Fundamentals of Healthy Behavior Change |
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Learning Objectives:
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Lifestyle medicine is a growing area of medicine that focuses on empowering patients to adopt healthy habits using evidence-based approaches. Coaching is the key verb in lifestyle medicine (Frates, 2019) that is used in health education and promotion to enhance the well-being of our patients through maximizing their full potential to facilitate the realization of their health-related goals. When approaching our patients, we should have that curiosity to know more about them, their aspirations, and goals so we will be able to understand them. We should be open enough to hear them out and not judge them on their behavior. We should appreciate them and their efforts no matter how small, that could make ripples and are instrumental for big changes. We should have the compassion to help us realize what our patients need, like what has to change for them to progress out of their situation, what resources they have within themselves for them to achieve a certain health behavior goal, and be honest enough to tell that change may be difficult and that there will be challenges ahead but it is achievable and doable.
Our role is to help our patients define their health goals, encourage self-efficacy, collaborate with the patient’s solutions and strategies, and hold the patient responsible and accountable for their health. (International Coach Federation (ICF), 2014). Successful coaching happens when patients can use their inner strength and outside resources for sustainable change. (National Consortium for the Credentialing of Health and Wellness Coaches, 2012). We should be able to see the patient holistically keeping in mind that health is not just the absence of disease but a “state of complete physical, mental, and social well-being”. (WHO, 2020) That the patient will be able to enjoy doing normal, routine, and every day activities by empowering them to make changes that will lead them to their optimal level of health and wellness.
Our role is to help our patients define their health goals, encourage self-efficacy, collaborate with the patient’s solutions and strategies, and hold the patient responsible and accountable for their health. (International Coach Federation (ICF), 2014). Successful coaching happens when patients can use their inner strength and outside resources for sustainable change. (National Consortium for the Credentialing of Health and Wellness Coaches, 2012). We should be able to see the patient holistically keeping in mind that health is not just the absence of disease but a “state of complete physical, mental, and social well-being”. (WHO, 2020) That the patient will be able to enjoy doing normal, routine, and every day activities by empowering them to make changes that will lead them to their optimal level of health and wellness.
Lifestyle medicine treatment is generally long term where patients are active partners and not just passive receivers of the treatment interventions. Health and wellness coaches emphasize collaboration with a group of medical professionals -physicians, health and wellness coaches, nutritionists, nurses, therapists, psychologists, fitness professionals, case managers that communicate and work together with patients in disease management, reversal, and prevention. The expert approach should not be used in patients with chronic diseases particularly if the patient has low self-efficacy. As “experts”, we are trained to deal and treat symptoms, diagnose diseases, prescribe medications, and order patients what to do. The patient comes back to us and we evaluate if they were able to follow our prescribed meds and impose to them “to be healthy”.
Experts are problem solvers and feel responsible for the patient’s health, and focus on the wrong (behavior) and try to correct them. Patients believe that the experts have the answers to their problems thus experts work harder than the client and what the patient needs to do is to take the prescribed medications. Experts are trained to diagnose diseases, prescribe, and order the patient on what to do and this sends off a message to the patient that the patient is not in-charge. As experts, we sometimes wrestle/argue with our patients if they are unable to follow our prescriptions.
Expertise is needed for acute care, in cases of emergency or when considering surgical interventions. However, this is not ideal when dealing with stress reduction, weight loss management, behavior change, and developing a positive mindset. There are times when expert opinions are needed but should be given in an appropriate and timely manner. We should bear in mind that patients know themselves better than anyone else and should be able to decide for themselves when it comes to behavior change. People want to change but are resistant when changed. Coaches guide clients and the coaching process. A coach is a partner, a listener, a facilitator of change, that brings out the patient’s goal and engage the clients to discover their strengths, increase their awareness, clarify their values and priorities, help promote self-efficacy, seek possibilities, and gear towards positive actions.
Experts are problem solvers and feel responsible for the patient’s health, and focus on the wrong (behavior) and try to correct them. Patients believe that the experts have the answers to their problems thus experts work harder than the client and what the patient needs to do is to take the prescribed medications. Experts are trained to diagnose diseases, prescribe, and order the patient on what to do and this sends off a message to the patient that the patient is not in-charge. As experts, we sometimes wrestle/argue with our patients if they are unable to follow our prescriptions.
Expertise is needed for acute care, in cases of emergency or when considering surgical interventions. However, this is not ideal when dealing with stress reduction, weight loss management, behavior change, and developing a positive mindset. There are times when expert opinions are needed but should be given in an appropriate and timely manner. We should bear in mind that patients know themselves better than anyone else and should be able to decide for themselves when it comes to behavior change. People want to change but are resistant when changed. Coaches guide clients and the coaching process. A coach is a partner, a listener, a facilitator of change, that brings out the patient’s goal and engage the clients to discover their strengths, increase their awareness, clarify their values and priorities, help promote self-efficacy, seek possibilities, and gear towards positive actions.
We empower patients to discover who they are, what they want to achieve and co-discover solutions to their health problems. Sometimes it is hard to let go of our expert hat, as we are trained extensively with a lot of knowledge and skills to support as we order our patients on what to do, give advice, provide solutions, make suggestions, warn and caution them about the consequences of their ill health behavior. In a systematic review by Wolever and colleagues, health and wellness coaching is a process that is fully or partially patient-centered that helps clients determine their goals, encourage self-discovery, allow accountability of health behavior goals, educate when needed using the coaching processes.
We should be able to lead patients to self- determination where they reach their highest level of motivation, engagement, thus lead them to action for sustainable change, and flourish. Lifestyle medicine physicians do not need to become certified coaches or train in health and wellness coaching but it is helpful that we listen mindfully not only to the patient’s words but also their body cues. Instead of lecturing, we ask more open-ended questions, empower the patient to be in charge of their health.
We should be able to lead patients to self- determination where they reach their highest level of motivation, engagement, thus lead them to action for sustainable change, and flourish. Lifestyle medicine physicians do not need to become certified coaches or train in health and wellness coaching but it is helpful that we listen mindfully not only to the patient’s words but also their body cues. Instead of lecturing, we ask more open-ended questions, empower the patient to be in charge of their health.
Health behavior change theories
In this course series, we will be learning about the health behavior models, the health belief model, theory of planned behavior, the social cognitive and learning theory, and the transtheoretical model of change to help us prepare for the next topics of discussion.
Chronic lifestyle-related diseases like cardiovascular disease, diabetes mellitus, chronic obstructive lung disease, and cancer are prevalent not only in the high-income countries like the United States but also in the mid-lower income countries like the Philippines as well. According to our Department of Health, more than one in every 5 deaths are caused by diseases of the cardiovascular system and is the number one cause of death among Filipinos. (DOH, 2016)
These lifestyle-related diseases have impacted rising healthcare costs and loss of productivity among the working class. It has drained our already depleted healthcare resources. Most of these lifestyle-related diseases are preventable by addressing behavioral risk factors. Although most of us know that the key to health and longevity is having a good diet, proper exercise, adequate sleep, proper stress management, avoidance of risky substances, and forming and maintaining deep and quality relationships, yet a lot of people are not practicing these healthy behaviors and resort to quick fixes that do not last.
