Motivating Behavior Change in Patients

David W. Greaves, Ph.D.

Dept. of Psychiatry, OHSU

VA Portland Health Care System

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Behavior Change is Hard

• Not just instilling new behavior, asking people to break old habits

• Negative emotions do not help change (e.g., fear, shame)

• Real skills are required

• Historical culture of patient passivity in Medicine

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Patient Compliance and the Role of the Expert (1979)

• “Many studies of such [compliance] failure lead to the conclusion that every patient should be considered as potentially ‘non‐compliant.’ The most promising site for intervention is in the expert‐patient interaction.”

• Expert’s role: • explore the patient’s situation

• Anticipate patient’s difficulty following recommendations

• Communicate in a way that will maximize information’s effectiveness

Stone, George C. (1979). Patient Compliance and the Role of the Expert. J. of Social Issues, 35 (1), 34-59.

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Assumptions about Common Barriers to Change

• Underestimation of cost of current behaviors

• Lack of skills

• Lack of social support

• Lack of ownership

• “Social Proof”

• Fear of failure

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Likely Characteristics

• Basic understanding of what needs to happen and the potential risks of maintaining current course

• Certain level of ambivalence (MI)

• Multiple attempts to make changes (or at least multiple times they have thought about change)

• Failures lead to discouragement and lost confidence

• Complex reasons for lifestyle choices

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Promoting Behavior Changeby Applying Principles of Whole Health along with Motivational Interviewing OHSU

Whole Health Model • A collaborative approach to

healthcare that focuses on overall well-being

• Inspires, empowers and equips people to take charge of their health and live their life to the fullest.

• This is not just about obtaining physical health; broader definition of well-being

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•What really matters to you in your life?

•Why do you want to have your health?

•What brings you joy and happiness?

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Motivational Interviewing (MI)

• A counseling method that helps people resolve ambivalent feelings and insecurities to find the internal motivation they need to change their behaviorOHSU

Plan for facilitating change

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Healthy Engagement

• A partnership of “two experts”

• The patient truly feels like you are both working together; avoid the expert trap

• Putting patient at the center of care• They take ownership• They decide what it important to them

• Can your patient say….• “My doctor understands what I need”• “I trust my doctor”• “I have a say in my treatment plan”

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Simmons et al (2014)

• “The role of patient engagement…is…critical for improving health outcomes and reducing costs.”• Taking an active role in one’s own health

• Having knowledge and skills needed to succeed

• Choosing healthy behaviors

• Engagement is linked to improved outcomes

• Lack of engagement is a legitimate risk factor

Patient engagement as a risk factor in personalized health care: a systematic review of the literature on chronic disease. Leigh Ann Simmons, Ruth Q Wolever, Elizabeth M Bechard & Ralph Snyderman. Genome Medicine volume 6, Article number: 16 (2014)

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Characteristics of Therapeutic Relationships (TR) (Koloroutis & Trout, 2012)• Attuning

• Wondering

• Following

• Holding

• “These practices are not used in order to facilitate change in our patients but are instead therapeutic interventions in and of themselves.”

Sets the table for MI OHSU

Helping them find their reason to change

• “Changing the conversation”

• Basic questions of Whole Health

• MI process of helping patient navigate the ambivalence of change

• “Preparatory” and “Mobilizing” language • May hear talk that indicates desire, ability,

reasons or need to change

• Talk of commitment, activation, taking steps

• Listen for the status quo “Sustain Talk”

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Evoking Change Talk

• Ask for it!• In essence, asking the pro-change members of the committee in their head to

speak.

• OK to call out the ambivalence (“you’ve been of two minds….”)

• Examples from Miller (2013)

• The Importance Ruler

• Asking about extremes; Looking forward or back

• Looking at values

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The “MAP” of Whole Health

Mission• What do you see as your personal mission in

life? What are the values that guide you?

Aspiration• Hopes and lofty goals

Purpose• Why you? What is your role in the world?

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Mission, Aspiration and Purpose (MAP) exercise

• Create a list of words that describe you, your values, what you want out of life, your roles, what’s important

• Choose 2-3 words that stand out to you that really inspire you

• Select one of those words and free-write about it for 2 minutes

• Develop a six-word summary of your writing: a synopsis of what matters to you

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Next steps—nudging them toward change

• When you hear change talk, ask more about it!• Open ended questions

(elaboration or example)

• Affirming responses

• Positive Reflection

• Examples from Miller (2013)OHSU

Building Hope and Confidence

• Value of partnership and support

• Allow patient to talk about their preferred plan (suggestions are OK)• “what would work best for you?”

• “how could you do that?”

• Confidence Ruler

• Identify and affirm their strengths (and past successes)

• Use hypothetical thinking• “Suppose you succeed and look back on the process—what most likely worked

the best?”

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Begin to focus specific goals

• “An unhurried mind is an asset”

• Creating a Personal Health Plan• Self reflection and exploration

• Education and skill building

• Goal setting

• May be indirectly related to final goal

• May be related to other aspects of wellnessOHSU

SMART Goals

• Specific (what are you going to do)

• Measurable (how will you know you’ve made it)

• Action-oriented (what actions will you be taking)

• Realistic (is it reachable and desirable—relevant)

• Time-specific (when will it happen)OHSU

Building the support system

• Reward and reinforcement of positive change

• Motivation may come from • Competition

• Socialization

• Achievement

• Value of coach or mentor-type person

• Use of Apps

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Dealing with Lapses

• Framing the incident in positive ways

• Let them lead the analysis of the lapse

• Reconnect with stated values and aspirations

• Maintain hope

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Special Considerations

• Maintaining change

• Cultural competence is important

• Values of Provider OHSU

Fin

Questions?

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