 1210). Asking permission drawing on the expertise of the patient can be invaluable in this process. Downloaded 2024218 9:28 Aand Your IP is 63.247.225.21 Chapter 12: Promoting Behavior Change, Jennifer E. Hettema; Christopher Neumann; Bradley Samuel; Daniel S. Lessler; ChristopherPage Dunn11 / 18 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Box 1210. Example of Collaborative Planning Ms. Kirk is a 44yearold female with mild hypertension and recurrent bronchitis. She has been a lifetime smoker who is interested in quitting. physical activity, and smoking cessation.52,53,54,55,56 COLLABORATIVE REFERRAL AND SKILL EXCHANGE Mount Saint Vincent College Access Provided by: When sharing referral information or skills with patients, it is helpful to continue using collaborative processes, and avoid taking a topdown stance (Box 1210). Asking permission and drawing on the expertise of the patient can be invaluable in this process. Box 1210. Example of Collaborative Planning Ms. Kirk is a 44yearold female with mild hypertension and recurrent bronchitis. She has been a lifetime smoker who is interested in quitting. “What’s your understanding of ways in which a behavioral health specialist might be able to help you with your goal of quitting smoking?” “Because you already know how to quit, I am wondering if we could work on a plan together that would focus on how to stay quit even when you experience cravings. What ideas do you have?” While patients are typically able to generate their own plans for change, there are some circumstances when it is appropriate to share information or resources. Imagine Mrs. Fernandez, the obese, diabetic patient described earlier, has decided to improve her diet. It may be appropriate to refer this patient to an online resource that discusses healthy eating. Similarly, Mr. John could be given medication adherence tips, such as pairing his medication taking with another routine activity, like brushing his teeth. When sharing information or resources, the Elicit–Provide–Elicit technique can be a valuable tool. Consider Mr. Nguyen, the risky alcoholic patient described earlier (Box 1211). Box 1211. Planning with Elicit–Provide–Elicit Provider elicits what patient knows: “What ideas do you have for strategies for cutting down?” Patient: “I think just knowing the limit will help. I’ll keep track of my drinks and try not to have more than four.” Provider gives more information: “Setting specific goals and keeping track are excellent strategies. Some people have also found that switching between alcoholic and nonalcoholic drinks can be helpful. As can practicing how to say no when you decide you don’t want a drink.” Provider elicits reaction: “What do you think of those strategies?” Patient: “Alternating might help. That way I can still stay and hang out. I don’t think I’d have a problem saying no if I didn’t want a drink.” Addressing Barriers While the evocation process encourages us to focus on reasons for change, once ambivalence has been resolved and patients are reading to plan, it may be appropriate to draw out potential barriers to change so that they can be addressed. This could be done in an openended fashion: “What would your life be like if you made that change today? What would be missing….?” or providers could offer and explore obstacles they anticipate based on their clinical expertise. Once barriers are identified, using a collaborative approach to troubleshoot them is ideal. Often, patients themselves have the most appropriate and feasible solutions to barriers. As described earlier, using a systemsbased approach and integrating services of behavioral health and other allied health professionals can also allow providers to offer more intensive services to patients with extensive barriers. Another potential barrier to behavioral change may be health literacy. Health literacy is the ability to access and understand important health information (see Chapter 15). While health literacy is important throughout all processes involved in promoting behavior change, it is even more important during the planning stage, during which providers often share and exchange health information. It is important to be mindful of health literacy issues when developing and sharing resources with patients. In addition, taking a patientcentered, collaborative approach, including strategies such as Elicit–Provide–Elicit, can help prevent ineffective information exchange. Summary and Followup Clinic systems also can assist patients in following through on behavioral action plans. One simple strategy that can be implemented within a patient visit is asking patients to summarize the change plans they have made. Writing down change plans (also known as action plans) can increase the chances that a patient will follow through. Documenting behavior counseling discussions and action plans in medical records may serve as a cue to followup. It also makes other members of the healthcare team aware of a patient’s behavioral goals. Healthcare providers can also support patients Downloaded 2024218 9:28 A Your IP is 63.247.225.21 in achieving goals by proactively following up with patients between visits to assess Bradley progressSamuel; and helpDaniel troubleshoot