Empowering Individuals, Families & Communities
 
Home Dr. Botelho's Blog Buy Books Author Free Resources MHH Learning For Professionals
 Motivate Healthy Habits | My Healthy Habits Journal | Motivational Practice Guidebook

   
Linkedin: Motivate Healthy Habits    
     
Follow Dr. Rick Botelho on Twitter    

   
     
Motivate Healthy Habits

A Mutual Aid and Self-help guidebook for you, your family and friends with learning exercises, examples and stories.
Learn more

Motivational Practice

A guidebook for lay health guides & professionals. Learn professional skills for everyday life.
Learn more

"Be the change that you wish to use in the world"

M.Gandhi

MP - Introduction

Let's use the tobacco pandemic as the leading example of how health care systems and the scientific community underestimate the complexity of changing behavior. The tobacco pandemic will reach its peak in 20 to 30 years and kill one in eight persons worldwide (20 million to 30 million deaths per year), with 70% of these deaths occurring in the developing countries. This global threat far exceeds the negative impact of all acts of wars and terrorism, alcoholism, drug abuse and HIV disease combined. Yet, despite these shocking facts, young people are still relentlessly initiating this addictive, lifelong habit. We provide inadequate guidance to our youth in how to deal with the manipulative influences of the tobacco companies, popular media and negative peer influences.

How do tobacco marketers take this deadly product and sell it as a pleasure? They use sophisticated methods to manipulate human beliefs (e.g., smokers deceive themselves into believing that tobacco relieves their stress, when in fact nicotine addiction adds to it).

So, what is the power of the tobacco industry's emotional appeals? They exploit human vulnerability by creating positive biases toward tobacco-associating images of pleasure, sexuality and/or attractive identities with smoking and targeting this association to an individual's needs, wants, desires, vanities, aspirations and/or fantasies in an implicit and meaningful way. They hook youth on tobacco during their vulnerable stages of development. They masterfully develop dynamic approaches with new angles on positive biases to influence health beliefs and to promote smoking behaviors. They produce spectacular results in the real world, without generating any hard evidence from randomized controlled trials about how marketing actually works.

In contrast, the scientific approach in health care is based on the premise of minimizing or removing biases in research studies: in effect, taking a neutral, factual and skeptical stance, in sharp contrast to tobacco marketers. The scientific community develops hard evidence from randomized controlled trials, but this evidence does not translate into significant results at a population-based level. For example, the smoking cessation guideline that uses the five A's model (ask, advise, assist, assess and arrange follow-up) relies on practitioners providing information and advice to patients. The impact of this guideline on cessation rates varies from 2-10%, depending on the duration of the intervention. But this guideline doesn't use sophisticated emotional appeals and negative biases against tobacco use, a strategy that goes against the grain of scientific impartiality of being bias-neutral. Because the factual evidence does not support it, the guideline provides little assistance in how practitioners can

        • Work with adolescent smokers
        • Help smokers in precontemplation
        • Motivate patients who do not respond to the five A's approach

Many practitioners tire of or stop using this guideline protocol in any systematic way, for a variety of legitimate reasons. What we need are new, dynamic and innovative ways of engaging all smokers in the change process, using the best available evidence and state-of the-art practices. In particular, we can use emotional appeals and biases that marketers use for tobacco initiation and apply them in the opposite direction to help patients work on the emotional aspects of tobacco cessation. But these techniques alone are not sufficient, because tobacco cessation is far more complex than its initiation. In addition to treating nicotine addiction, we need more sophisticated behavioral interventions. One approach (based on multiple methods) can be found in motivational practice. This approach provides practitioners with a wide range of interventions to address smoking cessation and other behaviors such as

        • Risk behaviors: excessive alcohol use, illegal drug use, obesity, unhealthy diets,
            lack of exercise, unsafe sex and unwanted pregnancies
        • Disease management: nonadherence to medication and treatment
            recommendations, suboptimal self-care of chronic diseases and failure to attend
            follow-up appointments
        • Preventive measures: immunizations, mammogram and pap smears and injury
            prevention

WHAT IS MOTIVATIONAL PRACTICE?

This interdisciplinary book addresses how practitioners can learn to develop individualized interventions that meet patients' changing needs over time. The clinical approach of motivational practice builds on the shoulders of these trailblazers:

        • Self-efficacy theory: A. Bandura1-4
        • Transtheoretical model of change: J. Prochaska and C. DiClemente5-7
        • Motivational interviewing: W. Miller and S. Rollnick8;9
        • Self-determination theory: E. Deci and R. Ryan10
        • Relapse prevention: G. Marlatt and J.Gordon11
        • Solution-based therapy: S. De Shazer12-15
        • Patient-centered approaches: M. Steward and colleagues16

No single theory, model or clinical approach has a monopoly on clinical effectiveness in predicting positive outcomes, but clearly some clinical approaches peak in popularity, and some fade over time as the field advances. The concept of self-efficacy has shown some durability but it has limitations (as described in Chapter 7). A systematic review (www.ncchta.org/fullmono/mon624.pdf) of interventions based on the stages of change model has questioned its effectiveness in promoting behavior change. Motivational interviewing has gained stature and popularity with a supportive foundation of evidence. (For those interested in exploring different perspectives on evidence and the concept of translational research, go to www.MotivateHealthyHabits.com to download two chapters that address these issues in more detail.)

To assist you with the limitations of current evidence, this book incorporates state-of-the art clinical practices and learning processes that involve

        • Using continuous innovation, testing and evaluation of individualized interventions
        • Applying motivational principles for overcoming the knowledge-behavior gap
           (e.g., "I know what to do but I don't do it")
        • Developing the art of dialogue (nonlinear, dynamic processes) to address
           cognitive-emotional dissonance (e.g., "I think I should change but don't feel like
            it") and so-called irrational behavior
        • Incorporating learning portfolios (e.g., gathering personal evidence about
           developing motivational skills) into your continuing professional development

Consider exploring your professional role, mental maps (ways of thinking) and assumptions before developing your motivational skills. This premise may help you learn how to work more effectively and efficiently with patients. You may even have to unlearn some of your training-of-origin perspectives so that you can expand your repertoire of skills. This process can challenge your assumptions and evoke emotional reactions, such as ambivalence or even resistance to the introspective process.

Instead of imposing a concept/model/theory-driven worldview on patients, you learn how to work from the patients' worldviews and select theories and models that fit into their worldviews rather than the other way around-making patients fit into a particular mould. This learning process can help you develop individualized interventions that activate patients to become researchers of their own behavior change and learn new ways of acting in their best interest.

Do not quench your inspiration and your imagination;
do not become the slave of your model

-Vincent Van Gogh

May this quotation inspire your creativity and sustain your enthusiasm for lifelong learning on how to help patients change.