People want to be healthy, feel better, have more energy, and live longer. A healthy lifestyle is achieved if habits and mindsets are changed. However, most people are not confident in their ability to quit smoking, start their exercise regimen, or lose weight. Physicians and other health care providers must be equipped with tools to support patients who are willing to change their health behavior and must also set an example and to walk the talk. We are uniquely placed to help patients make positive lifestyle changes by making them understand the reasons for changing. We are usually the people patients turn to when they are thinking about making the change.
According to the Wellcoaches, Coaching Psychology Manual, fewer than 5% of adults engage in the top health behaviors defined by the American Heart Association as “ideal cardiovascular health” (Rippe, 2018) and only 20% of adults are thriving. Even with the traditional practice of medicine, the rates of nonadherence to chronic illness regimens have been reported as high as 50-80%.
In our Lifestyle Medicine Core Competency, the number one in the list is to promote healthy behaviors as foundational to treatment, remission, and reversal of disease, as well as health promotion, and disease prevention. So, to move further in helping our patients, we must first understand the different health behavior change models. These are the health belief models, the theory of planned behavior, social learning, or cognitive theory. They have similarities in that of the risks and benefits, motivation, self-efficacy, and environmental influence.
According to the Wellcoaches, Coaching Psychology Manual, fewer than 5% of adults engage in the top health behaviors defined by the American Heart Association as “ideal cardiovascular health” (Rippe, 2018) and only 20% of adults are thriving. Even with the traditional practice of medicine, the rates of nonadherence to chronic illness regimens have been reported as high as 50-80%.
In our Lifestyle Medicine Core Competency, the number one in the list is to promote healthy behaviors as foundational to treatment, remission, and reversal of disease, as well as health promotion, and disease prevention. So, to move further in helping our patients, we must first understand the different health behavior change models. These are the health belief models, the theory of planned behavior, social learning, or cognitive theory. They have similarities in that of the risks and benefits, motivation, self-efficacy, and environmental influence.
HEALTH BELIEF MODEL (HBM) – perceived beliefs and consequences (LaMorte, 2019)
The health belief model is a social psychological health behavior change model developed to explain and predict health-related behaviors, particularly the utilization of health services. This was developed by social scientists in the early 1950s to understand the reason people fail to adopt disease prevention strategies or screening tests for early detection of diseases. Later, it is used for patient’s response to symptoms and compliance with medical treatments. HBM demonstrates that a person’s health beliefs towards an illness or disease along with the person’s belief in the effectiveness of the recommended health behavior or action will predict the likelihood that the person will adopt the behavior.
The health belief model is a social psychological health behavior change model developed to explain and predict health-related behaviors, particularly the utilization of health services. This was developed by social scientists in the early 1950s to understand the reason people fail to adopt disease prevention strategies or screening tests for early detection of diseases. Later, it is used for patient’s response to symptoms and compliance with medical treatments. HBM demonstrates that a person’s health beliefs towards an illness or disease along with the person’s belief in the effectiveness of the recommended health behavior or action will predict the likelihood that the person will adopt the behavior.
- Perceived susceptibility: refers to a person’s subjective perception of the risk of acquiring an illness or disease. People who think that they are susceptible to having a particular health problem will engage in behaviors that will lower their risk of developing the disease, meanwhile those who think they have low perceived susceptibility of having a particular health problem may deny that they are at risk for having a particular disease so they are more likely to engage in unhealthy, or risky behaviors.
- Perceived severity: refers to a person’s subjective assessment of the seriousness of getting the disease (or leaving the illness or disease untreated) and its potential consequences. Person’s feeling of severity varies for instance death and disability as a medical consequence or disruption in the family or social relationships as social consequences when disease severity is evaluated. HBM suggests that individuals who views a certain health problem as something serious is more likely to do his best so that he will prevent the disease or health problem to occur. For example, one has hypertension, and the patient do not think that an elevated blood pressure will do him harm or would lead to stroke or heart attack so the patient will not do anything about it. But if a person knows someone or their loved ones died because of cardiovascular disease due to elevated blood pressure, he will try his best to maintain a normal blood pressure for fear of dying the same disease as the loved one most especially if he was able to feel the burden of the disability of the disease caused and the burden it brought to the family.
- Perceived benefits: person’s beliefs about the effectiveness of engaging in health-promoting actions to reduce the possibility of illness or disease or to cure an illness or disease. The course of action a person takes in preventing or curing an illness or disease relies on both the perceived susceptibility and perceived benefits. The person will move into action is he will acknowledge that the recommended health action would be of benefit to him. If one believes that a behavior will reduce the likelihood to a health problem or decrease its seriousness, then one is likely to engage in that behavior regardless of objective facts regarding the effectiveness of the action. For example, exercise, if he thinks that doing exercise will help one achieve a better BMI, then the patient will do his best to stick to the program or explore other ways to exercise even if it may be uncomfortable to them. They will make time no matter what. If you think a behavior is worth it, you will to it no matter what.
- Perceived barriers: refers to one’s assessment of the obstacle to behavior change. This includes cost/benefit analysis ( the person weighs the effectiveness of a treatment recommendation in that it may be expensive or dangerous as to its side effects), or unpleasant for example, if the treatment recommendation is uncomfortable or painful, or it may be time consuming or the person may perceive it as an inconvenient thing to do. The perceived benefit must outweigh the perceived barriers for behavior change to occur. (i.e. Exercise: barriers could include, membership costs of going to the gym, the pain after exercising, lack of time to do it)
- Cues to action: is the stimulus needed to trigger for a person to change and accept the health recommended action. These cues may be internal for example pain or wheezing or it may be external like advice from others like colleagues or significant others, follow-up reminder from a doctor, product health labels, illness or death of a family member or loved one, newspaper article, etc.. The intensity of cues needed to prompt action varies between individuals by perceived susceptibility, seriousness, benefits, and barriers. (smoking, death of a loved one)
- Self-efficacy: refers to one’s confidence in one’s ability to succeed in specific situations or accomplish a task or competence. One’s sense of self-efficacy can play a major role in how one approaches goals, tasks, and challenges.
THEORY OF PLANNED BEHAVIOR
This theory is also called reasoned action or intentions are the best predictors of behavioral change. If we plan on something, then we are more likely to do it. These are the predictions of whether we intend to do a behavior.
This theory is also called reasoned action or intentions are the best predictors of behavioral change. If we plan on something, then we are more likely to do it. These are the predictions of whether we intend to do a behavior.
- Behavioral attitudes: how we think and feel about the behavior reflects our behavior to do it
- Affective attitude: whether the behavior is enjoyable or not
- Instrumental attitude: whether the behavior is beneficial or harmful
- Subjective norm: is the support given by family, friends, loved ones or significant others, and is being observed or done by the others in the community or in our social circle
- Injunctive norms: others encourage the behavior
- Descriptive norm: others do the behavior as well
- Perceived behavioral control: The extent that a patient feels that he is capable of confident that one will be able to execute the behavior plays an important role in our intentions to the actual behavior and likewise one’s ability to overcome potential barriers and challenges.
For one to adapt to a certain behavior, in this theory, one must find it enjoyable with great benefits and there is support from the family members or certain group of individuals significant or has an influence on us and that we feel that we are in control and that we are capable of doing it.
