Helping People Change Health-Related Behaviors
Judith Swan, MSN, BSN, ADN
Persis M. Hamilton, EdD, MSN, BSN, PHN, PMHN
It is readily recognized that changing a behavior and forming new habits is a hard thing to accomplish, and healthcare professionals are often frustrated when patients do not follow medical advice or treatment recommendations. It may be difficult to understand the reluctance or unwillingness of a patient to make important changes that have been shown to improve health and well-being, especially after healthcare professionals have repeatedly stressed the importance of doing so.
Recognizing both the difficulties and resistance to change, researchers continue to examine the nature of change and how healthcare professionals can motivate, educate, and support individuals throughout the process of change.
Borrowing from knowledge gained concerning efforts to make change within organizations, healthcare professionals have adopted the concept of a change agent whose role involves assisting individuals in understanding why change is necessary, but more importantly in understanding how change benefits them. An effective change agent is an active listener who provides tools, assistance and resources that will enable change to occur (Kennedy, 2014). To accomplish this, healthcare professionals must:
- Understand the nature of change
- Develop a collaborative relationship and negotiate an action plan
- Communicate in ways that facilitate behavioral change
THE NATURE OF CHANGE
Change is movement, alteration, adaptation, and action. Change is inevitable.
Change is a process and not an event; it occurs with or without a particular timetable, expert direction, or even planning. Sometimes change occurs slowly and subtly, sometimes quickly and dramatically. Even when it is planned and specific outcomes are identified, change occurs haphazardly and seldom proceeds in a straight line or at a steady pace because it is affected by multiple internal and external factors.
All planned change has an end goal: a specific outcome the planner hopes to achieve. Even so, healthcare professionals differ regarding the most effective way to bring about such an end. Some clinicians take a content-driven approach to planned change, while others follow an outcome-driven approach.
Those who take a content-driven approach theorize that when patients receive information about a disorder or a harmful activity, they will “see the light,” apply the data to their personal situation, and change their behavior. This approach tells people what they need to change but does not build motivation to change. Content is necessary, of course, but not sufficient (Hamel & Zanini, 2014).
A more effective method of bringing about planned change in patients is to use an outcome-driven approach. This approach focuses on specific, measurable objectives. Information is personalized and related to specific goals.
STAGES OF CHANGE
In order to help patients make change and to maximize the success of interventions, it is important that healthcare professionals have a theoretical understanding of change. Such theory comes from the accumulated knowledge about what mediates and moderates change behavior. There are currently at least 82 theories of behavior and behavior change (David et al., 2015).
FOUR MAJOR THEORIES AND MODELS OF CHANGE BEHAVIOR
- Theory of Planned Behavior (TBP): Change in behavior is determined by intention to perform the behavior.
- Health Belief Model (HBM): Behaviors are based on attitudes and beliefs.
- Social Cognitive Theory (SCT): Change is driven through interaction between environment, personal factors, and attitudes.
- Transtheoretical Model (TTM): There are six stages of change.
Of the four major theories and models, the most widely applied and tested of them is the Transtheoretical Model (TTM), also referred to as Stages of Change. This model identifies six sequential stages that people move through as they change from old behaviors to new ones:
Stage 1: Precontemplation
Precontemplation is the stage when there is no conscious intent to make a change. A precontemplator may have a sense that a behavior is not beneficial but is reluctant to consider change. Some individuals may be rebellious or resistant to being told what to do. Others may be resigned, having given up hope about any possible change. And others may use rationalization to deny that there is a need to change a behavior.
Stage 2: Contemplation
Contemplation is the stage when individuals are aware that the behavior is a problem and intend to change behavior relatively soon, but they may vacillate for a long period of time. Often, people in the contemplation stage are not yet truly ready to change. They may procrastinate or doubt their ability to change. Individuals in this stage are often highly ambivalent, may be interested in learning about how to make change, but still cannot make a decision.
Stage 3: Preparation
Preparation is the stage in which individuals know they must change and become committed to take action to change. Often something happens to motivate a person to take action, such as an emotion-laden crisis, recent illness, or plea from an important person in their life. During this stage, not all ambivalence has been resolved but it no longer is an impossible barrier to overcome. Preparation involves creation of a realistic action plan with achievable goals, often with the help of a healthcare professional.