REFERENCES

1. Bandura A. Self-efficacy: The exercise of control. New York: W.H. Freeman; 1997
2. Bandura A. Self-efficacy in changing societies. New York: Cambridge University Press;
    1995
3. Bandura A. Social foundations of thought and action. Englewood Cliffs, NJ: Prentice
    Hall; 1986
4. Bandura A. Self-efficacy: Toward a unifying theory of behavior change. Psychological
    Review 1977;84: 191-215
5. Prochaska JO, DiClemente CC. Toward a comprehensive model of change. In: Miller
    WR, Heather N, eds. Treating addictive behaviors: Processes of change. New York:
    Plenum Press; 1986:3-276.
6. Prochaska JO, DiClemente CC. The transtheoretical approach: Crossing traditional
    boundaries of therapy. Homewood, IL: Dow Jones/Irwin; 1984
7. Prochaska JO, DiClemente CC. Transtheoretical therapy: Toward a more integrative
    model of change. Psychotherapy Theory, Research and Practice 1982;19: 276-288
8. Miller WR, Rollnick S. Motivational interviewing: Preparing people to change addictive
    behavior. New York: Guilford Press; 1991
9. Miller W, Rollnick S, Conforti K. Motivational interviewing, 2nd Edition: Preparing
    People for Change. New York: Guilford Press; 2002
10. Deci EL, Ryan RM. Intrinsic motivation and self-determination in human behavior.
      New York: Plenum Press; 1985
11. Marlatt GA, Gordon JR. Determinants of relapse: Implications for the maintenance of
      behavior change. In: Davidson P, Davidson S, eds. Behavioral medicine: Changing
      health lifestyles. New York: Brunner/Mezel, Inc.; 1980:410-452
12. De Shazer S. Words were originally magic. New York: W.W. Norton & Co.; 1994
13. De Shazer S. Putting difference to work. New York: W.W. Norton & Co.; 1991
14. De Shazer S. Clues: Investigating solutions in brief therapy. New York: W.W. Norton &
      Co.; 1988
15. De Shazer S. Keys to solutions in brief therapy. New York: W.W. Norton & Co.; 1985
16. Stewart M, Brown JB, Weston WW, et al. Patient-centered medicine: Transforming the
      clinical method. Thousand Oaks, CA: Sage Publications; 1995

 

SECTION I

CONSIDER CHANGING YOURSELF
BEFORE HELPING OTHERS


Chapter 1 invites you to learn about improving your own health behaviors and transforming your professional role before learning how to help patients change. A case study in Chapter 2 contrasts how a fix-it and a motivational practitioner deal with the same patient. The purpose of this example is to emphasize the advantages of a new role rather than to illustrate the limitations of the traditional role for addressing behavior change. Chapter 3 describes a conceptual framework for better understanding how you can adapt your role to meet patients' needs. Chapter 4 explores how assumptions can either hinder or facilitate the change process for patients and their families. Over time, you can discover for yourself whether this premise (change yourself before helping others) helped you become a more effective and efficient motivational practitioner.

 

CHAPTER 1
WHEN GIVING HEALTH INFORMATION
AND ADVICE DOESN'T WORK


FOR REFLECTION

What do you do when patients do not change their unhealthy behaviors
in response to your health information and advice?


OVERVIEW

When we use only a hammer (provide advice), we treat patients' unhealthy behaviors as nails. Most patients and their behaviors, however, are more like nuts and bolts rusted together. Hammering away can damage the threads of the bolt, so the nut never comes off. With advice only, patients may become more resistant and less likely to consider change.

Do you keep hammering away, give up the advice-giving approach altogether, or do you learn from your clinical experiences about how to work with patients in alternative ways?

 

Mere knowledge about the negative consequences of risk behaviors is insufficient to motivate most patients to change. Even when individuals know what is good for them and have the skills to change, many do not. Resistant patients work against our attempts to help them change. Unmotivated ones are indifferent to change. Ambivalent patients have mixed thoughts and feelings about change.

Thus, most patients are not ready to change their unhealthy behaviors. They may or may not even be thinking about change.1;2 Not surprisingly, health information and advice do not help most patients to change. We need to develop skills to help our patients work on changing over time.

This book invites you to consider learning about how you change yourself as you learn how to help patients change. It encourages you to consider

        • Analyzing your health behaviors, professional roles and assumptions
        • Internalizing the six-step approach (described in Sections II and III) as a mental
           map for working with patients over time
        • Initiating the process of gathering a learning portfolio for your continuing
           professional development
        • Learning micro skills to address tobacco use and excessive alcohol intake

If you are curious about why patients do or do not change, this book may assist you on a journey of lifelong learning about motivating health behavior change.


LIMITATIONS OF GIVING INFORMATION AND ADVICE

What is the impact of giving health information and advice to patients, in relation to the overall magnitude of unhealthy behaviors and their consequences? (Section IV in this book and the Web sites listed in the tables and footnotes provide additional evidence for using such interventions. abcd) Such approaches are the first step in helping patients change their unhealthy behaviors, but they benefit only 5-20% of patients.3-10 Let's briefly focus on the tobacco issue again, because it is the single greatest preventable contributor to disease and premature death internationally. In community surveys conducted in the United States, 40% of smokers are not thinking about quitting, and 40% of smokers are thinking about it.11-14 Giving information and advice may be appropriate for only 20% of smokers who are ready to quit. This approach helps 2.3-12.8% of smokers to quit, depending on the time length of the session, the total number of sessions and the number of different clinicians involved in delivering interventions.3

Consider this fact in relation to the tobacco pandemic, as described in the Introduction. The report Trust Us: We're the Tobacco Industry helps us to understand how the tobacco industry contributed toward creating this pandemic e. To counteract these disease-promoting practices, the World Health Organization's Tobacco Free Initiative (http://www.who.int/toh) and the Framework Convention on Tobacco control aim to decrease global tobacco consumption. Yet in spite of our knowledge about this problem, tobacco use will remain the leading cause of death worldwide for the foreseeable future.

Giving information and advice does not always change behavior. Furthermore, this seemingly helpful approach can have negative consequences that may or may not be apparent.15;16 For example, increases in depression, anxiety and overall disability occurred at three months after physicians advised patients to quit smoking, but this finding was not found with medication-related or dietary change advice.15;16 Two examples highlight this issue from a practitioner and patient perspective:

Dr. N., a general practitioner from Nepal, was treating a patient who was a smoker and a doctor. Dr. N. advised his patient to quit smoking on three separate occasions over time. The patient got fed up with Dr. N. and decided to see another doctor, a doctor who smoked cigarettes and would not advise him to quit smoking. Dr. N. felt rejected and wished that he could have been more helpful to his patient. He was interested in learning more about how to work with smokers in alternative ways.

Mrs. D. was an overweight middle-aged woman who had diabetes. Her overweight endocrinologist repeatedly advised her to change her eating habits, to lose weight and to exercise more. She could not live up to her doctor's expectations and had resigned herself that she would need to rely on her medications to control her diabetes. Mrs. D. had mixed feelings about continuing to see the endocrinologist because he made her feel guilty, but she also respected him and depended on him for her ongoing care. Mrs. D. resented his lack of empathy, given that he was also overweight, and wished that he was better trained in how to understand her situation.

Michael Balint once stated that doctors are the most commonly prescribed drug in general practice.17 This drug metaphor has merit in acknowledging the psychotherapeutic impact of the doctor, but its literal interpretation highlights how we fail to resolve behavior change issues effectively with our patients. Giving 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 form of medical error.

LIMITATIONS OF THE BEST EVIDENCE

In helping our patients change, we should always use the best available evidence from randomized controlled trials (RCTs). However, most behavioral RCTs conducted in primary care provide limited guidance in how to help patients change, because they use only one or two health information and advice-giving interventions with patients, with time-limited follow-up, for a year or so. Such rational interventions are the most frequently studied for tobacco cessation in primary care.4;6;18-21 Doctors are encouraged to use these approaches routinely and repeatedly with all smokers at each visit, but this does not happen in practice.

