The physician’s role in change

As physicians, we are uniquely positioned to guide our patients in health-related change.  We are trusted advisors and understand the impact of health behaviors and the potential benefits of change.  By combining our knowledge of human behavior with our interviewing skills and compassion, we can help our patients achieve personally meaningful goals.

We can be most effective in promoting change when we honor our patients’ autonomy and evoke their reasons and plans for change.  Only they know what’s most important to them, and what the costs and benefits of change will be.  Only they can make the decision to change. Without this patient-centered partnership, we risk alienating patients and increasing their resistance to change.

This video shows how a well-intentioned behavior change conversation can go awry – frustrating, ineffective, unrewarding, and rapport busting. Have you experienced either side of a conversation like this before? This physician’s intention was to help – why doesn’t it work? This is a short clip from a longer video (available on YouTube) – you’ll see a better version of this interaction later in this module.

Physicians often use a directive communication style, leading with their own expertise, advice, and power. If there’s an emergency or a clear best treatment, this may be appropriate, but telling someone what to do doesn’t usually lead to change. While knowledge is a prerequisite for change, it usually isn’t sufficient. Most of us are naturally inclined to resist unsolicited advice or coercion and have trouble changing unless the reasons for change are our own.

An alternative to this frustrating interaction is motivational interviewing (MI), which was developed in the 1980s by clinical psychologists Drs. William Miller and Stephen Rollnick. They describe MI as “a collaborative person-centered form of guiding, to elicit and strengthen motivation for change.” Although it was originally used to treat addiction, MI has been shown to impact many issues common in primary care, including medication adherence, glycemic control, fruit and vegetable intake, and alcohol and tobacco use.

Motivational interviewing is guiding rather than directive. The clinician knows the benefits of change in preventing and treating illness. But instead of telling the patient what to do, they use strategic questions and reflections to guide the patient in finding their own ideas and motivation for change. In this workshop, we will explore the ‘spirit’ that underlies effective and ethical MI and practice key communication techniques and strategies.

Patient-centered behavior change conversations

This excellent video from the Yale/Coursera Addiction course introduces key principles of motivational interviewing for people with substance use disorders. These same skills and principles apply to any behavior change you might discuss with patients. Please watch this video to begin.

Three types of reflection

Simple reflections

A simple reflection repeats or paraphrases what your patient has said, confirming that you heard them and encouraging them to say more. In behavior change conversations, a simple reflection can also be a neutral response to patient statements arguing against change (sustain talk ) which is expected for people considering change. Reflection can also be used to respond to change talk, encouraging your patient to build on what they’ve already said. Because these reflections are statements rather than questions, your voice should go down at the end. This is key – if your voice goes up as if you are questioning, it completely changes the meaning and can increase resistance to change.

Complex reflections

Complex reflections go beyond paraphrasing to explore a deeper feeling or meaning.  For example, a complex reflection can reframe what a patient has said to suggest a new way of looking at something negative, to try to help them get unstuck.

Patient: I’ve tried so many times and failed

Physician: You are very persistent, even in the face of discouragement

They can also reflect feelings that have been either stated or implied.

Patient: I haven’t had my hemoglobin A1c tested in over a year, I guess I’ve been avoiding it

Physician: You’re worried what the results will be.

Complex reflections can also use metaphor to create a picture that clarifies your patient’s position.

Patient: I don’t want to take pills. I should be able to handle this on my own.

Physician: Drugs seem like a crutch to you.

Double sided reflections

Double sided reflections highlights the gap between goals and values that your patient has shared and their current behavior. This gap is called discrepancy and recognizing it can help people move towards change.

Double sided reflections use the conjunction “AND“ (or “at the same time”) rather than “but”. ‘And’ holds both sides of the reflection to be true, as they really are for ambivalent patients. ‘But’ can change the feeling completely, making the patient feel like you’re skeptical rather than collaborative. An effective double-sided reflection also ends in the direction that supports change, which encourages your patient to respond with change talk.

Assessing readiness to change

Most people do not change any behavior quickly and decisively; they move through a process of change, often toggling back and forth between stages or spending years in one stage before moving quickly through to the next. Relapse is common and returns the person to one of the earlier stages of change.  Your first step is to determine which stage of change you patient may be in as communication skills will differ.