So let us have an example, Maria does not enjoy eating fruits and vegetables (affective attitude) but she knows that vegetables are good for the health and if she will not be eating them, she knows the risk that she could develop the cardiovascular disease because her blood pressure is starting to be elevated (instrumental attitude). However, this may not give her strong intentions. Her doctor encouraged her to eat vegetables as well as her family members (injunctive norms), however, they are not doing it as well (descriptive norms) increasing Maria’s ambivalence towards the behavior. She may feel she has low control of eating the vegetables and lacks the confidence and the ability to try and cook delicious vegetable dishes. This could be perceived as a barrier for her a least initially. On the positive side, there is a newly opened market in the neighborhood that gives free cooking demo every Sunday and it is just near her house and she is usually free on Sundays (control). Her friends have heard good reviews about it and are will be attending the sessions as well (capable).
So let us have an example, Maria does not enjoy eating fruits and vegetables (affective attitude) but she knows that vegetables are good for the health and if she will not be eating them, she knows the risk that she could develop the cardiovascular disease because her blood pressure is starting to be elevated (instrumental attitude). However, this may not give her strong intentions. Her doctor encouraged her to eat vegetables as well as her family members (injunctive norms), however, they are not doing it as well (descriptive norms) increasing Maria’s ambivalence towards the behavior. She may feel she has low control of eating the vegetables and lacks the confidence and the ability to try and cook delicious vegetable dishes. This could be perceived as a barrier for her a least initially. On the positive side, there is a newly opened market in the neighborhood that gives free cooking demo every Sunday and it is just near her house and she is usually free on Sundays (control). Her friends have heard good reviews about it and are will be attending the sessions as well (capable).
SOCIAL LEARNING (COGNITIVE THEORY) – self-efficacy (LaMorte, 2019)
This theory emphasizes how the social environment and one’s external and internal factors influence individuals to perform the behavior (Bandura, Albert).
While the social environment and the personal characteristics of a person influences one’s behavior, a person has also the power to exert a change in their situation through their own choices and behaviors.
These key behavior theories recognize that behavior change can occur if one:
1. is aware of the risks and benefits of a particular behavior
2. has that intrinsic motivation to change
3. believes that he is confident and capable to make the change
4. knows that he can face the barriers and is able to deal with them
5. is aware that one's environment can influence his choices.
This theory emphasizes how the social environment and one’s external and internal factors influence individuals to perform the behavior (Bandura, Albert).
- Reciprocal determinism: a person’s behavior is influenced by personal factors and the social environment and these are continually interacting with one another.
- Behavior capability: One must have the knowledge and skills on how to do the behavior for the person to do it.
- Observational learning: People learn a particular behavior by observing other people do it.
- Reinforcements: is the positive and the negative reward of an action that influences whether a behavior will be initiated or not.
- Expectations: are the person’s anticipation of the consequence of behavior before one does it.
- Self-efficacy: a person’s confidence in his ability to be successful in performing a behavior and overcome barriers and challenges.
While the social environment and the personal characteristics of a person influences one’s behavior, a person has also the power to exert a change in their situation through their own choices and behaviors.
These key behavior theories recognize that behavior change can occur if one:
1. is aware of the risks and benefits of a particular behavior
2. has that intrinsic motivation to change
3. believes that he is confident and capable to make the change
4. knows that he can face the barriers and is able to deal with them
5. is aware that one's environment can influence his choices.
Transtheoretical model
Stages of Change Model is the blueprint for effecting self-change in health behavior and was developed by Prochaska and DiClemete in the late 70s when they management smokers. They noticed that smokers can quit on their own while others requiring further treatment. It was observed that people quit smoking if they are ready to do so and believe that they can quit (they have the confidence and resources to do so). TTM is a psychological theory that encompasses a cycle of mental stages that the patients go through as they change their behavior.
According to James Prochaska and Carlo DiClemente, a person is in one of the five stages of change at any given time and that each stage is a preparation for the next one and that it must not be hurried. The stages will help physicians or coaches move the patient from one stage to another to help them in their behavior change. The stages include pre-contemplation, contemplation, preparation, action, maintenance, termination, or relapse.
The goal of the transtheoretical model is to increase self-efficacy that one can make the desired change. The more you believe that you can do it, the more you will be able to see changes and it motivates you to do more. Success begets success.
PRECONTEMPLATION STAGE
In pre-contemplation, it is the "I can not", or "I will not" stage. Patients will say, "I am not going to do it." "I refuse to do it." "I do not think I need to change, and I do not want to talk about it." "I will not quit smoking." They are resistant to change and have no plans of acting anytime in the future. There is no conscious intention of making a change and it may be due to the lack of awareness or information. They may not aware that their behavior is problematic or can have serious health consequences, and if they do, the cons of changing the behavior outweigh the risk. This is the stage when you need to use motivational interviewing.
Our goal is to make the patient think about changing. You have a patient in his early 50’s who recently got married and tells you, "I am not going to quit smoking." What are the intervention principles that we could apply to? One is raising conscious awareness of the behavior. However, give information when the patient agrees to. Dramatic relief involves paying attention to the feelings, or evoke emotion -like fear, excitement.
In pre-contemplation, it is the "I can not", or "I will not" stage. Patients will say, "I am not going to do it." "I refuse to do it." "I do not think I need to change, and I do not want to talk about it." "I will not quit smoking." They are resistant to change and have no plans of acting anytime in the future. There is no conscious intention of making a change and it may be due to the lack of awareness or information. They may not aware that their behavior is problematic or can have serious health consequences, and if they do, the cons of changing the behavior outweigh the risk. This is the stage when you need to use motivational interviewing.
Our goal is to make the patient think about changing. You have a patient in his early 50’s who recently got married and tells you, "I am not going to quit smoking." What are the intervention principles that we could apply to? One is raising conscious awareness of the behavior. However, give information when the patient agrees to. Dramatic relief involves paying attention to the feelings, or evoke emotion -like fear, excitement.
Environmental reevaluation is realizing the negative impact of unhealthy behavior or the positive impact of healthy behavior on the social and or physical environment.
Social liberation is the commitment to change one's behavior based on the belief that achieving healthy behavior is possible.
To move past pre-contemplation, one needs to acknowledge the unhealthy behavior for one not to achieve their important life goals like being healthy enough to enjoy traveling or spending time with their children and grandchildren.
Social liberation is the commitment to change one's behavior based on the belief that achieving healthy behavior is possible.
To move past pre-contemplation, one needs to acknowledge the unhealthy behavior for one not to achieve their important life goals like being healthy enough to enjoy traveling or spending time with their children and grandchildren.
Case:
C: Are you familiar with the risk of smoking? Do you know that it can have a direct effect in causing erectile dysfunction?
P: I did not know about that doc, how is that possible?
Raising conscious awareness. Make sure that it is necessary and that the patient can relate to it and is relevant to his current situation. If you are talking to a man who just recently got married in his 30s for example, then you give out information to him about the correlation between how cigarette smoking can decrease blood supply to the penile artery.
C: Are you familiar with the risk of smoking? Do you know that it can have a direct effect in causing erectile dysfunction?