Stage 4: Action
This is the stage where people believe they have the ability to change behavior and are actively involved in taking steps to do so. They develop new habits and work toward what some have called “SMART objectives.” These objectives are specific, measurable, attainable, realistic, and time-bound.
|S||Specific||“I will no longer smoke cigarettes or any other substance.”|
|M||Measurable||“I will keep not one cigarette, even an ‘emergency smoke,’ in my environment.”|
|A||Attainable||“I have overcome other cravings. Other folks have stopped smoking, and I can too.”|
|R||Realistic||“Smoking is not necessary for survival, and in fact, it may kill me.”|
|T||Time-bound||“I will stop smoking on January 1, the beginning of a new year.”|
Stage 5: Maintenance
Many people relapse into old behaviors. Relapse is common and may even be inevitable. Maintenance is the stage in which people work to prevent relapse. They are tempted to go back to their old behaviors and need ongoing support to develop new patterns of living. Such support is enhanced by encouragement from primary care providers, colleagues, friends, and members of self-help groups or counseling groups. Most people spiral up and down these five stages of change several times before they make a lasting change. But it is said that as long as the person is in the spiral, he or she is making progress.
Stage 6: Termination
Termination is that time when temptation to relapse is no longer a threat. The person now has complete confidence that change has been accomplished and no longer fears relapse.
TECHNIQUES FOR FACILITATING CHANGE
To bring about behavioral change, healthcare professionals use a variety of techniques to support clients in making significant, health-promoting changes in their lives. Techniques used for this purpose include:
- Applying motivational interviewing in practice
- Eliciting change talk
- Arranging follow-up
- Encouraging those clients who do not seek change
Motivational Interviewing (MI) in the Healthcare Setting
All of the following supportive techniques help to bring about behavioral change and constitute what is called motivational interviewing. Those who practice motivational interviewing:
- Show nonjudgmental empathy. Nonjudgmental empathy is the ability to encourage patients to fully express themselves, allowing the patient to dominate the discussion. The empathic listener is attentive to what is being said, does not judge, does not interrupt, is sensitive to the emotion being expressed, and attempts to see the world through the patient’s eyes.
- Listen attentively and reflectively to patients to draw out rather than impose ideas. Attentive listening involves the use of positive body language such as facing the person and making frequent eye contact to actively be “seen” as listening. Reflective listening involves expressing back to the patient was has been heard using either the patient’s own words or rephrasing them.
- Develop and examine the discrepancy between the individual’s goals and current behavior. This involves helping the person focus on how current behavior differs from desired behavior by describing what the person’s values are and how current behavior is in conflict with them.
- “Roll” with resistance by recognizing, acknowledging, and exploring the patient’s resistance rather than opposing it. Resistance is evident by such behaviors as rejecting an idea, disagreeing, excusing, minimizing, inattention, ignoring, or being defensive. The clinician avoids arguing for change and addresses the underlying concerns and fear of change.
- Empower the patient to make change and give responsibility to the patient, rather than being a passive recipient of healthcare. Empowerment is a process that involves collaborative interaction, education, counseling, coaching, as well as self-education.
- Support self-efficacy. Self-efficacy is the patient’s belief that change is possible and that he or she has the ability to make change. The clinician focuses on eliciting and supporting optimism by recognizing past successes, highlighting skills and strengths.
(Miller & Rollnick, 2002; Ingersoll, 2015; MINT, 2014; Lochte & Markgraf, 2015; Tartakovsky, 2016)
ROADBLOCKS TO LISTENING
- Commanding, directing, ordering
- Threatening, warning
- Providing solutions, making suggestions, or giving advice
- Using logic, lecturing, or arguing in order to persuade
- Preaching, moralizing, using “should do’s”
- Judging, disagreeing, blaming, or criticizing
- Approving, praising, agreeing
- Ridiculing, labeling, shaming
- Interpreting or analyzing
- Sympathizing, consoling, or reassuring
- Probing with questions
- Humoring, changing the subject, distracting, withdrawing
Source: MINT, 2014
Eliciting Change Talk
The more an individual talks about change, it is said, the more likely they are to change. Change talk consists of responses the clinician elicits from patients. Patients’ responses normally contain reasons for change that are important to them personally.