The Stages of Change model was developed by Prochaska and DiClemente in relationship to tobacco use, but it’s applicable to most behavior change. Different strategies to promote healthy behavior are appropriate at each of these stages – understanding someone’s readiness to change will allow you to meet each person where they are.

Precontemplation

To assess the stage of change, clinicians may ask if someone is considering a change within the next six months. If the answer is ‘no’, the person is pre-contemplative. Pre-contemplative patients are not yet considering change and may voice resistance if it’s suggested.  Verbal responses or nonverbal cues can also suggest pre-contemplation.

Although we may assume they just don’t understand the reasons to change, studies show this usually isn’t the case. While knowledge is necessary, it’s often not enough – competing priorities, lack of resources, culturally inappropriate care, past failures and structural oppression can all act as potent barriers to healthy behavior.

In the pre-contemplation stage, your goal is to open the door to change by building a therapeutic relationship, exploring and honoring your patient’s priorities and values, and – with permission – providing information. It may be tempting to try to “fix the problem” by cheerleading for change, but this unsolicited advice can break down rapport and build resistance.

Contemplation

Contemplative patients are considering change, usually within the next 6 months. The hallmark of this stage is ambivalence – there are reasons your patient wants to change but they still have reasons to maintain the status quo. Here, your goal is to build intrinsic motivation by eliciting their reasons and ideas for change. This change talk may come out spontaneously or it may be pulled out with the communication techniques described in the next few chapters.

Preparation

In the preparation stage, patients are actively planning to make a change. They are motivated but don’t yet know how to make it happen. Our goal is to support them in developing a specific and realistic plan that honors their individual barriers and resources. Listen to our patient in the preparation phase.

Action

In the action phase, patients have started making the planned changes. This stage requires a considerable amount of time and energy because each action still requires conscious choice or executive control, and the risk of relapse is high. The more times and in more contexts the new behavior is repeated, the more routine it becomes and the less conscious control it requires.

In this stage of change, you can offer affirmations of efficacy, ask about positive impacts of the change (more change talk!), and use open-ended questions to explore barriers and needed resources.

Maintenance

In the maintenance phase, patients are working to prevent relapse and to consolidate the changes they made in the action phase. Solidifying this new habit usually takes about 6 months, but it varies depending on the behavior.

In this stage, physicians should anticipate and explore lapses, and differentiate them from relapse. Even a well-established behavior might lapse when the context changes unexpectedly. These lapses provide information that helps solidify change and build resilience. Eliciting information about how they have overcome other unusual circumstances, affirming commitment and flexibility, and brainstorming options for responding to new challenges helps to solidify the new habit.

Supporting our patients’ autonomy, wisdom and resilience gives them the tools to sustain change over the long run.

Relapse

Relapse is common.  Our society tends to blame individuals when behavior doesn’t line up with values, but as physicians we know that will power and morality have very little to do with establishing habit. Anticipating the possibility with your patient up front can prevent shame and avoidance if it happens.

Patients must know that we will provide care for them with or without a specific behavior change. If we have laid the groundwork well, both we and they know that the change was not for the physician and the patient need not be ashamed. Many patients may find themselves “recycling” through the stages of change several times before the change becomes truly established. Normalizing this for patients is helpful.

• “Change involves ups and downs. I’m here for both.”
• “I‘m on your side. I look forward to checking in next month whether this idea works or not.“

Relapse returns a patient to one of the early stages of change: pre-contemplation, contemplation or preparation, as they decide how to respond. But whether a patient decides to try again or not, they can benefit from exploring the journey they’ve taken. When things were going well what did they like about the new behavior? What did they learn about themselves? Acknowledging and reinforcing the successes they did have helps shift the focus away from failure.

The physician must take care to recognize the transition to relapse and use skills appropriate to the new stage. Helping the patient reflect back on their original reasons for change, re-establish goals, and troubleshoot barriers can be helpful.

