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:

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.

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.

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.

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:

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:

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?

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 Change	Desired 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 plan	Helps patients move from preparing to change to taking action.
Step 6: Following through	Helps 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.

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

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:

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.

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