P: I did not know about that doc, how is that possible?
Raising conscious awareness. Make sure that it is necessary and that the patient can relate to it and is relevant to his current situation. If you are talking to a man who just recently got married in his 30s for example, then you give out information to him about the correlation between how cigarette smoking can decrease blood supply to the penile artery.
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CONTEMPLATION STAGE
Contemplation is the “I may” or“I am thinking of making a change” stage. People are intending to start healthy behavior in the next 6 months. They acknowledge that they need the behavior change and are aware that the behavior is a problem, but they are not sure how to do it or still have not made a commitment to act. This stage is marked by ambivalence and motivational interviewing is the appropriate approach. If there is no intervention, patients can be chronic contemplators. The pros of changing a certain behavior equal the cons of change, that is why it is difficult to change. Our goal is for our patients to realize how the benefits will outweigh the risks.
CONTEMPLATION STAGE
Contemplation is the “I may” or“I am thinking of making a change” stage. People are intending to start healthy behavior in the next 6 months. They acknowledge that they need the behavior change and are aware that the behavior is a problem, but they are not sure how to do it or still have not made a commitment to act. This stage is marked by ambivalence and motivational interviewing is the appropriate approach. If there is no intervention, patients can be chronic contemplators. The pros of changing a certain behavior equal the cons of change, that is why it is difficult to change. Our goal is for our patients to realize how the benefits will outweigh the risks.
Case: "I am thinking about quitting but I do not know how."
I do not think I can do it, I am not sure if this will work."
It still uses the same intervention principles as raising conscious awareness, dramatic relief, environmental reevaluation, and social liberation and also uses self-reevaluation that helps the patient create a new image. In self- reevaluation, it is letting the patient realize that “not smoking” is a part of who they want to be.
“what would keep you from changing?”
“what keeps you from making the change?”
“what do you want to change this time?”
“what made you want to quit smoking?”
“what do you think you need to go about changing?”
“what are the reasons for not changing?”
Imagine you are free from smoking, how would it change your life?
I do not think I can do it, I am not sure if this will work."
It still uses the same intervention principles as raising conscious awareness, dramatic relief, environmental reevaluation, and social liberation and also uses self-reevaluation that helps the patient create a new image. In self- reevaluation, it is letting the patient realize that “not smoking” is a part of who they want to be.
“what would keep you from changing?”
“what keeps you from making the change?”
“what do you want to change this time?”
“what made you want to quit smoking?”
“what do you think you need to go about changing?”
“what are the reasons for not changing?”
Imagine you are free from smoking, how would it change your life?
Validate their feelings that change is difficult. Ask for possible barriers or challenges and arrive at a commitment to pursue a plan of action. Expressing empathy is especially important in this stage than confrontation. There are several ways you can help one to move to the next stage of change like making a list of the pros and cons, costs vs the benefits, examining the obstacles or barriers, and letting them think about how to deal with and overcome them. Educate your patient about the effects of smoking or being overweight that could lead to cardiovascular mortality and help them list options for achieving behavioral change. Schedule follow up to monitor and reinforce behavior change.
PREPARATION STAGE
Preparation is “I can”, "I want to do this", "I am going to do this", "I plan to do this soon" stage. Patients are ready to change in the next 30 days and are making small steps. They believe that changing their behavior can lead to a healthier life. Our goal is to move the patient into action when the patient will say, "I am going to quit smoking next week."
For these people, it is recommended that they move into behavioral steps like self-liberation on the belief that doing a healthy behavior is possible. "I am going to exercise tomorrow." "I am going to quit smoking next week." "If I have the urge to quit smoking, I will try to jog, or I will drink water or eat a banana" (counterconditioning). Make the patient write it down and tell the patient to write the specifics so that the plan is personalized. When the patient has a concrete, written action plan, this can be liberating for the patient. The patient is ready and willing to change and identifying a supportive spouse or family member, or buddy (helping relationships) can help the patient move into action.
That is why in alcohol use cessation, alcoholics anonymous, a support group can help each other stop the behavior. Counterconditioning or substitution is important for this stage also, like in smoking cessation when the urge to smoke is felt, jogging, or eating a banana can be substituted for it.
Preparation is “I can”, "I want to do this", "I am going to do this", "I plan to do this soon" stage. Patients are ready to change in the next 30 days and are making small steps. They believe that changing their behavior can lead to a healthier life. Our goal is to move the patient into action when the patient will say, "I am going to quit smoking next week."
For these people, it is recommended that they move into behavioral steps like self-liberation on the belief that doing a healthy behavior is possible. "I am going to exercise tomorrow." "I am going to quit smoking next week." "If I have the urge to quit smoking, I will try to jog, or I will drink water or eat a banana" (counterconditioning). Make the patient write it down and tell the patient to write the specifics so that the plan is personalized. When the patient has a concrete, written action plan, this can be liberating for the patient. The patient is ready and willing to change and identifying a supportive spouse or family member, or buddy (helping relationships) can help the patient move into action.
That is why in alcohol use cessation, alcoholics anonymous, a support group can help each other stop the behavior. Counterconditioning or substitution is important for this stage also, like in smoking cessation when the urge to smoke is felt, jogging, or eating a banana can be substituted for it.
ACTION STAGE
Action is the “I am” stage. Change is ongoing for the last 6 months. Patients have acquired new healthy behaviors and our goal is to let the patient maintain the behavior for 6 months or more. “I quit smoking for 3 days now.” New behaviors have been formed and it is important to acknowledge their strengths and values as they get along. It is also helpful to connect them to other individuals wherein they could foster new social relations who share the same interests as them.
Action is the “I am” stage. Change is ongoing for the last 6 months. Patients have acquired new healthy behaviors and our goal is to let the patient maintain the behavior for 6 months or more. “I quit smoking for 3 days now.” New behaviors have been formed and it is important to acknowledge their strengths and values as they get along. It is also helpful to connect them to other individuals wherein they could foster new social relations who share the same interests as them.
CASE:
C: "How is the exercise plan that you have made from our last session?"
P: "I was able to do 5 rounds around the village and we did more than 30 mins. It made me feel better and I can sleep well at night now."
C: "That is a great start, you have set your walking to 10 mins, but you did more than 30 mins even. What helped you go beyond your goal?"
P: "Well, some friends saw us, and they joined us as well. We talked and laughed while walking and we were having fun. Walking now helps me let go of my stresses and it relaxes me."
C: "Wow! I am happy to hear that. What strengths and strategies have you used to sustain your walking habit?"
P: "I want to walk more often now most especially at night, it feels good to reconnect with friends and neighbors. Before, we watched TV after dinner, but now we look forward to walking each night."
C: "How is the exercise plan that you have made from our last session?"
P: "I was able to do 5 rounds around the village and we did more than 30 mins. It made me feel better and I can sleep well at night now."
C: "That is a great start, you have set your walking to 10 mins, but you did more than 30 mins even. What helped you go beyond your goal?"
P: "Well, some friends saw us, and they joined us as well. We talked and laughed while walking and we were having fun. Walking now helps me let go of my stresses and it relaxes me."
C: "Wow! I am happy to hear that. What strengths and strategies have you used to sustain your walking habit?"