Providing information respectfully: Ask-tell-ask

Unsolicited advice often leads to resistance and impairs rapport. But patients do need accurate information to guide their choices about change.  How can we provide information in a way that doesn’t feel like unsolicited advice?

Ask–tell–ask is a flexible framework for providing information in a way that honors the patient’s autonomy and individual context. Ask-tell-ask is not an excuse to lecture or to give advice, rather a respectful way to offer key information that the patient might be missing.

Eliciting change talk

Motivational interviewing helps people to talk themselves into a change that they have identified as important. Change talk builds self-efficacy and makes any change more likely to stick. It may be spontaneous or be prompted by a question; either way, follow up with OARS to try to draw out more. The mnemonic ‘DARN CAT’ can help you elicit and recognize change talk. DARN statements suggest your patient is contemplative. CAT statements, which are usually spontaneous, suggest readiness to make a plan.

“Yeah, but…”

Motivational Interviewing skills are designed to evoke motivation, commitment, and planning from the patient, often expressed in the form of change talk. When we overestimate a patient’s readiness for change or begin to give too much advice, we may notice an increase in sustain talk. By pushing too hard, we’ve put the patient in the position of arguing against change. In MI, this is also called resistance.

If you hear “yeah, but…”, you may be pushing too hard. Rolling with resistance means pivoting to open-ended questions (try pros and cons of the current behavior), neutral reflections (“this just doesn’t feel possible right now”) or affirmations (“you‘ve made a lot of important changes before, I believe you‘ll know when the right time is.”)

Pros and cons

This communication technique highlights the ambivalence of people who are contemplating change.  Asking about the pros of the current behavior acknowledges the difficulty of change up front and makes your patient feel heard.

Here are some questions for exploring pros. After the first response, you could ask again about pros, repeating until there is nothing more to add.

• What are the good things about…?
• What are some of the things you enjoy about…?
• What do you like about…?

When asking about the cons of the current situation, use words like “enjoy less” or “not so good” rather than “bad”. People at the pre-contemplative stage are often not thinking about negative consequences, so it may be easier for them to agree to ‘less good’. Sample questions to elicit cons:

• What are some of the not-so-good things about…?
• What worries you about …?
• What are some of the things you enjoy less about…?

If your patient has mentioned a specific change that they’re considering, you can also explore the cons and finally the pros of the healthier behavior. This order is important: you want to end on the good that could come of change so your patient can build upon that. To wrap up the pros and cons, use a double-sided reflection or summary, again ending in the direction of change.

If time is limited, a simple way to explore pros and cons of both the status is with these two questions:

1. First: What are the good things, and the not-so-good things about…
2. Then: When you think about changing what would be hard, and what would be best?

Readiness Rulers

This technique assesses readiness to change, which is a product of a belief that the change is important, and confidence that one can succeed. Rulers can also elicit change talk and uncover barriers that you can address. 

Making a plan

In the preparation stage, the goal is to work with your patient to create a plan that is specific enough to succeed. Action plans work best when patients identify their own goals, resources, support systems and coping strategies.

A common mistake clinicians make is to end the conversation when a patient agrees, in concept, to a change. “Yeah, I really should start exercising.” Without a specific plan that addresses a patient’s unique context, change is unlikely to occur. Remember: Don’t leave CHANGE on the table. Make a plan!

One approach to planning is contained in a mnemonic borrowed from the business world. The SMART goal approach helps patients develop specific goals that are measurable and meaningful. When goals are too vague it can be hard to know where to get started and how to track your progress.

Some ways to start the conversation around goal setting could include asking “What are some steps you would like to take?” “What is one step you could take this week?” “What is a step you think you could take now?” “If you were going to do this, how would you start?”

Once the conversation is started you can help the patient tailor their goals using the SMART approach. These are the key steps to developing a patient driven plan.

Specific: What does the patient want to do? What EXACTLY is their goal? Eating healthier sounds like a good idea. What does that mean to you? Any specific thoughts on changes you could make to your diet? What would you need to carry out that change?

• • • Menu of options:  if your patient is having a hard time coming up with specific changes to their behavior you may ask if you should share a “menu of options” for them to consider.
      “Would it be okay if I shared some ideas?”  “What about committing to a lunch time walk 2 days per week, or maybe signing up for a exercise class with a friend one day a week, or doing 20 squats every morning when you are brushing your teeth?”

