Meet the Author
I have developed a blend of learning
methods (online programs, workshops, telephonic
sessions, etc) for training the general public,
lay health guides and health care practitioners
about motivating healthy habits. I also work with
organizations and their leaders to create synergistic,
top-down and bottom-up approaches that promote
healthy habits, both inside and outside of organizations.
I look for opportunities to work outcome researchers
in evaluating complex process innovations. Read
on to learn more about my background and my fascination
with resistant behavior.
I am a family physician (25-years
in practice), process researcher, trainer (online/offline)
and motivational guide. After graduating from
Nottingham Medical School (1972-1977) and completing
my vocational training in general practice in
England, I moved to the U.S.A. in 1982 and became
a Board-certified family physician. I have been
a Professor of Family Medicine and Nursing at
the University of Rochester, New York since 2001.
I have given presentations on motivating health
behavior change in over 16 countries
Beyond My Fascination with Resistant Behaviors
My fascination with resistant behaviors
began early in my career, with a special interest
in the secondary prevention of alcohol problems.
I became curious about why people inflict harm
on themselves despite the apparent absence of
benefits. But this judgment represented my perceptions
and values, not the patient's perspective.
Beyond Professional Judgment
To avoid being judgmental about
patients, I tried to see the world through their
eyes. I listened to my patients to discover the
benefits of their unhealthy behaviors. In contrast
to my perceptions and values, patients commonly
maximized the benefits and minimized the harm
of their unhealthy habits. I remain fascinated
in the determinants of, and the driving forces
for unhealthy behaviors, such as unconscious emotions
(e.g., acting out suppressed anger in self-destructive
ways) and avoidance of feelings (e.g., using alcohol
to treat social anxiety).
Beyond Our Addiction to the "Disease" Care Systems
Like drug addicts, we are addicted
to our disease care system for quick fixes (interventions
to cure diseases) at the expense of preventing
diseases in the first place. We really do not
have a health care system. Our disease care system
was never designed to promote health and address
unhealthy habits in a population-based manner:
giving slim hopes of ever reversing these behavioral
In the "quality chasm" era of patient
safety and error prevention, we have overlooked
the greatest threat to patient safety: a disease-producing
culture that promotes unhealthy habits. These
habits develop for many cultural, community, family
and individual reasons. Resistance to change at
macro, meso and micro levels perpetuates these
Behavioral resistance is a much
greater problem than drug resistance. And yet,
a much greater emphasis is placed on treating
diseases than on promoting health, despite the
fact that preventing diseases is more cost-effective
than treating them. To reverse these epidemics
of unhealthy habits, we need to develop a health-promoting
culture that supports the development of a health
care system that can work with intersectoral approaches
and grassroots movement to deliver individualized
interventions in a population-based manner.
Beyond Scientific Rationality
Giving information and rational
advice to patients about changing unhealthy behaviors
is on a par with the placebo impact of 19th-century
drugs. The use of this "drug" over and over again,
when it is clearly not working, could be regarded
as a medical error.
To move beyond the limits of scientific
rationality, practitioners need to learn how to
adopt new roles and develop new skills: addressing
patients' perceptions, emotions, values and their
so-called " irrationality." This work moves beyond
predictable, linear world of rational science
and evidence-based guidelines to experience-based
practice and the unpredictable, nonlinear world
of human emotions. Don Schon described this shift
as a move out the ivory towers of academia to
the swampy lowlands of practice.
The shift from the controlled world
of research to the messy, real-world practice
means that practitioners cannot solely rely on
scientific rationality to guide them on how they
can work with patients. This shift beyond scientific
rationality to experience-based practice requires
reflective learning from personal experience,
for both practitioners and patients.
Beyond the "Fix-it" Role
Practitioners are predominantly
trained in the "fix-it" role, which is suitable
for treating diseases. In addressing health behavior
change, practitioners typically give information
and advice, make recommendations and set goals
for their patients.
For example, according to the current
U.S. tobacco cessation guidelines, the 5A's model
works at best with only 12.8% of patients. Any
drug that worked with only that percentage of
patients would be considered totally unacceptable
for treating diseases. This fix-it role is ineffective
for the vast majority of people.
Learn how to change from the "fix-it"
to the motivational role before developing motivational
skills: in other words, change yourself (professionally
and personally) before helping others. This strategy
will help you
- Engage your patients more effectively in dialogues
- Develop individualized interventions to meet
their changing needs over time.
- The interdisciplinary book Motivational
Practice: Promoting Healthy Habits and Self-care
of Chronic Diseases will help you to initiate
this lifelong learning process.
Beyond Professional Resistance
Practitioners resist changing their
professional role for many legitimate reasons.
Without understanding and lowering their resistance,
practitioners will struggle to learn how to motivate
patients. The topics of resistance and motivation
receive scant attention in professional education.
For this and many other reasons, busy practitioners
are highly unlikely to adopt a motivational role,
unless the health care system develops a team
approach for implementing behavior change and
disease management programs.
Beyond Mechanistic Metaphors
When practitioners have been trained
only to use hammers (give information and advice),
we tend to treat every patient as a nail. We need
to move beyond mechanistic metaphors and static
programs to ecological metaphors and dynamic programs
that evolve over time. Practitioners work most
effectively with patients when they act as gardeners:
cultivating the soil, fertilizing the ground and
planting seeds. The gardener metaphor embodies
the motivational role.
At micro level, behavioral innovations
must become as sophisticated and individualized
as the 21st century advances in the genetic treatment
of diseases at the one extreme. At the macrolevel,
we need to develop dynamic, ecological to reverse
these behavioral epidemics.
Beyond the Healthcare System
The magnitude of behavioral epidemics
far exceeds the capacity of the health care system.
To address these overwhelming epidemics, we need
intersectoral approaches that engage people in
mutual aid and self-help approaches. This top-down
approach of planting seeds in the community can
work synergistically with bottom-up approaches:
developing grassroots movements. To plant these
seeds on fertile ground, we need to create health-promoting
organizations and cultures.
Beyond the Dark Side
The dark side of marketing emotionally
manipulate people's behavior, without individuals
being fully aware of their influences. They mass
produce disease (e.g., caused by tobacco use and
obesity) and direct consumer-driven health care
into high-profit centers of no or marginal benefit.
According to Paul Zane Pilzer, the
wellness revolution is expected to become the
next trillion dollar business (www.thewellnessrevolution.com).
This revolution will bring out the good, the bad
and the ugly. But high-integrity marketing can
be used for social good with high impact: bringing
light to the dark side.
Blending marketing and academia
is like mixing vinegar and oil. With too much
vinegar (all hype and no substance), the process
is distasteful to academics. With too much oil
(all substance, no hype), the process is unpalatable
for the general public. But in the right proportions,
they can work effectively together.
Dr. Rick Botelho,
85 Eastland Ave.,
Rochester, NY 14618