P: "I want to walk more often now most especially at night, it feels good to reconnect with friends and neighbors. Before, we watched TV after dinner, but now we look forward to walking each night."
If the patient is in this stage, it does not mean that the physician can ignore the patient, because in this stage the patient is prone to relapse and can become chronic contemplators. Reinforcement management and stimulus control can be used along with identifying healthy relationships. Who do the patient asks support from and tap people who would be there to assist him in making the change?
Reinforcement management is rewarding the positive behavior and reducing the rewards that come negative behavior. Now that you have been exercising for a month already, any changes you want to tell me? Or the practitioner can point out how leaner the patient is from the last time you saw him.
Stimulus control is re-engineering the environment to promote healthy change like getting rid of the ash tray and lighter. Eliminate cues that could remind of the unhealthy behavior. (LaMorte, 2019). “Clients need to be inspired”. Too much support and we baby them, too much challenge and we overwhelm them. As our patients will encounter challenges in their journey, we are here to help them analyze and come up with relapse contingency plans.
If the patient is in this stage, it does not mean that the physician can ignore the patient, because in this stage the patient is prone to relapse and can become chronic contemplators. Reinforcement management and stimulus control can be used along with identifying healthy relationships. Who do the patient asks support from and tap people who would be there to assist him in making the change?
Reinforcement management is rewarding the positive behavior and reducing the rewards that come negative behavior. Now that you have been exercising for a month already, any changes you want to tell me? Or the practitioner can point out how leaner the patient is from the last time you saw him.
Stimulus control is re-engineering the environment to promote healthy change like getting rid of the ash tray and lighter. Eliminate cues that could remind of the unhealthy behavior. (LaMorte, 2019). “Clients need to be inspired”. Too much support and we baby them, too much challenge and we overwhelm them. As our patients will encounter challenges in their journey, we are here to help them analyze and come up with relapse contingency plans.
MAINTENANCE STAGE
Maintenance is the “I am still doing it” stage when patients have sustained their behavior change for at least 6 months. Our goal is to maintain the behavior and for relapse prevention. Patients in this stage work to prevent relapse to earlier stages like the contemplation stage. There could be lapses or relapses and therefore the physician should ask about the desired healthy behavior.
Challenges include boredom and the danger of gradually slipping back into unhealthy old habits. We plan to revisit and reconnect with our patients to follow up on the action plan.
Case: (follow-up)
C: "How is your walking going?"
P: "I feel great doc, we are already walking every day and our circle is getting bigger."
C: "Congratulations!!! I am happy to hear that. The rainy season is coming, I wonder how you will continue your walking around the village when that time comes."
P: "I found a video and I will be doing that, at least I can continue my exercise regimen."
C: "Great! I would love to hear more about how you do this."
C: "How is your walking going?"
P: "I feel great doc, we are already walking every day and our circle is getting bigger."
C: "Congratulations!!! I am happy to hear that. The rainy season is coming, I wonder how you will continue your walking around the village when that time comes."
P: "I found a video and I will be doing that, at least I can continue my exercise regimen."
C: "Great! I would love to hear more about how you do this."
The motivator is “feeling good” and the presence of social support in her social circle. How is your exercise regimen going? What are the difficulties that you have encountered trying to exercise? Look for barriers and challenges in maintaining the new behavior. Stimulus control can be useful in this stage.
“If it takes 21 days to develop a new, easy habit, it may take 21 months to develop a new lifestyle.” (Moore M. , 2016)
RELAPSE STAGE
Relapse is the "I am no longer making the change." Relapse is the most common outcome of health behavior change programs. Relapse rates average to 50% in the first six months when it comes to exercise programs. There is a difference between a lapse and a relapse.
A lapse is a single event when an unhealthy behavior re-emerges that may or may not result in relapse. An example would be, missing out on an exercise program or regimen in a session.
Relapse is when one goes back to their unhealthy behavior. (e.g. patient returns to patterns of inactivity). Relapse may occur at any stage and when this happens, revisit the reason for the health behavior change. Collaborate with the patient and identify triggers for lapses of an action plan and find out the events that lead to the recurrence. What was the occasion? With whom were you with? The patient must know how to notice lapses before it becomes a relapse. We should be able to help the patient identify a support system that could help during these times. The pros of a healthy behavior should be highlighted and future goals should be well established so that relapse can be prevented.
- Negative emotions or stressful events
- Inadequate motivation
- Inadequate coping skills to deal with the situation
- Lack of social support
- Environmental cues
- Most relapse prevention strategies are designed to prevent or control these antecedents
Termination is when one no longer thinks of the previous unhealthy habits or fear that they might be tempted to do the behavior again. (LaMorte, 2019)
THE FIVE As
Assess the patient of his biochemical markers, diagnostic results, patient’s readiness to change, patient’s health knowledge, motivators for change intrinsic (wanting to feel energetic) or extrinsic (wanting to be fit in a dress for an upcoming wedding). Ask what the patient wants to know more from you, assess the patient’s confidence, willingness, and readiness to change, patient’s goals, what are the things that are valuable or important to him. in doing so, you as the provider will be able to help the patient plan.
Advice. Be non-judgmental, open-minded. The patient will need the physician’s interpretation of his laboratories or anthropometric measurements but should do so without being judgmental. You could say, based on your lab results, your cholesterol is way beyond the normal. If the patient will say, everybody in our family has that, so I am expecting this already. Then, you as a physician can advise, “Research shows that high cholesterol levels can put you at risk of developing a heart attack or stroke". You might ask, "What do you think you can do to bring down your cholesterol levels?" Then you will have a conversation with the patient, not a lecture. The goal is to lay all the medical facts and to have a conversation with them.
Agree: this is the most crucial step in the 5As. The patient must agree with the plans for change, he should be the one to create the plan for himself with your assistance so that he will be responsible in implementing the plan. When you use the “coach hat”, there will help the patient make behavior change be a natural thing to do.
Assist: the lifestyle medicine physician assists the patient into co-formulating the plan with the patient and that the action plan should be SMART (specific, measurable, action-oriented/attainable, realistic, and time-bound). You can also assist the patients in finding ways to learn how to cook, engage in physical activity like referring them to local classes, gyms, markets that they could buy affordable, fresh produce, online videos on exercise. You can also assist the patient in looking for support like an exercise partner, connect them with people who have same interests or goals as them.
Assist: the lifestyle medicine physician assists the patient into co-formulating the plan with the patient and that the action plan should be SMART (specific, measurable, action-oriented/attainable, realistic, and time-bound). You can also assist the patients in finding ways to learn how to cook, engage in physical activity like referring them to local classes, gyms, markets that they could buy affordable, fresh produce, online videos on exercise. You can also assist the patient in looking for support like an exercise partner, connect them with people who have same interests or goals as them.
Arrange: for a follow-up, we need to evaluate them and check on them if the plans are realized. You must set the specific follow-up date based on the co-formulated plan so they may know how important the plan is and how serious you are in helping them realize their goals. In this way, the patient will feel important and valued.
people change because
people change because
- their values support it,
- they think the change will be worth it,
- they think they can,
- they think it is important,
- they are ready for it,
- they believe that they need to take charge of their health, and
- they have a good plan and adequate social support
Before a person adopt to change, according to the Wellcoaches, one may want to ask:
- why do I want to change, what makes the change important to me? (pros)
- why should I not change, what is keeping me from changing? (cons)
- do the pros outweigh the cons?