Measurable: How will you and your patient measure progress? How will your patient know when they have reached their goal? Walking more sounds like a great idea. You mentioned walking three days per week. How long will you walk for to start? That sounds like a goal you can track.

Achievable: Is this goal realistic? Is it in your patient’s power to accomplish this goal? What barriers or obstacles does your patient anticipate? What is their back up plan? What type of support do they have or do they need? You mentioned cutting out sugar all together from your diet? Do you think that is something you can reasonably do? Are there certain foods that you may be able to decrease to help you cut down on your sugar intake?

Relevant: Will achieving this goal affect your patient’s health? Will they get the desired results? Can they realistically achieve their goal? You mentioned wanting to be able to keep up with your children on the playground. It sounds like increasing your exercise would help you reach that goal.

Timely: When would be a good time to start this plan? When do they hope to achieve their goal? When would it be helpful to come back or check in? It sounds like you want to quit smoking next week after you finish your last pack of cigarettes. Would it be helpful for us to set a visit for a few weeks from them to check on how things are going and to help troubleshoot any challenges you encounter?

When developing a plan, the more specific, the better. Ask the patient to think specifically about how they will make the change happen. It is much better to spend some time troubleshooting one visit to the gym that actually happens than to make a lofty abstract goal. Actually visualizing the process functions as practice, and helps identify hurdles. Short term follow up can provide reinforcement and break the task into smaller parts.

Putting it all together

As you practice behavior change counseling, start with open-ended questions to get a sense of the patient’s stage of change then adjust your approach based on that.  Remember to go back to OARS to encourage further exploration. These are advanced communication skills that you will build over time. This is just the first step in becoming more comfortable with motivational interviewing.  Having a general framework with which to approach these conversations is helpful.

• Open-ended questions are used to explore concerns, goals and ideas for change
• Affirmations are used to highlight strengths & build self-efficacy
• Reflections are used to respond to sustain talk, evoke change talk and highlight ambivalence
• Summary is used to demonstrate active listening, highlight ambivalence, and make connections

For pre-contemplative patients:

• Ask-tell-ask to provide information that might lead your patient to consider change
• Pros and cons may help you better understand your patients values
• Reflections can be used to respond to sustain talk

For contemplative patients who are already thinking about change, you’re trying to build motivation and confidence.

• Pros and cons and readiness rulers to elicit change talk
• Open ended questions and reflections to amplify change talk
• Reflections to respond to sustain talk – remember this is to be expected!
• Double sided reflections to highlight ambivalence and their reasons for change

For patients in the preparation stage, your goal is a specific plan to increase the likelihood of success.

• Develop a SMART goal together
• Ask-tell-ask to provide information on options
• Menu of options that others have used

Compare the 5-minute video below to the snippet you saw in the introduction. In the first video, the physician used a more directive style, the conversation became confrontational and it ended without progress toward change. In the second example, the physician uses a more collaborative style and calls on motivational interviewing techniques – you can see this conversation guiding the parent toward change. This is what you are aiming for!

Harm reduction

Not everyone is able to completely discontinue a harmful behavior or entirely adopt a healthy one.  Harm reduction is another potential goal of behavior change. Harm reduction is an approach that suggests that the most pragmatic way to engage people is to reduce the harm (or increase safety) from a behavior while maximizing options without insisting that behavior be changed.

The following are examples of harm reduction approaches in various behaviors.  The left side of the continuum is the safest but lowest comfort with the right side of the continuum being the most harmful but highest comfort.  Discussing these approaches with patients may be helpful to them to reach their behavior change goals.

(Optional) The following is a video by SAMHSA on Harm Reduction and Opioid Misuse: Embracing positive change 

Knowledge Check

Resources and References

A Dialogue with MI Co-Founder William Miller, Columbia U School of Social Work, 25 minutes and interesting! YouTube

Summary of controlled clinical trials involving MI. https://motivationalinterviewing.org/sites/default/files/mi_controlled_trials_2020_nov.pdf