Part 2/2: Behavior Change and Motivational Interviewing
Part 1/2 can be read here.
Note: behavior change is a mammoth topic. I’ve tried to touch on key ideas, but by no means is this comprehensive. I hope to provide a general overview and practical take-away’s.
Most people have an idea of what they need to do, but are unable to take action for a number of reasons. Behavior is a product of our capability, motivation and opportunity (1). Capability relies on our capacity to enact a behavior, motivation is our inherent desire to do things and opportunity is what our environment makes possible (1). As primary care provider’s, we try to change behavior by tapping into a patients intrinsic motivation. We can direct the focus of our subjective interview by the skillful application of questions – asking quality questions will often lead to quality answers. If the goal is behavior change, it’s helpful to:
Fully understand the problem and limiting behaviors. Who needs to do what differently, when, where and how? (1)
Identify feasible intervention options. (1)
Implement appropriate and actionable decisions. Develop a total commitment to change via items one and two. (1)
Motivational interviewing is a useful strategy that can allow patient’s to develop their own enthusiasm for change (2). This communication style provides a framework for clinicians to work with a patient’s ambivalence rather than identifying it as a barrier for change (2). Using the OARS approach is a great place to start:
Open-ended questions – questions that cannot be answered with a “yes” or “no” response. This allows patients to direct the conversation towards what is meaningful to them. It also gives us an opportunity to provide our expertise where we see fit. (3)
Affirmation – positive reinforcement. Recognizing what the patient is already doing well. Empathizing with the patient’s difficulties. (3)
Reflective listening – re-phrasing the patients statement while adding an emotional/empathetic element. (3)
Summary – further application of reflective listening. Recapping the patient’s story to ensure you haven’t misunderstood or missed any salient points. (3)
When clinicians see a disagreement between how things are and how they ought to be, we feel the need to intervene by introducing solutions. However, reactance theory states that the more we confront someone, the more we will be met with resistance (2). It’s much more powerful for a patient to come up with the answer themselves, rather than being told to do something. Autonomy and self-efficacy are essential for sustainable change.
Practical Tips
Behavior change is difficult, but we can use certain strategies to stack the deck in our favor. Here are some helpful tips on promoting adherence and sustainable change:
General Strategies
Don’t try to change everything at once. Ask yourself: what is the next best step that I can be successful with? Measured consistency will lead to positive habits.
Encourage adherence to a behavior through social accountability. Create a healthy support system and surround yourself with people who have the behaviors that you hope to adopt.
Think about creating incentives or stakes to encourage accountability. For example, pre-pay for exercise classes so you are financially committed.
Engineer your environment for success. Leave your running shoes by the door or keep a fruit bowl on the counter to make healthy choices easier.
Tap into both short-term and long-term motivation by appealing to “the heart” and “the head”.
Short-term motivation (“the heart”) – fast, emotional, habitual and reflexive beliefs
Long-term motivation (“the head”) – slow, logical, planning and problem solving
For Clinicians and Coaches
Identify the client’s confidence and willingness to change. For instance, you could ask “on a scale of 1-10, how confident are you in your ability to be consistent with your home exercise program?”. Work together to identify strategies for success.
Relate the behavior change to why they came to see you. For example, emphasize how stress-management strategies can reduce the perception of threat (i.e. pain) and allow them to get back to the things they love.
Show your patients change to get them to buy-in. Test measures that are meaningful to the patient, apply an intervention, then observe how the measures change. Small wins provide momentum.
Reward progress no matter how small it is. Acknowledge what they are already doing well, and compound new behaviors on top of it.
Incorporate the patient’s personal values and preferences into the decision-making process.
Final Thoughts
The 5 pillars of movement, sleep, nutrition, stress-management and human connection will give us our biggest return on investment. I believe that we have the ability to self-regulate we give care to these areas. Changing behavior is difficult, but hopefully I’ve provided some useful strategies to get the ball rolling.
This concludes my two part series on the pillars of health and behavior change. If you enjoy this type of content, please let me know in the comments section below. I’d also appreciate if you could share it and subscribe to my newsletter for future updates!
References
1. Michie S, van Stralen M, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. 2011;6(1).
2. Morton K, Beauchamp M, Prothero A, Joyce L, Saunders L, Spencer-Bowdage S et al. The effectiveness of motivational interviewing for health behaviour change in primary care settings: a systematic review. Health Psychology Review. 2014;9(2):205-223.
3. Stewart E, Fox C. Encouraging patients to change unhealthy behaviors with motivational interviewing. American Academy of Family Physicians. 2011