Doctors prefer to give advice to patients who have smoking-related problems or who are ready to quit; conversely, they avoid confronting patients who do not fit into this group.22-25 Such avoidance has some justification: patients react negatively or prefer not to get such advice.26;27 For these and other reasons, the feasibility of implementing these guidelines has been questioned.28

Furthermore, rational interventions do not work for the majority of patients because they are simply not ready to take action. Evidence-based tobacco cessation guidelines tell us what works, but they don't tell us how to work with people when proven interventions fail. Something is missing in the conduct of RCTs in terms of dealing with the full spectrum of patients. RCTs rarely address the internal process of why change did or did not occur. They do not tell us the whole story about change, either from the practitioner's or the patient's perspective. Instead, they provide a very limited view for understanding human experience and behavior change.

With unhealthy behaviors, emotions often supersede reason. Patients frequently decide that the short-term emotional benefits (e.g., smoking to relax) are more important than the long-term quantifiable benefits (e.g., live longer). They make so-called "irrational" decisions. Recommendations from RCTs provide no guidance on how to deal with human emotions, perceptions and values. Scientific rationality lacks sophistication in dealing with human irrationality and otherwise knowledgeable patients who lack the critical factor: motivation.

ADOPTING NEW METAPHORS

Metaphors can help us understand better the gaps between scientific evidence and the complexity of dealing with individual patients' unhealthy behaviors. Here is a visual metaphor to illustrate the gaps in our understanding: RCTs are tiny square pegs in a large round hole. The hole (gaps in our understanding) simply gets bigger with each additional peg. No matter how many pegs are put into the hole, the gaps in our understanding will remain between rational evidence and the emotional complexity of issues affecting behavior change. Evidence-based medicine alone will never close all the gaps.

Metaphors that shape our professional behavior toward patients are embedded in our everyday language.29 Here are some metaphors that make explicit our fix-it approach toward our patients: "Medical care is a high-tech machine in a competitive market manufacturing magic bullets [e.g., drugs] to cure diseases."30;31 These mechanistic metaphors suggest objectivity, predictability, beating the competition, winning, cure, war, control and death.

Here, as a complementary worldview, are ecological metaphors that expand the narrow focus of medical care:30 "Health care is an endangered plant in a threatened ecosystem that needs environmental restoration; in addition to the fix-it role, we adopt a motivational role and become 'gardeners': cultivating the soil, fertilizing the ground, and planting seeds." These organismic metaphors suggest subjectivity, unpredictability, sharing interdependence, collaboration, care, growth, nurture and quality of life. Changing the dominant metaphors in medical care, however, is a major paradigm shift and no simple task. Metaphors can act as weapons against change, as well as agents for change. The underlying value system of the mechanistic metaphors in health care that work against mainstreaming organismic ones are summarized in Table 1.1.

Table 1.1. Comparing Medical and Behavioral Worldviews and Value Systems
Quick-fix: Treating Diseases
Long Haul: Motivating Healthy Behaviors
1. Address complicated, decontextualized tasks
    Use "closed system" approach
2. Focus on objectivity and entities
3. Use mechanistic thinking "Technicians using
    tools"
4. Use reductionist and linear approaches Apply     scientific rationality
5. Intervene in symptomatic phase Patients
    depend on their practitioners
6. Control and cure diseases Practitioners save
    lives
7. Focus on harms, deficits and pathology
8. Use high-tech treatments (drugs and surgery)
    Static, prescribed interventions
9. Produce dramatic results Immediate benefits
1. Address complex, contextualized tasks
    Use "open system" approach
2. Focus on subjectivity and context
3. Use organismic thinking "Gardeners
    planting seeds"
4. Use holistic and nonlinear approaches
    Address human irrationality
5. Intervene in asymptomatic phase Patients
    start thinking about change
6. Support autonomy to influence behavior
    Activate patients to take charge
7. Address emotions, perceptions and values
8. Employ low-tech interventions (dialogue)
    Dynamic, changing interventions
9. Foster incremental change
    Delayed benefits

 

THE NEED FOR A COMPLEMENTARY APPROACH

Modern drug research emphasizes purposeful nonvariation, that is, developing highly specific drugs to target particular enzymes, receptor sites or genes to treat and cure diseases. Unlike the development of drugs, purposeful variation is needed to design highly individualized behavioral interventions to enhance their potency and impact on patients. The "receptor site" is not only different for each patient but also for each of his or her unhealthy behaviors. In spite of the diversity of patient needs, we tend to fall into the trap of using the one-size-fits-all approach.

For this reason, the top-down, "from research to practice," rational choice model, while important in determining what works in some circumstances,32 has a limited impact, because evidence-based guidelines don't teach practitioners how to attend to the diversity of emotions, perceptions and values that affect patients' health behaviors.33 With the top-down approach, researchers often try to make patients fit a particular theory: in effect, a controlling method. The researcher is the principal investigator, and practitioners are coinvestigators ostensibly working with patients but in effect telling them what to do. The following quotation provides another perspective about the limitation of this approach.

Rational planning and decision-making are doomed to failure in the face of the remarkable complexity of human motivation, encompassing interlocking hurts, disappointments,, confusions, affections and aspirations.34

We need to use a bottom-up, "from practice to research" approach if we are to help our patients close the large gap between evidence and practice and to work with the discrepancy between so-called rationality and their emotions. With the bottom-up approach, the patient is the principal investigator researching his or her health behavior change, and the practitioner is the coinvestigator working with researchers to select theories that fit the particular needs of the patient.

We should also move beyond hierarchy (the top-down, one-way-street approach) and toward partnerships if we want to develop innovative approaches to health care and behavior change. It is vitally important that researchers, theorists and practitioners collaborate in a two-way street to develop partnerships with patients. Patient-centered approaches can help to develop such partnerships and enhance the process and outcome of health care.35;36 The motivational approach described in this book adds to the patient-centered concept, which addresses concerns, feelings, expectations and consequences relevant to episodes about their care and describes how to develop individualized interventions that help patients change their perceptions and values. To encourage such partnerships, this approach has been developed from state-of-the-art clinical practices (working with patients, students and health care practitioners), research evidence and different theories and models (described in Chapters 6 and 7) about health behavior change.37-39 Emerging research findings and clinical reviews provide some encouraging evidence to justify using motivational approaches.40-72 (Some Web sites to help you keep abreast of this developing field are listed below. f)

For those of us working with providing continuity of care to our patients, we have many opportunities to adopt a motivational approach and deliver individualized interventions that meet their changing needs over several years. Effective training methods can help us move beyond standard question-and-answer clinical interviews to engage patients in "change dialogues" so they not only adopt healthy behaviors but maintain these changes. 37-39;73 (The Web site www.MotivateHealthyHabits.com is under continuous development to improve the training methods for helping both practitioners and patients learn how to work more efficiently on this change process.)

LIMITATIONS OF THE FIX-IT ROLE

Clinical experience can teach us a lot about the shortcomings of our professional training and the limitations of the advice-giving, or fix-it, approach. When we adopt this approach, we impose our own values and perceptions about healthy behavior without knowing what our patients think. We give answers rather than ask questions.

The following account provided by Dr. W., a family physician, reveals the limitations of the fix-it approach and highlights the advantages of a motivational approach. Over a nine-year period, Dr. W. struggled before figuring out how best to work with resistant patients. He shared this account of his professional experience after attending a workshop on motivating health behavior change.

After graduating from a family practice residency program, I spent the first three years getting frustrated with patients when dealing with their risk behaviors and the next three years confused about what I should do with them. For the next three years, I really took the time to listen to my patients and learn from them about what it would take for them to change. After being in practice for nine years, I don't go home worrying about any patient's self-destructive behavior.