- What would it take for me to change the behavior and overcome the obstacles to change? What is my plan?
- Can I really do it?
core influence on behavior change
Human behavior is probably one of the most studied phenomena. Several theories have been formulated explaining how and why certain behaviors are developed even from the beginning, in infancy and childhood, and how they are the modified or maintained till the end of life (Coleman & Pasternak, 2012). Health behaviors include not just lifestyle but also those that are clearly associated with clinical consultations from help-seeking to adherence to medical management. The scope is wide. While it is difficult to tease out individual factors since they tend to be all related, an attempt will, nonetheless, be made in the succeeding sections to highlight their importance. some of the theories explaining health behaviors will be mentioned in the discussion of these factors. These factors - self-efficacy, attribution, locus of control, and cognitive dissonance address the individual's perceptions as to where control over personal actions lie. The aim is to heighten awareness of personal control.
SELF-EFFICACY
Based on the theory formulated by Albert Bandura (1986), self-efficacy defines the person's belief in one's own capabilities. It is often linked with self-esteem or self-confidence although self-efficacy has more to do with capabilities, whereas the latter has more to do with self-worth. Generally, however, it is considered that high self-efficacy brings about high self-esteem and vice versa. This makes it a core influence on a person's behavior. Children learn early in life that they have some capability of controlling their environment. Through this ability, the child learns to successfully execute actions necessary to meet his/her needs. During these crucial years, the family is particularly important in providing encouragement, as well as becoming models and standards of behaviors when compared to those with a lower sense of personal control (Bandura & Locke, 1988; Anees & Gorjala, 2010). Smokers who think they are incapable of quitting will not even try to, but those who believe they can succedd are actually able to quit and stop the habit (DiClemente, Prochaska, & Gibertini, 1985). Strong evidence was found for the effects of self-efficacy on making people consume more fruits and vegetables (Shaikh, Yaroch, Nebeling, Yeh, & Resnicow, 2008). The role of self-efficacy has become so established that, in fact, strategies that improve self-efficacy are used to measure successful behavior change (Brown, Wengreen, Vitale, & Anderson, 2011).
Based on the theory formulated by Albert Bandura (1986), self-efficacy defines the person's belief in one's own capabilities. It is often linked with self-esteem or self-confidence although self-efficacy has more to do with capabilities, whereas the latter has more to do with self-worth. Generally, however, it is considered that high self-efficacy brings about high self-esteem and vice versa. This makes it a core influence on a person's behavior. Children learn early in life that they have some capability of controlling their environment. Through this ability, the child learns to successfully execute actions necessary to meet his/her needs. During these crucial years, the family is particularly important in providing encouragement, as well as becoming models and standards of behaviors when compared to those with a lower sense of personal control (Bandura & Locke, 1988; Anees & Gorjala, 2010). Smokers who think they are incapable of quitting will not even try to, but those who believe they can succedd are actually able to quit and stop the habit (DiClemente, Prochaska, & Gibertini, 1985). Strong evidence was found for the effects of self-efficacy on making people consume more fruits and vegetables (Shaikh, Yaroch, Nebeling, Yeh, & Resnicow, 2008). The role of self-efficacy has become so established that, in fact, strategies that improve self-efficacy are used to measure successful behavior change (Brown, Wengreen, Vitale, & Anderson, 2011).
ATTRIBUTION
Closely related to self-efficacy is the concept of attribution. To attribute means to assign. Medical studies reveal that individuals attribute undertakings to either one of four things: ability, effort, task difficulty, or luck (Anderson& Anderson, 1990). Internal attribution is differentiated from external attribution. Internal attribution is demonstrated by people who credit their accomplishments to their abilities and the effort with which they are able to achieve their goals. External attribution is expressed when circumstantial factors and luck are invoked to explain an occurrence (Hewstone, Fincham, & Foster, 2005). The Filipino "bahala na" is a form of external attribution (Church & Katigbak, 1990). Events are often attributed to fate rather than to personal effort. Those who subscribe to individualism are better able to confidently claim success.
Closely related to self-efficacy is the concept of attribution. To attribute means to assign. Medical studies reveal that individuals attribute undertakings to either one of four things: ability, effort, task difficulty, or luck (Anderson& Anderson, 1990). Internal attribution is differentiated from external attribution. Internal attribution is demonstrated by people who credit their accomplishments to their abilities and the effort with which they are able to achieve their goals. External attribution is expressed when circumstantial factors and luck are invoked to explain an occurrence (Hewstone, Fincham, & Foster, 2005). The Filipino "bahala na" is a form of external attribution (Church & Katigbak, 1990). Events are often attributed to fate rather than to personal effort. Those who subscribe to individualism are better able to confidently claim success.
LOCUS OF CONTROL
Locus of control may also be internal or external. People who allow themselves to constantly affected by circumstances around them have an external locus of control. Actions are dictated by what others say or by circumstances. In contrast, people with an internal locus of control take matters into their own hands and create their own destiny. Much of the initiative in health promotion in the Philippines are aimed at people empowerment or, as often declared, placing 'health in the hands of people" (Alfonso, 1989).
Locus of control may also be internal or external. People who allow themselves to constantly affected by circumstances around them have an external locus of control. Actions are dictated by what others say or by circumstances. In contrast, people with an internal locus of control take matters into their own hands and create their own destiny. Much of the initiative in health promotion in the Philippines are aimed at people empowerment or, as often declared, placing 'health in the hands of people" (Alfonso, 1989).
COGNITIVE DISSONANCE
Cognitive dissonance points to the internal conflict created when a long-held beliefs is challenged by a new one. An alcoholic automatically denies the negative consequences of his/her drinking habit until something actually happens - loss of job or a break-up of a significant relationship (Agustyn, & Simons-Morton, 2000). A smoker is contented and considers the habit a source of relaxation until confronted by facts about the diseases associated with cigarette-smoking. In counseling, clients often not in agreement with their perception. This dissonance created is intentional in this case. It is expected that the clients change their perception and eventually choose a different path.
Cognitive dissonance points to the internal conflict created when a long-held beliefs is challenged by a new one. An alcoholic automatically denies the negative consequences of his/her drinking habit until something actually happens - loss of job or a break-up of a significant relationship (Agustyn, & Simons-Morton, 2000). A smoker is contented and considers the habit a source of relaxation until confronted by facts about the diseases associated with cigarette-smoking. In counseling, clients often not in agreement with their perception. This dissonance created is intentional in this case. It is expected that the clients change their perception and eventually choose a different path.
It is more effective to enlist strategies that address the complex interaction of motivations, cues to action, perception of benefits and consequences, expectancies, environmental and cultural influences, self-efficacy, state of readiness to change, ambivalence, and implementation intentions. Motivational interviewing is one such approach.
In the stage-matched intervention, there are steps you could use in assisting behavior change so that you could give treatment recommendations and provide stage-matched interventions. Our goal is to move the patient forward to the next level of change not necessarily the action itself. Offer interventions that fits the level of the patient’s readiness. And if one is in the contemplation stage, do not suggest exercise programs to the patient.