barriers to implementing Page 18 Chapter 12: their Promoting Behavior Change, Jennifer E. Hettema; Christopher Neumann; S. Lessler; Christopher Dunn12 / an 57 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility action plan. Summary and Followup Mount Saint Vincent College Access Providedwithin by: Clinic systems also can assist patients in following through on behavioral action plans. One simple strategy that can be implemented a patient visit is asking patients to summarize the change plans they have made. Writing down change plans (also known as action plans) can increase the chances that a patient will follow through. Documenting behavior counseling discussions and action plans in medical records may serve as a cue to followup. It also makes other members of the healthcare team aware of a patient’s behavioral goals. Healthcare providers can also support patients in achieving their goals by proactively following up with patients between visits to assess progress and help troubleshoot barriers to implementing an action plan.57 OTHER MODELS 5AS MODEL In addition to motivational interviewing, several other models are available to guide providers in promoting behavioral change. For example, the 5As model, which was originally developed to promote smoking cessation but has been more recently applied to other behavioral health issues such as obesity, provides an overarching framework for behavior change counseling. The 5As, described in Box 1212, provide practical, actionoriented steps for identifying and intervening around behavioral health issues. Box 1212. Brief Overview of Other Behavior Change Promotion Models The 5As SBIRT A s k: about health behavior Screening: determine the severity of the problem Advise: health behavior change Brief intervention: increase motivation for change or plan for change Assess: willingness to change Referral to treatment: provide access to specialty care for those needing more extensive services Assist: provide skills, medications, or referrals Arrange: followup The 5As framework provides less guidance about the interpersonal style in which each step should be conducted and, consequently, such an approach could have low or high consistency with the motivational interviewing approach described earlier, depending on the style of intervention. For example, asking about health behavior could take place before or after the development of engagement, advice could occur with or without permission, and assistance could be given in a topdown or collaborative and evoking fashion. SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT The screening, brief intervention, and referral to treatment (SBIRT) is an approach designed to quickly assess the severity of substance use, provide brief intervention to risky users, and refer those requiring more extensive services to specialty treatment. Like the 5As, SBIRT could be conducted in a fashion that is highly consistent or highly inconsistent with motivational interviewing. In fact, the most commonly implemented SBIRT protocol, developed by the National Institute on Alcohol Abuse and Alcoholism (2005),58 has elements of both. The degree of motivational interviewing underlying an SBIRT protocol has been cited as a potential moderator of treatment effect that has not been adequately described in treatment outcome reports.59 CONCLUSION Promotion of behavior change is integral to the practice of medicine, particularly with vulnerable populations, who often have higher rates of unhealthy behaviors. Modifiable behavioral risk factors are the leading actual causes of death; differentially affect vulnerable populations, and merit attention from healthcare providers. Providers can have a significant impact on health behaviors with brief interventions, particularly if they employ patientcentered practices consistent with a motivational interviewing approach. Such patientcentered approaches may be especially important with lower SES and ethnic m inority patients, who are less likely to be approached with a collaborative style. In this chapter, we discussed practical strategies for engaging patients, a process that is necessary to effectively promote behavior change. We highlighted several strategies collaborating with patients to identify the best targets of behavior change counseling. For behavior changes in which there is a clearly healthier choice, providers seek to evoke, or draw out the patient’s own motivations to change. This is done by listening for the change talk in what patients say and strategically responding to it, or Downloaded 2024218 9:28structured A Your IPactivities is 63.247.225.21 by asking questions or doing designed to draw out change talk. Finally, when patients are sufficiently ready, a collaborative plan Chapter 12: Promoting Behavior Change, Jennifer E. Hettema; Christopher Neumann; Bradley Samuel; Daniel S. Lessler; ChristopherPage Dunn13 / 18 for change can beHill. made. CBT and ACT principles canofbe integrated the planning Using the patientcentered techniques of motivational ©2024 McGraw All Rights Reserved. Terms Use Privacyinto Policy Notice process. Accessibility interviewing allows clinicians to effectively support their patients in making changes in their behavior