This kind of workshop could have helped me learn much earlier about how to individualize my approach in working with patients over time. I wish I had had this training in medical school. It could have prevented many years of frustration and confusion because I would not have given the same kind of health education and advice messages over and over again to patients

Dr. W. first assumed a fix-it role and acted as though he could make patients change their risk behaviors. This take-charge approach works well for treating diseases, but it plays a limited role in addressing risk behaviors; directive or controlling advice works with only a minority of patients. Dr. W.'s clinical experiences taught him a lesson: trying to control patients' behavior usually does not work. A version of the Serenity Prayer by Reinhold Niebuhr-a Protestant theologian and social critic born in 1892-reinforces the lesson that experience taught Dr. W.:

            Grant me the serenity to accept the things I cannot change, the courage to
              change the things I can, and the wisdom to know the difference.
74

Dr. W. typifies how most of us have been trained to adopt a fix-it role for working with resistant patients. This educational shortcoming handicaps our professional development and creates a blind spot in our learning. Clinical experiences after completing his training taught Dr. W. how to adopt a motivational approach. He did this by carefully listening to, and learning from, his patients. By doing this, he became more effective at helping them change their behavior.

The key differences between fix-it and motivational approaches to behavior change are summarized in Table 1.2.38;75 Fix-it practitioners, for example, erroneously assume that they can control patients' behavior, whereas motivational practitioners realize that only patients can take charge of their health. Motivational practitioners thus help patients explore the possibility of change, rather than try to control the patient.

Table 1.2. Contrasting Assumptions about Patients
Fix-it Approaches
Motivational Approaches
 Patients need to act now.
 They lack knowledge about the need to change.
 Education will convince patients to change.
 They need advice to change.
 Patients may not yet be ready for action.
 They lack motivation to change.
 They have knowledge and skills to change.
 Most patients are willing to explore change.

 

MOTIVATING CHANGE

Opportunities for motivating healthy behaviors occur in almost every patient encounter.76 Yet most of us are poorly trained to take advantage of such opportunities. Furthermore, the development of simple yet sophisticated interventions for motivating healthy behaviors over time (particularly in nonspecialist, time-pressured health care settings) has lagged far behind the advances in drug treatment of diseases. This lag is especially significant, given that an estimated 50% of preventable mortality is due to unhealthy behaviors.77

Carl Rogers, a seminal thinker about human psychology, captures an essential ingredient for motivating change-listening:

We think we listen, but very rarely do we listen with real understanding, true empathy. Yet listening, of this very special kind, is one of the most potent forces for change that I know.78

In many instances, listening with empathy is a prerequisite for helping patients to change. Paolo Freire, a radical contemporary educator, builds on this fundamental principle by emphasizing another critical ingredient needed to work toward effective action:79;80

Listening precedes Dialogue, which precedes Action.

Freire's aphorism highlights the need to engage patients in constructive dialogue about change in order to motivate them to action.

Motivational practitioners appreciate that each person is unique in what might motivate him or her to change. These practitioners use motivational principles (see Table 1.3) as a guide to engaging patients in the change process over time and work through the three phases of Freire's aphorism (listening, dialogue, action), whereas fix-it practitioners jump in at the action phase.

Table 1.3.
Motivational Principles
 • Develop empathic relationships with patients
 • Clarify roles and responsibilities for health behavior change· Gain consent from patients
    to address behavior change
 • Respect patients' autonomy-use influence, not control, to effect change
 • Work at a pace sensitive to the patients' needs and their readiness to change
 • Help patients explore and understand better their values and perceptions
 • Help patients decide whether to change their values and perceptions
 • Focus on strengths, successes and health, not weaknesses, failures and pathology
 • Focus on solutions rather than on problems
 • Enhance patients' confidence and competence to change (self-efficacy)
 • Negotiate reasonable goals for change
 • Help patients believe that healthy outcomes are possible
 • Help patients increase their supports and reduce their barriers to change.
 • Develop plans to prevent relapses and use so-called failures as learning opportunities

 

Attempts to force patients to act in healthy ways when they are not ready can sometimes have the opposite effect.81;82 For example, if you are a parent, consider the last time that you gave strong, directive advice to your children (especially teenagers) about changing their behavior. Or recollect when you were a teenager and were told not to do something by your parents or teachers. Sometimes you did it anyway! Years later, you realized that their advice was right, but how did you feel about the advice at the time it was given? Controlling or threatening messages, such as providing highly directive advice -
"Do this . . . you should . . . or else"- often proves counterproductive. Individuals may become even more resistant in response to such controlling advice. Strong unsolicited advice, even if logical, can bring out the rebellious teenager in all of us.

We must move beyond the idea of control,83 that is, beyond trying to control our patients or having patients control themselves, to the idea of autonomy.84 Patients are more likely to adopt healthy behaviors if they want to rather than if they ought to or have to change. Over time, patients are more likely to behave in healthy ways if we openly acknowledge their choice to engage in an unhealthy behavior rather than trying to make them change. Autonomy-supportive approaches (offering choices) are more effective in helping patients change than are coercive measures.84 Examples of the distinctions between controlling and autonomy-supportive approaches are interspersed throughout this book.85

CONSIDER CHANGING YOURSELF

Consider taking a step back from changing patients' behaviors to focus on your own health behaviors, professional roles and assumptions. Learning from your attempts to change your personal and professional behaviors may help you empathize and work more effectively with your patients. This suggestion is important for another reason. Our health habits affect how we work with patients. Physicians with healthy behaviors (e.g., nonsmoking, low-risk drinking or abstinence, regular exercise) are more likely to counsel patients about the same behaviors.86-90 In a few countries, an overall decline in the smoking rate was preceded by a decline in the smoking rate among physicians. Yet the smoking rate among health care professionals remains high in many countries. Perhaps the health care professions can indeed do a better job of helping its members develop healthier habits. No one, of course, is perfect. We all have something that we could do to improve our health (healthy diets, weight reduction and more exercise).

Mohandas K. Gandhi emphasized the importance of beginning with oneself when addressing change:

Be the change that you want to see in the world. I have only three enemies. My favorite enemy, the one most easily influenced for the better, is the British Empire. My second enemy, the Indian people, is far more difficult. But my most formidable opponent is a man named Mohandas K. Gandhi. With him I seem to have very little influence.

An important take-home message is that you may find it easier to influence patients to change than to change your own family members, or even yourself.

The inner process of learning how to change your health behaviors and how to become a motivational practitioner can accelerate the outer process of expanding your depth and range of motivational skills and of developing individualized interventions to meet your patients' changing needs. This premise, however, can be threatening or seem irrelevant or unnecessary to some practitioners, so they avoid exploring personal or professional issues about self-change. As you read through the next section of this chapter, assess your internal reactions about the extent to which you have positive, negative or mixed responses to different aspects of this premise or this chapter. In what ways are your internal reactions similar or different from some of your patients?

Practitioner Example of Internal "Mixed" Reactions: A general practitioner from Bergen, Norway, felt that this chapter was persuasive about promoting healthy habits but also expressed concerns about practitioners "overdoing it" with their patients and acting as health care imperialists.

Commentary: These concerns speak to a crucial issue about the differences between autonomy-supportiveness and behaviorally controlling ways. This chapter introduces the motivational principle of autonomy-supportiveness, but some practitioners may not fully understand how to put this principle into practice and may unknowingly act in controlling ways that are antithetical to this principle. In effect, they fall into the trap of health care imperialism. At the other extreme, we fall into the enabling trap-acting as our patients' unconditional advocates to support their choice to do as they please, without setting any limits. As a middle way between these extremes, we can support patients' autonomy without either of us abandoning or imposing our health care values. Instead of becoming immobilized by this ethical dilemma, we can respect, explore and work with our differences in values with our patients, all, of course, with their explicit consent or implicitly based on mutual trust.