In the early stage of change that is the precontemplation and contemplation, motivational interviewing is used and cognitive behavior therapy (CBT) Techniques in the later stage for the preparation, maintenance, and action. In all stages employ positive psychology.
We evaluate the patient’s readiness for change stage and provide stage-matched interventions. One of the goals is to increase a sense of self-efficacy that one has the capacity to make a change in a desired area. To foster self-efficacy to our patients, we should pay attention to these sources, physiological/affective states, verbal persuasion, vicarious experiences, and mastery experiences. These when combined with the transtheoretical model of change, appreciative inquiry, motivational interviewing, positive psychology would complement the coaching process. (Moore m. , 2016)
In the stage-matched intervention, there are steps you could use in assisting behavior change so that you could give treatment recommendations and provide stage-matched interventions. Our goal is to move the patient forward to the next level of change not necessarily the action itself. Offer interventions that fits the level of the patient’s readiness. And if one is in the contemplation stage, do not suggest exercise programs to the patient.
In the early stage of change that is the precontemplation and contemplation, motivational interviewing is used and cognitive behavior therapy (CBT) Techniques in the later stage for the preparation, maintenance, and action. In all stages employ positive psychology.
We evaluate the patient’s readiness for change stage and provide stage-matched interventions. One of the goals is to increase a sense of self-efficacy that one has the capacity to make a change in a desired area. To foster self-efficacy to our patients, we should pay attention to these sources, physiological/affective states, verbal persuasion, vicarious experiences, and mastery experiences. These when combined with the transtheoretical model of change, appreciative inquiry, motivational interviewing, positive psychology would complement the coaching process. (Moore m. , 2016)
- Physiological/affective states: when evoking a behavior change, we should make sure our patient is comfortable (relaxed and confident) physically and emotionally in the change he is going to embark. They become engaged when they are in control and not overwhelmed. This happens when there are in the flow zone and patients tend to do more of the things that fill them with energy.
- Verbal Persuasion-Evoking Change Talk: patients’ self-efficacy is influenced by things that people say to us and the things that people so around us. Verbal persuasion cannot happen when we wear the expert hat telling the patients what to do. The more we persuade our patient of what they should do, the more resistant they become and thus reduces their readiness for change. The more we convey our heart-felt and sincere confidence in the ability of our patients to reach their goals, based on their strengths, the more self-efficacy is developed.
- Vicarious Experiences- Observing similar role models. Guide the patients in leading them to the success of others doing the behavior. Collaboration of stories between the patient and the physician is a better approach than physicians telling the stories himself. They physician can assist patients in finding the platform from which our patients can watch others do what they want to do. The more they can witness how a certain behavior can produce great results, the more self-efficacy grows.
- Mastery Experiences – Successful, Perseverant Efforts. Initially patients just observe others and when they adapt it and have great experience themselves, the more self-efficacy grows. To increase the intensity and quality of the patient’s mastery experiences, physicians should accurately determine where the patient is in the transtheoretical model of change and guide them to the stage-specific interventions, step-wise goals that are both engaging, doable and manageable and not overwhelming. Using motivational interviewing principles, physicians and clients work hand in hand to see the whole picture and set goals, identify the patient’s intention with motivation and meaning, co-create specific SMART goals, and assess the patient’s level of confidence and tailor the action steps necessary to increase confidence, create plans for lapses or relapses, help patient envision success and positive outcomes and reiterate commitment, strengths and capability, thus creating flow and self-efficacy.
We are about to discuss evidence-based behavior change techniques and the core skills physician “coaches” should have:
- Motivational interviewing for early stage of change
- Cognitive behavioral techniques for later stages
- Positive psychology in coaching for all stages and empowering the patient
motivational interviewing
HISTORY
Motivational interviewing started in the 1980s by psychologists Stephen Rollnick and William Miller within the setting of alcohol addiction treatment wherein when patients were elicited their reasons for change the resistance in changing the habit decreased and their motivation for behavior change also increased. Patient-centered communication skill that promote self-efficacy based on the patient’s own desire for change with the focus on increasing one’s readiness for change.
It focuses on the patient’s strengths, values, and goals, as we listen to their concerns, boosting their confidence in their own ability to change and eventually collaborate with them on their plans of changing. Motivational interviewing is a skill a lifestyle medicine physician should master. People want to change but it is easier to stay the same and requires less effort. Motivational interviewing will help them strengthen their motivation for change by eliciting change talk. Patient will verbalize their own reasons for change and end up convincing themselves on changing. We could help the create a decisional balance, weighing the pros and the cons of behavior so the patient can reevaluate their thoughts and attitudes toward smoking or exercise.
Principles of motivational interviewing includes engaging, focusing, evoking, planning. Evoking or encouraging change talk. Helps the patient convince themselves that the change will be worth it. The guiding principles of Motivational Interviewing includes:
1. Express empathy through reflective listening - foundation of Motivational counseling style
2. Develop discrepancy between the clients’ goals or values and their current behavior
3. Roll with Resistance. Avoid argument and direct confrontation. If you can sense resistance, it is an opportunity for you to change direction or listen more carefully to what the patient is saying.
1. Express empathy through reflective listening - foundation of Motivational counseling style
- Listens rather than tells
- Gently persuades while maintaining patient autonomy
- Provides support throughout the process of change
- Ambivalence is normal
- Accepts the patients nonjudgmentally
2. Develop discrepancy between the clients’ goals or values and their current behavior
- Helps patients examine their behavior and their motivation for change
3. Roll with Resistance. Avoid argument and direct confrontation. If you can sense resistance, it is an opportunity for you to change direction or listen more carefully to what the patient is saying.
- The more the physician is seeking to understand the patient, the more open the patient becomes.
- The more the physician believes in the confidence of the patient to do the behavior, the more likely they will do it.
- The more collaboration is made by the patient and the physician, the more engaging the change becomes
- The more the physician counterbalances client’s ambivalence with appreciative awareness of the good reasons not to change, the more change talk is generated.
5. Support self-efficacy and optimism and the feasibility of accomplishing change. This is critical that you believe in the patient’s ability to achieve their goals. Other patients would want to hear success stories that may give them more encouragement. They could ultimately come to realize that change is their responsibility and that long-term success can begin with a single baby step. When the patient will begin to feel the advantages of the behavior change, the more likelihood the behavior will be continued. Mastery experiences generate a constructive upward cycle in the stage of change.
Success of Motivational Interviewing entails being able to:
- Express empathy through reflective listening.
- Develop discrepancy between patient’s goals or values and current behavior, and helping patient recognize this discrepancy between where they are and where they hope to be.
- Roll with resistance
- Convey Respect and accept the patient and how they feel
- Compliment rather than criticize
- Listen rather than tell
- Gently convince while keeping in mind that change is up to the patient
- Give support throughout the process of change
- Avoid debate and confrontation that can lead to altercation and power struggle
- Adjust to client’s resistance
- Support self-efficacy and positive emotions that is focusing on the patient’s strengths to support hope and optimism needed to make change
In motivational interviewing, we use reflective listening skills, asks open ended questions. It's a question that can start with what, or how to elicit a patient’s values. How important is it to you to wake up in the morning not feeling tired? The patient may say, if I wake up in the not tired, I can be more productive. Connecting health behaviors to patient’s values can give them reasons on why they should change. Open-ended questions enable the patient to speak more and share what they have in mind.