to improve and protect health. attention from healthcare providers. Providers can have a significant impact on health behaviors with brief interventions, particularly if they employ Mount Saint important Vincent College patientcentered practices consistent with a motivational interviewing approach. Such patientcentered approaches may be especially with Access Provided by: lower SES and ethnic m inority patients, who are less likely to be approached with a collaborative style. In this chapter, we discussed practical strategies for engaging patients, a process that is necessary to effectively promote behavior change. We highlighted several strategies collaborating with patients to identify the best targets of behavior change counseling. For behavior changes in which there is a clearly healthier choice, providers seek to evoke, or draw out the patient’s own motivations to change. This is done by listening for the change talk in what patients say and strategically responding to it, or by asking questions or doing structured activities designed to draw out change talk. Finally, when patients are sufficiently ready, a collaborative plan for change can be made. CBT and ACT principles can be integrated into the planning process. Using the patientcentered techniques of motivational interviewing allows clinicians to effectively support their patients in making changes in their behavior to improve and protect health. CORE COMPETENCY Behavior Change Counseling Engage the Patient Ask about your patients’ healthrelated goals and values. Actively listen using reflections. Use discord as feedback to respond differently. Focus with the Patient Collaboratively set agenda Ask permission, normalize, or use a menu of options to introduce your own focus Use Elicit–Provide–Elicit to provide feedback intended to promote focus (e.g., lab results) Evoke Change Talk Recognize motivational speech when you see it. Respond to change talk with reflections, summaries, or open questions that ask for elaboration. Draw out change talk using readiness, importance, and confidence rulers (Why are you not a lower number?) Plan When Appropriate Only plan when patients are ready to change Draw out the patient’s own ideas about how change should occur Use Elicit–Provide–Elicit to share resources and skills Source: Adapted from Miller WR, Rollnick S. Motivational Interviewing: Helping People Change, 3rd ed. New York: Guilford Press, 2013. DISCUSSION QUESTIONS 1. “Dancing versus wrestling” can be a useful metaphor for behavior change counseling. “Wrestling” ends with a winner and a loser (or two losers!). “Dancing” means the provider is guiding the conversation while the patient is doing most of the talking. Think back to a recent patient with whom you danced and another with whom you wrestled. What do you think you may have done that led you to dance with one and wrestle with the other? 2. Think back to a healthy behavior change that you made some time in the past. Did you perceive making the change as important for your health? Why? What are some evocative questions that could have led you to argue for making the change? 3. Think about the last time you tried to help a patient or someone else in your life plan a change. In retrospect, was the person ready? What pieces of information help you decide when a patient is ready? RESOURCES Downloaded 2024218 9:28 A Your IP is 63.247.225.21 Chapter 12: Promoting Behavior Change, Jennifer E. Hettema; Christopher Neumann; Bradley Samuel; Daniel S. Lessler; ChristopherPage Dunn14 / 18 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Rollnick S, Gobat N, Batson J. Motivational interviewing in brief consultations. British Medical Journal online interactive learning module, 2014. http://learning.bmj.com/learning/moduleintro/.html?moduleId=10051582. 2. Think back to a healthy behavior change that you made some time in the past. Did you perceive making the change as important for your health? Why? What are some evocative questions that could have led you to argue for making the change? Mount Saint Vincent College Access Provided by: 3. Think about the last time you tried to help a patient or someone else in your life plan a change. In retrospect, was the person ready? What pieces of information help you decide when a patient is ready? RESOURCES Rollnick S, Gobat N, Batson J. Motivational interviewing in brief consultations. British Medical Journal online interactive learning module, 2014. http://learning.bmj.com/learning/moduleintro/.html?moduleId=10051582. http://www.motivationalinterviewing.org. REFERENCES 1. Mokdad AH, Marks JS, Stroup DF, Gerberding, JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238–1245. [PubMed: 15010446] 2. Kahan M, Wilson L, Becker L. Effectiveness of physicianbased interventions with problem drinkers: A review. CMAJ 1995;152:851–859. [PubMed: 7697578] 3. Mojica WA, Suttorp MJ, Sherman SE et al. Smokingcessation interventions by type of provider: A metaanalysis. Am J Prev Med 2004;26:391–401. [PubMed: 15165655] 4. Miller WR. Rediscovering fire: Small interventions, large effects. Psychol Addict Behav 2000;14:6–18. [PubMed: 10822741] 5. Moyer A, Finney JW, Swearingen CE, Vergum P. 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