Now, if you wish, consider identifying a professional or personal issue that you want to change. Much can be learned from your attempt to unravel the individual and contextual factors that shape this behavior-doing so may help both you and your patients. Kurt Lewin succinctly captures the essence of this kind of learning opportunity:

If you want to understand something, try to change it.91

Personal Change: Your Health Behaviors and Life Situation
Personal health habits influence our professional behavior. Practitioners with unhealthy behaviors (e.g., lack of exercise, unhealthy diet and overeating, causing obesity) are less likely to counsel patients who have the same behaviors. This is yet another reason why it's important to address change by beginning with yourself. Learning Exercise 1.1 helps you reflect about changing yourself as a way to understanding yourself. Such self-understanding can help you become a more effective motivational practitioner with patients. Find out where you stand by completing the exercise.

Learning Exercise 1.1. Assess your overall health behaviors and life issues
Complete the questionnaires for 10 Health Behaviors and 10 Life issues.
Circle N or Y for each health decision.
N = Not applicable to me.                                                              
Y = Yes. For each yes response, use this readiness-to-change" scale:
1= not thinking about change 2 = thinking about change
3 = preparing to change

Health Behaviors and Life Issue
A Self-evaluation
Self-assessment
Readiness to change
1.   Tobacco use
N              Y
1   2   3
2.   Eating habits
N              Y
1   2   3
3.   Weight
N              Y
1   2   3
4.   Physical activity
N              Y
1   2   3
5.   Alcohol use
N              Y
1   2   3
6.   Illegal drug use
N              Y
1   2   3
7.   Safe sex practices
N              Y
1   2   3
8.   Contraception to prevent pregnancy
N              Y
1   2   3
9.   Regular use of prescribed drugs
N              Y
1   2   3
10. Safety belt use and bicycle helmets
N              Y
1   2   3
11. Social relationships
N              Y
1   2   3
12. Job satisfaction
N              Y
1   2   3
13. Financial situation
N              Y
1   2   3
14. Work/family/social balance
N              Y
1   2   3
15. Professional/personal overfunctioning
N              Y
1   2   3
16. Physical and sexual abuse
N              Y
1   2   3
17. Emotional health
N              Y
1   2   3
18. Coping with stress
N              Y
1   2   3
19. Environmental health (work/home)
N              Y
1   2   3
20. Spiritual health
N              Y
1   2   3

• For each health behavior and life situation of concern (those circled "Y"), complete the scale of your readiness to change. Look at each concern where you're not thinking about change or are thinking about it but are unsure what to do. Questions to Ponder: How long have you been thinking about change? What is holding you back? What is keeping your foot nailed to the floor in addressing change?
• Think about a recent time when someone did not follow your advice to address a health concern.
Question to Ponder: How does your previous analysis of difficulties in changing your own behavior help you understand why it can be so difficult for someone else to change, especially when it is an issue that is not a concern for you personally?
• Think about the occasions when a health issue came up with someone you know: a patient, colleague, family member or friend.
Questions to Ponder: How was your behavior in this interaction influenced by your own health choices? Can you see any positive or negative patterns in the ways that you interact with others, for better or worse?

You may even need some additional assistance to address some behaviors such as lack of exercise, unhealthy diet or even overwork. If so, you may find it helpful to use Motivate Healthy Habits: Stepping Stones to Lasting Change (a self-guided change version of this book) to work on your behaviors.92 Your personal experience of using it can then help you to help your patients learn how to use this guidebook with or without your ongoing support.

Professional Change: Roles, Perspectives and Mental Models
We need to incorporate new similes and metaphors into well-established ones. The mechanistic similes (hammer and nails, nuts and bolts) used at the beginning of this chapter only tell practitioners to stop using the fix-it role when health information and advice doesn't work. As previously noted, the machine and gardener metaphors characterize the fix-it and motivational roles respectively. Organic metaphors can help us move beyond the toolbox metaphors; it is not just a question of picking up a new tool. These metaphors more aptly capture how we need to work in addressing health behavior change with our patients. This process also involves professional change: changing your roles appropriately, learning about different perspectives on resistance and motivation and using mental maps for developing individualized interventions to meet your patients' changing needs over time.

Changing roles
An understanding about different roles (motivational, preventive and fix-it) lays the foundation for learning how to enhance your skills at motivating behavior change. (Chapters 2-4 present these three roles in detail and describe how different roles can have both positive and negative impacts on our work with patients.) A brief description about the distinctions between these roles will help you to understand why it is important to change your role before developing new skills.

The term agent of change is used figuratively to clarify different roles that you may assume in working with patients. Practitioner-centered advice is the agent of change for fix-it roles. Such advice is based on what practitioners think patients should be given, rather than on what patients may prefer or need. In a preventive role, education tailored to the needs of patients becomes the agent of change. In a motivational role, you work with, rather than against, indifferent or resistant patients. Your dialogue with patients becomes the agency of change. You use such dialogue (together with a motivational assessment) to help develop individualized interventions to meet patients' changing needs over time.

The fix-it role is more appropriate for treating diseases caused by risk behaviors (e.g., giving antibiotics for acute bronchitis) than it is for helping patients change risk behaviors (e.g., giving advice to quit smoking). If we remain in a fix-it role, we may persist in providing more information and advice to resistant, indifferent and ambivalent patients than they want. This situation can evoke mutual frustration in addition to possible anger and guilt and become such a negative experience that patients may avoid us or fail to seek appropriate care.

Learning about resistance and motivation
Patient resistance is a normal and expected phenomenon, but it is also a learning opportunity to understand why patients resist change in spite of our good intentions to help them. We are often on different wavelengths from our patients. Unless we change our wavelength, we cancel out each other's energy, so nothing happens but perpetual inertia and wariness. How can you motivate these patients to change? First, learn how to adapt your role to meet patients' needs. Different perspectives on resistance and motivation (Chapters 5-7) can help you learn how to work with resistance, rather than work against it. Then you are in a better position to help patients redirect their energy in healthy directions.

Internalizing the six-step approach as a mental map
A mental map is a framework or way of thinking derived from internalizing a model. You can use the six-step approach (summarized in Table 1.4 and explained in Chapters 8-14) as a mental map for negotiating about behavior change with patients. Even if you internalize this map, it does not mean that you are skillful in navigating the territory-in this case, the patient's world. Always keep in mind that the map is not the territory.93 It is just a guide, but it can help you learn to negotiate an appropriate rate at which to work through the change process with your patients.94 In addition, a mental map can help you learn how to use words, language and dialogue more effectively in working with your patients. With repeated practice in using this guide, you can become more effective over time in developing individualized interventions for your patients.

Table 1.4. Six-step Approach for Negotiating Change
Mental Map for Negotiating ChangeDesired Impact on Patients
Step 1: Building a partnership
Step 2: Negotiating an agenda
Helps patients move from not thinking about change to thinking about it.
Step 3: Assessing resistance and motivation
Step 4: Enhancing mutual understanding
Helps patients move from thinking about change to preparing to change.
Step 5: Implementing a planHelps patients move from preparing to change to taking action.
Step 6: Following throughHelps patients move from taking action to maintaining change.