Affirmations: are statements and gestures that recognize client strengths and highlight behaviors that lead in the direction for positive change no matter how small it is. When genuine and congruent, Affirming the efforts of the patient will help build confidence in one’s ability to change.
Reflective statement: active listening and offer patients to clarify or elaborate what was said, for example, it seems like you are frustrated that you wake up in the morning feeling tired. You may allow him to concur and reflect on the topic (e.g. Yes, I would like to sleep early so that I will be more productive and do more activities during the day.)
Summaries: this reaffirms the patient that the patient is being listened to because the physician can summarize and understand what the patient has conveyed in his verbal and non-verbal cues. Doing motivational interviewing gains rapport, trust, and confidence that the patient is in good hands because the provider has understood the patient.
Knowing what the patient already knows, can help you target the information that you may give to the patient, relevant information that may ignite his receptivity to you. So, for example, What resources are you aware of, that may help you quit smoking? Understanding what the patient already knows will save time for both the health care provider and the patient.
During the self-discovery process, the patient can explore and formulate his or her reasons for change. Motivational interviewing is useful in the earlier stage of the Transtheoretical Model for change in which the patient is not yet ready or motivated for change. This approach engages patients in problem solving rather than the health care provider telling them or prescribing them to change.
During the self-discovery process, the patient can explore and formulate his or her reasons for change. Motivational interviewing is useful in the earlier stage of the Transtheoretical Model for change in which the patient is not yet ready or motivated for change. This approach engages patients in problem solving rather than the health care provider telling them or prescribing them to change.
Early sessions approach:
We should listen to the patient as they enumerate the pros of smoking and understand the patient’s motivators. You can use assessment tools for readiness for change using the Likert score. When discussing the cons (change talk) use the Likert (importance) scale to help the patient determine how important is it to him to go about changing (like from 0-10, 10 being the most important and 0 being not important). If patient verbalizes that starting an exercise regimen is an 8, you will know that the patient feels strongly about doing it. The next area to check is the level of confidence using again the Likert scale. How confident are you that you will be able to start exercising, if the patient says, 5, you may ask, why not 2 or 1. The patient can enumerate reasons why they are confident than the number they picked, this way, the patients are convincing themselves that they can actually quit.
- Help patients address their natural ambivalence
- Assess their readiness to change
- Ask open-ended questions (encourages patients to do the talking)
- Listen reflectively
- Summarize what transpired in the counseling session
- Enables patients to evaluate their response and contemplate on their own experiences
- Affirm your support to the client promotes self-efficacy
- I understand, I hear while validating the client’s feelings and experiences
- Initiating the exercise must have been hard for you.
- Elicit self-motivational statements
We should listen to the patient as they enumerate the pros of smoking and understand the patient’s motivators. You can use assessment tools for readiness for change using the Likert score. When discussing the cons (change talk) use the Likert (importance) scale to help the patient determine how important is it to him to go about changing (like from 0-10, 10 being the most important and 0 being not important). If patient verbalizes that starting an exercise regimen is an 8, you will know that the patient feels strongly about doing it. The next area to check is the level of confidence using again the Likert scale. How confident are you that you will be able to start exercising, if the patient says, 5, you may ask, why not 2 or 1. The patient can enumerate reasons why they are confident than the number they picked, this way, the patients are convincing themselves that they can actually quit.
SITTING IN THE RED CHAIR
Coaching interaction often includes 2 person sitting in two different chairs:
Coaching interaction often includes 2 person sitting in two different chairs:
- One person in the red chair -- "can't be done; too many barriers"
- One person in the green chair -- "can be done; there must be a way around the barriers"
SMART GOAL SETTING
SMART goal setting assist patients make specific goals will help them see the end in mind and make plans in between to bring that goal nearer to the patient. Being specific with regards to the details, the patient can envision how the goal can be accomplished in a specific time frame. Goals should be measurable like a 5kgs-drop after the end of a month, or to lower blood pressure or cholesterol levels, or to follow an exercise program 5x a week for 30 mins a day in which I will be able to talk but not sing. When goals are specific, the patient will know when they have successfully achieved their goals. Realistic goals like, "I am going to swim" if there is a swimming pool nearby of if patient has access to a pool. Why do we need to set goals? To give our patients directions and mobilize what they need to do, it also increases persistence into doing something while having a vision board ahead of them, and this leads to them being enthusiastic. Behavior must be tailored to the person’s stage of change. Not until the patient is ready to action, coaches can stay in the listening and inquiry mode and assist clients into “thinking of doing” to increase their readiness to change.
In managing behavior change, one needs to include stress management interventions because we all know the negative consequences of stress has to our physical and emotional well-being, doing mindfulness practices to regulate one’s emotions, having positive emotions also improve our physical and mental health, and having a greater meaning and purpose in life. (Moore M. , 2016) When all of these things are addressed one can have a long lasting, internally motivated -sustainable health behavior change. We can pave a way to health transformation and cultivate these health promoting behaviors in the treatment, management, prevention, and reversal of many chronic diseases that is very prevalent in our society today. We can apply our coaching skills in many settings, (in-person and telephone, individual and in groups).
Lifestyle prescriptions are actions needed to treat or prevent a condition based on the scientific evidence and the patient’s medical condition. Example: A patient is prescribed to perform strength building exercises at least 2 days a week based on the exercise guidelines.
Action plans are the lifestyle prescriptions adjusted for the patient’s ability, readiness, and confidence. Example: Start with 5-kgs kettle bell and increase as tolerated (among the chosen activity) that uses all major muscle groups in both the upper and lower body and be repeated as tolerated.
Action plans are the lifestyle prescriptions adjusted for the patient’s ability, readiness, and confidence. Example: Start with 5-kgs kettle bell and increase as tolerated (among the chosen activity) that uses all major muscle groups in both the upper and lower body and be repeated as tolerated.
Sample action plan.
- What? Gardening
- How much? At a pace that I can still speak but not sing
- How long? 20 minutes
- How often? 3-4x a week
- With whom? With kids or house help
- When? In the morning just before sunrise
- Support system? Husband and kids who can remind me to do gardening
- Biggest barrier? When it rains
- Solution to barrier? Alternative physical activity like doing exercise videos from the internet
- Confidence level? 8/10
Goal setting
Goal setting
- When we set goals for our patients we should make sure that the goals are specific, measurable, attainable, realistic and time-bound or else the patient will be overwhelmed and would not be able to do the desired change because it is too much for them to do. An example of a SMART action plan, "I will do three 10-minute brisk walking around the village every after meal everyday with my dog and husband" Focus on developing the habit slowly and make sure that it is doable, and that we can quantify the task at hand not just saying “start exercising 5x a week”. You must elicit from the patient what she wants to do, what her/his flow experiences are. The patient must be able to self-discover how he or she might do her exercise -small baby steps, one step at a time goes a long way. Do not overwhelm. A regular follow-up with them is necessary as relapse or setbacks is viewed as an expected part of change.
Video Review
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