The Concept of
Evidence-based, primary care guidelines for addressing risk behaviors
predominantly address surface change. Practitioners give information and advice
to patients, with the goals of eliciting their good intentions and setting goals
for change. The guidelines quantify the mean impact of behavioral interventions
(absolute risk reduction and/or Number Needed to Treat) on specific populations:
or more simply, what is the intervention benefit to the average person from
a specific population.
Practitioners still face the challenge of working out whether
the "proven" interventions from these guidelines are relevant to their individual
patients. Regrettably, these interventions work in modifying their risk behaviors
for only a minority of patients. These interventions predominantly address surface
change: imparting information, giving advice, eliciting good intentions and
setting goals. Most patients do not change their risk behaviors in response
to these interventions.
Why do the guidelines fail for the vast majority of individuals?
These guidelines underestimate the complexity of changing from unhealthy to
healthy habits. Practitioners assume a health adviser role and deliver simplistic
interventions that take only minutes. Such interventions are unlikely to change
unhealthy habits that most patients have taken years to develop. Furthermore,
patients spend most of their lives on autopilot: doing what they have to do,
without going beyond surface change.
The challenging question is: what can work, in particular, for
an individual patient when the "proven" interventions are ineffective? Do you
keep hammering away with ineffective interventions as though patients were nails?
Hammering away at patients may only make some patients more resistant that they
avoid coming to see you. An alternative approach is needed. The development
of motivational approaches to behavior change should promise in addressing the
shortcomings of the current guidelines.
Most patients know (and even think) that they should change, but
they do not feel like it. They not only lack motivation, but they also emotionally
resist change. Emotional resistance to change is the hidden force in clinical
encounters, and practitioners are often unaware of how its presence defeats
their efforts to effect change.
Practitioners need go beyond surface change to deep change: helping
patients explore their feelings, perceptions, motives and values.
This intra-personal process can help patients learn how to lower
their emotional resistance and increase their motivation to change. In other
words, what does it mean for individuals to work through their ambivalence about
changing their risk behavior?
This paradigm shift from the outside-in (objective) to inside-out
(subjective) approach moves beyond the limits of scientific evidence and guideline
to personal evidence and practical wisdom that arises from reflecting on structured
learning experiences. This shift transfers the "principal investigator" role
for behavior change from the scientist to the individual patient. Practitioners
assist individual patients in taking charge of generating their own personal
evidence, based on their reflective learning experiences.
With this role transition, the practitioner assumes the "co-investigator"
role and works as a motivational guide to the "principal investigator". Or alternatively,
the patient is the driver's seat with the practitioner in the passenger seat
using a map to guide their journey. Both of these analogies put patients in
charge of working on behavior change: in other words, supporting patients in
taking the one-up position.
Anytime that practitioners consistently put more effort into the
change process than the patients is a signal that they need to change their
relational process. For example, with the health adviser role, practitioners
often fall in the trap of taking the one-up, fix-it role. The role is dysfunctional
when using ineffective interventions over and over with patients: a frustrating
Motivational practice involves practitioners engaging patients
in ongoing opportunities that evoke reflective learning experiences about behavior
change. Patients can use this introspective process to generate their own personal
evidence about making deep change, and re-program their automatic behaviors
to develop healthier habits.
This intra-personal process may use blended learning methods with
any combination of the following activities (listed below). Health care settings
can develop a comprehensive program by adopting an organizational culture based
on the concept and principles of motivational practice. To extend beyond their
setting, they develop outreach activities to community organizations who are
willing to become trained in the Motivate Healthy Habits learning process.
- Reading the MHH, mutual aid and self-help guidebooks
- Working with, and getting support from family and friends
- Journaling experiences in using learning exercises
- Participating in online learning programs (individual and group)
- Using supportive groups to address contextual issues, such social deprivation,
poverty, and complex psychosocial issues.
- Counseling with practitioners and/or lay health guides (in-person or telephonically)
- Working with community programs
These learning methods are an epiphenomenon to the inner, core
experience of the individual who is willing to explore deep change. The primary
focus of motivational practice is on helping individuals participate in meaningful,
learning experiences that facilitate deep change. This sense-making process
can activate patients to optimize their health habits and/or self-care of chronic
diseases. The intra-personal process can involve patients in any combination
of the following activities:
Understand the challenge of change
- Clarify their issues about change
- Assess their resistance based on what they think and how they
- Assess their motivation based on what they think and how they
- Explore perceptions about risks, benefits and harms
- Assess energy levels to change and competing priorities
- Examine their values and motives
Master the process of change
- Alter their perceptions about risks, benefits and harms
- Lower their emotional resistance
- Increase their motivation
- Change their values
Rise to the challenge to change
- Enhance confidence and ability to change
- Implement an action plan
- Prevent lapses and relapses
How Practitioners Interact with Patients
In the health advisor role, practitioners wait for "teaching moments"
in clinical encounters to promote healthy behaviors. In effect, they impose
their perceptions and values on patients. They may act in behavioral controlling
ways that are antithetical to the motivational principle of being autonomy-supportive.
To interact more effectively with patients, practitioners first need to unlearn
this professional role in order to go beyond the rational and linear interventions
described in the guidelines.
To develop motivational skills as a lifelong learning process,
practitioners need to learn how to adopt the motivational role. In this role,
they help patients decide for themselves if they want to change their perceptions
and values about behavior change. Instead of conducting a question and answer,
information-giving interview, they engage patients in dialogues about change
that help them develop individualized interventions to meet their changing needs
over time. They also engage patients in ongoing learning opportunities inside
and outside of the clinical encounter. Practitioners can use the concept of
motivational practice to benefit patients and their own professional development.
Motivational practice integrates the following theories, models
and concepts (table 1) into a cohesive framework of six steps (table 2) that
practitioners can use with patients to facilitate behavior change. Practitioners
work best when they use theories, models, methods and concepts to meet patients'
changing needs over time, rather than making patients fit a particular mould.
This orientation represents a shift from the practitioner's loyalty and fidelity
to a particular theory, model, method or concept to the changing needs of the
individual patient over time.
Practitioners use motivational principles (Table 3) to engage
patients in change dialogues during clinical encounters that can guide the patients'
ongoing learning process. These dialogues can help patients develop individualized
interventions for motivating behavior change and select additional learning
methods. The concept of motivational practice can enhance the capabilities of
practitioners to work in more patient-centered ways, using a variety of learning
methods that accommodate their preferences.
Table 1-Major Influences*
Motivational interviewing iii
Self-determination theory iv
Cognitive behavioral approaches
Solution-based therapy v
Relapse prevention vi
Patient-centered approached vii
Table 2: A Six-step Approach
| 1: Building a partnership
2: Negotiating an agenda
3: Assessing resistance & motivation
4: Enhancing mutual understanding
5: Implementing a plan
6: Following through
Table 3: Motivational Principles
A. Support and respect autonomy
Understand patients' perspective
Develop empathic relationships
Clarify roles and responsibilities
Clarify patients' issues about change
Work at a pace sensitive to patients' needs
Understand patients' perceptions, motives & values
Adopt a positive, non-directive stance
Focus on strengths rather than on weaknesses
Focus on health rather than on pathology
Focus on solutions rather than on problems
Provide constructive feedback
Help patients believe in healthy outcomes
Encourage patients to do emotional work
D. Elicit patients' problem-solving skills
Enhance patients' confidence and ability
Increase supports and reduce barriers
Negotiate reasonable goals for change
Develop plans to prevent relapses
Use "failures" as learning opportunities
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