Patients have good reasons for their health decisions, but you may disagree with their logic. To work with the so-called irrationality, you need to work with patients at the level of their perceptions and values. A decision balance (used in Step 3) is a simple tool that can help you do this. This tool can help your patients organize their thoughts about staying the same (resistance) versus changing (motivation), and uncover what lies beneath their thoughts about change: emotions, perceptions and values. If you understand how their values affect their perceptions, and in turn their behaviors, you will at least understand their decision-making process. The example below illustrates how you can use this tool to understand so-called human irrationality when seeing your patients in your office.

Resistance to the Practice of Safe Sex: Mrs. S., a 45-year-old woman, came to her family physician (Dr. M.) for a follow-up to her HIV test. Two years ago, she remarried after being divorced for many years. She had recently moved back to her hometown after her husband broke his parole and was returned to jail. Mr. and Mrs. S. had regularly attended an HIV clinic because Mr. S. was HIV-positive. Even though Mrs. S. knew how to put a condom on her husband, he did not want to wear one. Fortunately, she remained HIV-negative even without practicing safe sex. The doctor at the HIV clinic had advised Mrs. S. to have an HIV test done every three months. Dr. M. ordered the HIV test and asked her if she would be willing to fill out a decision balance in order to better understand why she did not want to use condoms. Dr. M. saw another patient while Mrs. S. completed this task, and then returned to see what she had written.

Learning Exercise 1.2. Reflect on Mrs. S.'s decision balanc
Reflect on the following questions as you read Mrs. S.'s decision balance.
• How does she perceive her reasons to stay the same versus her reasons to
    change, based on how she thinks and feels?
• What does she feel about her husband?
• What does she feel about herself?
• How does she value her relationship as compared to herself and her own
    family?

Then analyze her decision balance. The left column represents Mrs. S.'s reasons to stay the same, and the right column represents her reasons to change.

Mrs. S.'s Decision Balance about Safe Sex
Reasons not to use condoms (resistance)Reasons to use condoms (motivation)
1. Benefits of not using condomsNot make him feel he is failing at being sexually competent.He feels secure that I'll stay with him.2. Concerns about not using condomsDon't want HIV.Don't want my family hurt.Maybe people will think he doesn't care to protect me.
3. Concerns about using condomsHe will have erection problems and it will make him sad.He will wish he were with his ex-girlfriend (who is HIV) so he won't have to use them.
4. Benefits of using condomsWon't get HIV so won't upset family.Won't get sick myself so I can take care of him when he gets sicker.Will feel that he cares enough about me and will not allow me to get sick.
Resistance Score = 9
Feeling score = 9 Think score = 6
Motivation Score = 4
Feeling score = 4 Think score = 8

 

Assessing Mrs. S.'s perceptions about her resistance and motivation: When Dr. M. reentered the room, he read what Mrs. S. wrote and first pointed to the left-hand column of her decision balance. He asked her to use a scale from 0 to 10 (0 = not important and 10 = very important) to rate her overall reasons for not using condoms. Mrs. S. gave a resistance score of 9. Dr. M. then asked to rate her reasons for using them. She gave a motivation score of 4. Dr. M. asked her whether her scores were based on her feelings or her thoughts. Mrs. S stated that her scores were based on her feelings. Dr. M. then asked her to rate her overall reasons to stay the same versus her reasons to change based on what she thought about it. Mrs. S. gave 6 for her resistance score and 8 for her motivation score. This process helped her understand much better how much her heart ruled her head in making decisions. Emotionally, she felt that she should stay the same, but rationally she thought she should protect herself.

Assessing Mrs. S's emotions and values: Looking over her decision balance again, Dr. M. reflected back to Mrs. S. that she must really love her husband. Mrs. S. smiled in total agreement and expressed devotion to her husband, stating that she wanted to care for him when he gets terminally ill. Dr. M. asked her how she valued her relationship with her husband in comparison to herself and the relationship to her own family. Mrs. S. loved her husband so much that she was willing to sacrifice her life for him, but admitted to having mixed feelings when thinking about her own children from her first marriage. Her adult children did not know about her current situation. Mrs. S. stated she came from an abusive family and has suffered from chronic low self-esteem since childhood.

 

This example demonstrates how you can begin to engage patients in dialogue about change and to develop individualized interventions during a 15-minute appointment. Over time, effective interventions can assist your patients in deciding whether to change their values and perceptions in ways that motivate them to take charge of changing their behavior. The six-step approach described in Section III can help you learn how to use words, language and dialogue more effectively with your patients. With repeated practice in using this approach, you could become a more effective and efficient motivational practitioner.


CONTINUING PROFESSIONAL DEVELOPMENT

A continuing professional development (CPD) curriculum on motivating health behavior change must revisit topics at increasing levels of complexity to foster lifelong learning, enrich professional development and improve clinical performance. Such a dynamic curriculum could help us develop skills at self-directed learning as well as provide opportunities for small group learning, individual supervision and/or a longitudinal relationship with a mentor throughout our formal education and career. Given that such ideal curricula are rare, however, it is important to take charge of your own CPD. Whatever your level of clinical experience, you can use this book to prepare for and design a learning plan for your ongoing professional development.

Taking Charge of Your Professional Development
Even if you were not trained in how to motivate behavior change, you can use self-directed learning methods, ideally working with patients over time. Section IV in this book describes how you can develop skills for initiating dialogues with patients in addressing specific behaviors. If available, workshops can also help you enhance your motivational skills. Dr. S.'s written evaluation of such a workshop captures the merits of such training:

Although it has been 15 years since I have done any role-playing, I found it extremely captivating. Afterward, I found that I was immediately applying in the office what I had learned in role-playing. I became consciously aware of resistance during patient interviews and was more apt to closely examine patients' agendas, as well as their perceptions. Patients appeared extremely gratified. My frustration level was also considerably diminished. These have been the gifts:

• Seeing the therapeutic relationship as a worthy goal in and of itself
• Seeing where someone is at along the change continuum and using that to
    respect the patient's autonomy and our own humble role as advisers
• Finding out what people want and how they see things rather than working
    with what I think they want and how I think they see things
• Being sensitive to resistance helps me change my approach to patients

 

With training and practice, you can become more effective, deliberate and purposeful in helping patients work through the change process. At first, this process will take more time and even slow you down, but in time you will expand your range and depth of motivational skills. However, you can develop a learning plan for continuing professional development so that you can monitor your progress, whatever your starting point or level of clinical experience, on your journey from a novice to a master. Becoming a master is not a destination but a journey without end.


YOUR SUMMARY

Reflect: write a note (in 200 words or so) summarizing how this chapter helped you understand better the potential benefits of exploring your own health behaviors, professional roles and assumptions, as you learn about how to develop motivation skills. Which aspects of this premise, if any, evoke some resistance in you? What have you learned that was new for you?

 

 
 
 
 


Enhance: write down your ideas about how your new learning could improve your interactions with patients. Add your notes to your learning portfolio.

