COMMENTARY

How Can I Help Patients Change Unhealthy Behaviors?

Kathryn Pollak, PhD

Disclosures

April 11, 2011

Americans are in an unprecedented state of poor health, with an alarmingly high obesity rate and a stagnant smoking rate.[1] So what is a doctor to do with patients who smoke or are overweight? Most physicians make some attempt to counsel patients, yet they feel like they are banging their heads against the wall, as few patients actually follow their advice. Research shows, however, that when physicians address the root problems effectively, patients do quit smoking and lose weight.[2]

Unfortunately, few physicians have been taught how to help patients change. Communication skills are rarely addressed in medical school, residency, or afterward, and even less education focuses on behavior change counseling.

Prescriptive care is what most physicians know, and it is appropriate for most situations. For instance, when a patient comes in with a sore throat, the doctor assesses symptoms, makes a diagnosis, and assigns a treatment. The patient has little input into this process because the physician is the expert. Changing nutrition or smoking habits, though, is quite different. In these cases, patients have more expertise in what they can and cannot do and are more likely to change if physicians involve them as partners in decision making. Partnership building is critical to helping patients change their behaviors, and it is a central tenet of "motivational interviewing" (MI). This approach originally was developed to help alcoholics stop drinking, but it has been applied more recently to primary care settings as well.

MI involves a set of specific behaviors directed by a guiding philosophy. This philosophy emphasizes partnership and eliciting patients' internal motivations. It relies on 3 principles: collaboration, autonomy, and evocation.[3]

Collaboration. Physicians and patients work together as partners to reach a common goal. Instead of viewing themselves as the experts, physicians accept patients as experts in their own lives.

Autonomy. In general, telling people how and why to behave is not effective in helping them change. For example, a physician may suggest to a patient that he consider taking up swimming. The patient may nod, not wanting to contradict the doctor but silently knowing this won't happen. In contrast, MI-trained physicians treat patients as autonomous and respect their right to decide whether and how to adopt new behaviors.

Evocation. Patients are more likely to change when they can express their own values, goals, and ideas for change. Physicians, in turn, can elicit information from patients about their internal motivations and help them reflect on the advantages and barriers to change.

Putting MI Into Practice

How do caregivers implement the MI philosophy? Four key principles, represented by the acronym RULE, serve as a guide[4]:

1. Resist the righting reflex. Many physicians have reflexive reactions when they see patients making unhealthy lifestyle choices. For instance, a patient who smokes might know about the negative health effects of smoking yet be fatalistic about developing cancer and therefore have no interest in quitting. When confronted with such resistance, physicians often try to "right" the patient by providing medical advice and information. Unfortunately, research shows that this "righting reflex" can actually increase patient resistance by eliciting more arguments against change.[4] With MI, physicians are encouraged to resist this urge and instead acknowledge the patient's resistance and explore the values behind it.

2. Understand the patient's motivation. Physicians should approach their patients with a spirit of open-mindedness and curiosity. When they understand a patient's own motivations, they can better guide them toward choices that are consistent with their values.

3. Listen to the patient. Patients need time to work through conflicts and weigh the trade-offs as they struggle with changing their behaviors.

4. Empower the patient. Narrowing the power differential that naturally exists between physicians and patients is essential. Empowering occurs, in part, when physicians support patients' confidence in accomplishing a task such as quitting smoking or losing weight.

The tools that are used to promote the above principles include open-ended questions, affirmations, reflections, and summaries. Questions that cannot be answered with a "yes" or "no" can help explore patients' goals and values. Instead of questions that start with "do you" or "are you," those starting with "why" and "tell me about" can elicit patients' stories. Affirmation allows physicians to show respect and support for patients. Reflections are simply restatements of patients' words or guesses at what patients meant. Physicians who reflect are essentially acting as mirrors for patients to hear back what they said, which may increase insight and self-reflection. In fact, MI theory recommends at least 2 reflections for every question.[2]

Reflections have many purposes. They can convey empathy and show that the physician is actively listening. Reflections help highlight patients' emotions and beliefs and give them an opportunity to explore their values further, which may help resolve ambivalence. Reflective statements also encourage patients to talk more (and physicians to be quiet). In fact, reflective statements empower patients to take control of the conversational platform. The typical clinical encounter involves a physician's question, a patient's response, followed by further physician questions. That format reflects physicians' agendas rather than patients' and can inhibit patients from telling their stories.

Many questions can be changed into reflection simply by reordering the words or changing the vocal inflection. For instance, the question, "You're not sure you can lose weight?" can be transformed into a reflection by saying, "You're not sure you can lose weight."

Summarizing is another core MI skill that is simply a collection of reflections that is presented to the patient. Summaries help patients organize their experience. A summary statement often ends with a question to check accuracy with the patient. Summaries can be used to transition from exploration to providing information and then to decision making.

Does It Really Work?

My colleagues and I conducted a large observational study (40 primary care physicians from 10 practices) to examine the effect of MI on patient weight loss.[5] Called Project CHAT, the dataset is the largest collection of audio-recorded primary care visits between physicians and overweight or obese adults. Physicians discussed weight in 69% of the visits. We found that these discussions generally were not related to whether patients lost weight within 3 months. However, the quality of the counseling did make a difference: after controlling for relevant patient, physician, and visit-level variables, we found that patients experienced greater weight loss 3 months post-visit when they were counseled by physicians who used MI techniques. Similar patterns were found for reflective listening and MI-consistent behaviors such as praising and asking permission before giving advice.

Another analysis of the database indicates that patients who saw "more empathic" physicians were more likely to improve fat intake and report higher satisfaction (K.I. Pollak, PhD, unpublished data, 2011). In addition, patients had higher perceived autonomy support when physicians made reflective statements and had higher satisfaction when physicians were empathic.

Although clinicians need special training to become skilled MI counselors, they can make a few simple changes to improve patient interviews. Making reflections rather than asking questions, for instance, can have a great impact on their conversations.

How can you judge success? Evaluate with these criteria:

  • Patients talk as much as the physician.

  • The physician asks minimal questions and uses reflective statements.

  • The physician avoids judging and instead tries to put himself or herself in the shoes of the patient.

Helping patients change behavior is challenging. MI provides techniques to address roadblocks skillfully. Through empathy, collaboration, support for autonomy, and evocation, MI techniques can be applied to help patients make decisions that are congruent with their values and goals.

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