The clinician elicits change talk by:
- Asking evocative questions (what, when, where, how) and avoiding why questions
- Exploring decisional balance (pros and cons of change)
- Asking for elaboration or example (“Tell me more about …”)
- Looking back to the time before the onset of the behavior (“How was it different/better?”)
- Looking to what life would be like a few years from now (goals and values)
- Asking about extremes (“What are the worst things that may happen if change does not occur, and what are the best things if it does?”)
- Siding with the status quo (“Drinking is so important to you that you won’t stop no matter what it costs you.”)
Sources: APA, 2016b; Bienenfeld, 2016; Topp et al., 2015; Manea et al., 2016.
Many people relapse into old behaviors. Relapse is common and may even be inevitable. Maintenance is the stage in which people work to prevent relapse.
As change agents, healthcare professionals realize that even when their patients are well along on the path toward their objective, they must work to prevent relapse. Though patients are confident they can continue their identified change, they are still vulnerable. For this reason, caregivers need to arrange and encourage follow-up measures to help people maintain the changes they have worked so hard to achieve, such as ongoing visits, membership in support groups, participation in managed care that emphasizes wellness, and mentoring.
When patients do “crash” and regress to an earlier stage of change, their self-confidence may vanish and they may feel they have failed. Happily, research indicates that in the case of smokers, only 15% regress all the way back to the precontemplation stage of change. Most of those who crash go back only one or two stages and then move forward again. It is during these times that encouragement by healthcare professionals helps people achieve their goal.
Encouraging Those Who Do Not Seek Change
Many patients want to change and only need the encouragement of a professional. However, some people with problems do not want to change. These people may be:
- Afraid of the consequences of seeking help
- Ignorant of resources for help
- Discouraged because they have been unsuccessful in the past
- Angry because of their lot in life
- Believers of some untested theory or miracle cure
Caregivers cannot force adults to seek help to change, however they can encourage patients and assure them that professionals are there to help them flourish.
Change is hard, but change is not impossible. This is a fact healthcare providers should remember when feeling frustrated by a patient’s failure to make changes known to improve their health and well-being. Understanding the nature of change, the stages of change, and factors affecting change can assist the clinician to remain supportive rather than dismissive of someone’s ability or willingness to change.
By using the supportive techniques discussed in this course, healthcare professionals can help guide their patients through the process of change by collaborating with them, negotiating action plans with them, empowering them, and supporting their self-efficacy. Making change possible can result in a well-deserved sense of satisfaction for both clinicians and patients.
David R, Campbell R, Hildon Z, Hobbs L, & Michie S. (2015). Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. Health Psychology Review, 9(3), 323–4.
Hamell G & Zanini M. (2014). Build a change platform, not a change program. Retrieved from http://www.mckinsey.com/business-functions/organization/our-insights/build-a-change-platform-not-a-change-program
Ingersoll K. (2015). Motivational interviewing for substance use disorders. Retrieved from https://www.uptodate.com/contents/motivational-interviewing-for-substance-use-disorders?source=search_result&search=motivational%20interviewing&selectedTitle=1~50
Kennedy K. (2014). Being a change agent in a dynamic health care environment. Retrieved from http://healthinsight.org/about-us/healthinsight-blog/entry/1-healthinsight-blog/39-being-a-change-agent-in-a-dynamic-health-care-environment
Lochte K & Markgraf M. (2015). Motivational interviewing: how to help people make changes in their lives. Retrieved from http://wkms.org/post/motivational-interviewing-how-help-people-make-changes-their-lives
Miller WR & Rollnick S. (2002). Preparing people to change. New York: Guilford Press.
Motivational Interviewing Network of Trainers (MINT). (2014). Resources for trainers. Retrieved from http://www.motivationalinterviewing.org/sites/default/files/tnt_manual_2014_d10_20150205.pdf
Tartakovsky M. (2016). Therapists spill: my thoughts on change and how I help clients get there. Retrieved from http://psychcentral.com/lib/therapists-spill-my-thoughts-on-change-and-how-i-help-clients-get-there/
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