 
 
 
 
 

 

REFERENCES

1. Prochaska JO, DiClemente CC. Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy
    Theory, Research and Practice 1982;19: 276-288
2. Prochaska JO, DiClemente CC. The transtheoretical approach: Crossing traditional boundaries of therapy. Homewood, IL:
    Dow Jones/Irwin; 1984
3. A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. The Tobacco Use
    and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. Journal of the American
    Medical Association 2000;283: 3244-3254
4. Law M, Tang JL. An analysis of the effectiveness of interventions intended to help people stop smoking. Archives of
    Internal Medicine 1995;155: 1933-1941
5. Ritvo PG, Irvine MJ, Lindsay EA, et al. A critical review of research related to family physician-assisted smoking
    cessation interventions. Cancer Prevention and Control 1997;1: 289-303
6. Kottke TE, Battista RN, DeFriese GH, et al. Attributes of successful smoking cessation interventions in medical practice.
    A meta-analysis of 39 controlled trials. Journal of the American Medical Association 1988;259: 2883-2889
7. Kahan M, Wilson L, Becker L. Effectiveness of physician-based interventions with problem drinkers: A review. Canadian
    Medical Association Journal 1995;152: 851-859
8. Brunner E, White I, Thorogood M, et al. Can dietary interventions change diet and cardiovascular risk factors? A meta-
    analysis of randomized controlled trials [see comments]. American Journal of Public Health 1997;87: 1415-1422
9. Ashenden R, Silagy C, Weller D. A systematic review of the effectiveness of promoting lifestyle change in general
    practice. [Review] [51 refs]. Family Practice 1997;14: 160-176
10. Ebrahim S, Smith GD. Systematic review of randomized controlled trials of multiple risk factor interventions for
      preventing coronary heart disease. British Medical Journal 1997;314: 1666-1674
11. Velicer W, Fava J, and Prochaska J. Distribution of smokers by stage. Cancer Prevention Research Center, 1-26. 1995
12. Velicer WF, DiClemente CC. Understanding and intervening with the total population of smokers. Tobacco Control
      1993;2: 95-96
13. Kaplan RM, Pierce JP, Gilpin EA, et al. Stages of smoking cessation: The 1990 California Tobacco Survey. Tobacco
      Control 1993;2: 139-144
14. Burns D, Pierce JP. Tobacco use in California 1990-1991. Sacramento: California Department of Health Services; 1992
15. Butler CC, Pill R, Stott NCH. Qualitative study of patients' perceptions of doctors' advice to quit smoking: Implications
      for opportunistic health promotion. British Medical Journal 1998;316: 1878-1881
16. Bowman MA, Dignan M, Crandall S, et al. Changes in functional status related to health maintenance visits to family
      physicians [see comments]. Journal of Family Practice 2000;49: 428-433
17. Balint M. The doctor, his patient, and the illness. New York: International Universities Press; 1977
18. Simons-Mortin DG, Mullen PD, Mains DA, et al. Characteristics of controlled studies of patient education and
      counseling for preventive health behaviors. Patient Education and Counseling 1992;19: 175-204
19. Fiore MC. Treating tobacco use and dependence: An introduction to the U.S. Public Health Service Clinical Practice
      Guideline. Respiratory Care 2000;45: 1196-1199
20. Silagy C, Ketteridge S. The effectiveness of physician advice to aid smoking cessation. In: Lancaster T, Silagy C, eds.
      Tobacco addiction module of the Cochrane database of systematic reviews [updated 2 December 1996]. Oxford; 1996
21. West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: An update. Health Education
      Authority. Thorax 2000;55: 987-999
22. Coleman T, Murphy E, Cheater F. Factors influencing discussion of smoking between general practitioners and patients
      who smoke: a qualitative study. British Journal of General Practice 2000;50: 207-210
23. Coulter A, Schofield T. Prevention in general practice: The views of doctors in the Oxford region. British Journal of
      General Practice 1991;41: 140-143
24. Coleman T, Wilson A. Anti-smoking advice in general practice consultations: General practitioners' attitudes, reported
      practice and perceived problems. British Journal of General Practice 1996;46: 87-91
25. Tapper-Jones L, Smail S, Pill R, et al. Doctors' attitudes towards patient education in the primary care consultation.
      Health Education Journal 1990;49: 47-50
26. Stott NC, Pill RM. "Advise yes, dictate no": Patients' views on health promotion in the consultation. Family Practice
      1990;7: 125-131
27. Kviz FJ, Clark MA, Hope H, et al. Patients' perceptions of their physician's role in smoking cessation by age and
      readiness to stop smoking. Preventive Medicine 1997;26: 340-349
28. Coleman T, Wilson A. Anti-smoking advice from general practitioners: Is a population-based approach to advice-giving
      feasible? British Journal of General Practice 2000;50: 1001-1004
29. Lakoff G, Johnson M. Metaphors we live by. Chicago: University of Chicago Press; 1980
30. Royston G, Dick P. Healthcare ecology. British Journal of Health Care Management 1998;4: 238-241
31. Dick P. The NHS as an ecosystem. British Journal of General Practice 2001;51: 248-249
32. Boudon R. The limitations of rational choice theory. American Journal of Sociology 1998;104: 817-828
33. Goldman L. Enlightened individual choice vs the public's health: Rational prevention from whose perspective? Journal of
      General Internal Medicine 1995;10: 147-150
34. Somekh B, Thaler M. Contradictions of management theory, organizational cultures and the self. Education Action
      Research 1997;5: 141-160
35. Stewart M, Brown JB, Weston WW. Patient-centered medicine. Thousand Oaks, CA: Sage Publications; 1995
36. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. Journal of Family Practice
      2000;49: 796-804
37. Botelho RJ, Novak SJ. Dealing with substance misuse, abuse, and dependency. Primary Care 1993;20(1): 51-70
38. Botelho RJ, Skinner HA. Motivating change in health behavior: Implications for health promotion and disease
      prevention. Primary Care (Saunders) 1995;22: 565-589
39. Botelho RJ, Skinner HA, Williams GC, et al. Patients with alcohol problems in primary care: Understanding their
      resistance and motivating change. In: Stuart MR, Lieberman IJA, eds. Primary care: Clinics in office practice.
      Philadelphia: W.B. Saunders Company; 1999:279-298
40. Harackiewicz JM, Sansone C, Blair LW, et al. Attributional processes in behavior change and maintenance: Smoking
      cessation and continued abstinence. Journal of Consulting and Clinical Psychology 1987;55: 372-378
41. Ockene JK, Kristeller J, Goldberg R, et al. Increasing the efficacy of physician-delivered smoking interventions: A
      randomized clinical trial [see comments]. Journal of General Internal Medicine 1991;6: 1-8
42. Currie CE, Amos A, Hunt SM. The dynamics and processes of behavioral change in five classes of health-related
      behavior-findings from qualitative research. Health Education Research 1991;6: 443-453
43. Ryan RM, Plant RW, O'Malley S. Initial motivations for alcohol treatment: Relations with patient characteristics,
      treatment involvement, and dropout. Addictive Behaviors 1995;20: 279-297
44. Williams GC, Grow VM, Freedman ZR, et al. Motivational predictors of weight loss and weight-loss maintenance.
      Journal of Personality and Social Psychology 1996;70(1): 115-126
45. Williams GC, Rodin GC, Ryan RM, et al. Autonomous regulation and long-term medication adherence in adult
      outpatients. Health Psychology 1998;17: 269-276
46. Perz CA, DiClemente CC, Carbonari JP. Doing the right thing at the right time? The interaction of stages and processes
      of change in successful smoking cessation. Health Psychology 1996;15: 462-468
47. Patrick K, Sallis J, Long B, et al. A new tool for encouraging activity: The physician and sports medicine 1994;22
48. Calfas KJ, Long BJ, Sallis JF, et al. A controlled trial of physician counseling to promote the adoption of physical
      activity. Preventive Medicine 1996;25: 225-233
49. Long BJ, Calfas KJ, Wooten W, et al. A multisite field test of the acceptability of physical activity counseling in primary
      care: project PACE. American Journal of Preventive Medicine 1996;12: 73-81
50. Sutton S. Can "stage of change" provide guidance in the treatment of addictions? A critical examination of Prochaska and
      DiClemente's model. In: Edwards G, Dare C, eds. Psychotherapy, psychological treatments and the addictions.
      New York: Cambridge University Press; 1996
51. Farkas AJ, Pierce JP, Gilpin EA, et al. Is stage-of-change a useful measure of the likelihood of smoking cessation? Annals
      of Behavioral Medicine 1996;18: 79-86
52. Prochaska JO, Velicer WF. On models, methods and premature conclusions. Addiction 1996;91: 1281-1283
53. Farkas AJ, Pierce JP, Zhu SH, et al. Addiction versus stages of change models in predicting smoking cessation. Addiction
      1996;91: 1271-1280
54. Joseph J, Breslin C, Skinner HA. Critical perspective on the transtheoretical model and the stages of change. In: Tucher J,
      Donovan D, Marlatt A, eds. Changing addictive behavior: Moving beyond therapy assisted change. New York: Guilford
      Press; 1999:160-190
55. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: A review. Addiction 1993;88: 315-335
56. Ershoff DH, Quinn V, Boyd NR, et al. The Kaiser Permanente prenatal smoking-cessation trial: When more isn't better,
      what is enough? American Journal of Preventive Medicine 1999;17: 161-168
57. Miller WR, Sovereign RG, Krege B. Motivational interviewing with problem drinkers: II. The drinker's check-up as a
      preventative intervention. Behavioral Psychotherapy 1988;16: 251-268
58. Stephens RS, Roffman RA, Simpson EE. Treating adult marijuana dependence: A test of the relapse prevention model.
      Journal of Consulting and Clinical Psychology 1994;62: 92-99
59. Baer JS, Marlatt GA. Maintenance of smoking cessation [published erratum appears in Clinical Chest Medicine 1992
      Mar;13(1):ix]. Clinical Chest Medicine 1991;12: 793-800
60. Smith DE, Heckmeyer CM, Kratt PP, et al. Motivational interviewing to improve adherence to a behavioral
      weight-control program for older obese women with NIDDM. Diabetes Care 1997;20: 52-54
61. Brown JM, Miller WR. Impact of motivational interviewing on participation in residential alcoholism treatment.
      Psychology of Addictive Behaviors 1993;7: 211-218
62. Allsop S, Saunders B, Phillips M, et al. A trial of relapse prevention with severely dependent male problem drinkers.
      Addiction 1997;92: 61-73
63. Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH
      posttreatment drinking outcomes. Journal of Studies on Alcohol 1997;58: 7-29
64. May WW. Findings from Project MATCH: Fact or artifact? Behavioral Health Management 1998;
      January/February: 38-39
65. Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism,
      Clinical and Experimental Research 1998;22: 1300-1311
66. Saunders B, Wilkinson C, Phillips M. The impact of a brief motivational intervention with opiate users attending a
      methadone programme. Addiction 1995;90: 415-424
67. Heather N, Rollnick S, Bell A, et al. Effects of brief counseling among male heavy drinkers identified on general hospital
      wards. Drug and Alcohol Review 1996;15: 29-38
68. Woollard J, Beilin L, Lord T, et al. A controlled trial of nurse counseling on lifestyle change for hypertensives treated in
      general practice: Preliminary results. Clinical and Experimental Pharmacology and Physiology 1995;22: 466-468
69. Butler CC, Rollnick S, Cohen DA, et al. Motivational consulting versus brief advice for smokers in general practice: A
      randomized trial. British Journal of General Practice 1999;49: 611-616
70. Berg-Smith SM, Stevens VJ, Brown KM, et al. A brief motivational intervention to improve dietary adherence in
      adolescents. The Dietary Intervention Study in Children (DISC) Research Group. Health Education Research
      1999;14: 399-410
71. Lowman C, Allen J, Stout RL. Replication and extension of Marlatt's taxonomy of relapse precipitants: Overview of
      procedures and results. The Relapse Research Group. Addiction 1996;91: S51-S71
72. Carroll K. Relapse prevention as a psychosocial treatment: A review of controlled clinical trials. Experimental and
      Clinical Psychopharmacology 1996;4: 46-54
73. Botelho RJ. Negotiating partnerships in healthcare: Contexts and methods. In: Suchman AL, Botelho RJ,
      Hinton-Walker P, eds. Partnerships in healthcare: Transforming relational process. Rochester, NY: University of
      Rochester Press; 1998:19-49
74. Bartlett's Familiar Quotations. 14th, rev. and enl. ed. Boston: Little, Brown and Co.; 1968
75. Miller WR, Rollnick S. Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford
      Press; 1991
76. Rollnick S, Mason P, Butler C. Health behavior change: A guide for practitioners. Edinburgh, Scotland: Churchill
      Livingstone; 1999
77. McGinnis JM, Foege WH. Actual causes of death in the United States. Journal of the American Medical Association
      1993;270: 2207-2212
78. Rogers CR. A way of being. Boston: Houghton Mifflin; 1980
79. Freire P. Education for critical consciousness. New York: Seabury Press; 1973
80. Wallerstein N, Bernstein E. Empowerment education: Freire's ideas adapted to health education. Health Education
      Quarterly 1988;15: 379-394
81. Brehm JW. A theory of psychological reactance. New York: Academic Press; 1966
82. Brehm SS, Brehm JW. Psychological reactance: A theory of freedom and control. New York: Academic Press; 1981
83. Shapiro DH, Jr., Schwartz CE, Astin JA. Controlling ourselves, controlling our world. American Psychologist
      1996;51: 1213-1230
84. Deci EL, Ryan RM. Intrinsic motivation and self-determination in human behavior. New York: Plenum Press; 1985
85. Williams GC, Deci EL, Ryan RM. Building healthcare partnerships by supporting autonomy: Promoting maintained
      behavior change and positive healthcare outcomes. In: Suchman AL, Botelho RJ, Hinton-Walker P, eds. Partnerships in
      healthcare: Transforming relational process. Rochester, NY: University of Rochester Press; 1998:67-87
86. Lewis CE, Clancy C, Leake B, et al. The counseling practices of internists. Annals of Internal Medicine 1991;114: 54-58
87. Wells KB, Lewis CE, Leake B, et al. Do physicians preach what they practice? A study of physicians' health habits and
      counseling practices. Journal of the American Medical Association 1984;252: 2846-2848
88. Schwartz JS, Lewis CE, Clancy C, et al. Internists' practices in health promotion and disease prevention. A survey [see
      comments]. Annals of Internal Medicine 1991;114: 46-53
89. Frank E, Rothenberg R, Lewis C, et al. Correlates of physicians' prevention-related practices. Findings from the Women
      Physicians' Health Study. Archives of Family Medicine 2000;9: 359-367
90. Frank E, Breyan J, Elon L. Physician disclosure of healthy personal behaviors improves credibility and ability to
      motivate. Archives of Family Medicine 2000;9: 287-290
91. Lewin K. Field theory in social science. New York: Harper Torchbooks; 1951
92. Botelho RJ. Motivate healthy habits: Stepping stones to lasting change. Rochester, NY; 2004
93. Bateson G. Mind and nature: A necessary unity. New York: E.P. Dutton; 1979
94. Botelho RJ. A negotiation model for the doctor-patient relationship. Family Practice 1992;9: 210-21

Home | Contact | Site Map | Acknowledgements | Disclaimer | Privacy  
  Powered by MustBeOnline.net Copyright © 2004-2009 Motivate Healthy Habits