Table of Contents

Click on Section Headers or Chapter titles to read summaries

Section I. Consider Changing Yourself before
                      Helping Others

     1. When Giving Health Information and Advice Doesn't Work

Limitations of Giving Information and Advice Limitations of the Best Evidence Adopting New Metaphors The Need for a Complementary Approach Limitations of the Fix-it Role Motivating Change Consider Changing Yourself Continuing Professional Development

     2. Contrasting the Fix-it and Motivational Roles

     3. Adapting Your Role to Patients' Needs

Role Characteristics Role Functions Role Boundaries Role Outcomes Your Choice about Roles

     4. Becoming Aware of Assumptions

Range of Assumptions

Section II. Understanding Individual Change

     5. Forces of Change

The Forces of Change Model Leverage Points and Effort Supports and Barriers to Change (System Vectors)

     6. Understanding Resistance

Understanding Patient Resistance Evoking Patient Resistance How Do Patients Resist Change? Go with Resistance

     7. Understanding Motivation

Concepts, Models, Theories and Clinical Approaches Likelihood-of-Action Index

     8. Overview of the Six-step Approach

The Ladder of Change A Practical Application

Section III. Helping Patients Change: A Six-step Approach

     9. Step 1: Building Partnerships

Part A. Developing Empathy Part B. Using Relational Strategies Part C. Clarifying Roles and Responsibilities

     10. Step 2: Negotiating an Agenda

Clarifying Agendas Two Agendas Toward a Shared Agenda

     11. Step 3: Assessing Resistance and Motivation

Disease-centered Assessment Motivational Assessment

     12. Step 4: Enhancing Mutual Understanding

Working with Your Differences Four Essential Skills

     13. Step 5: Implementing a Plan for Change

Evaluate Commitment Toward a Plan for Change Decide about Goals for Change Work toward Solutions

     14. Step 6: Following Through

Rationale, Purpose and Reasons for Follow-up Timing, Duration and Frequency of Follow-up Appointments Methods to Ensure Change and Prevent Relapse

Section IV. Specific Behaviors

     15. Excessive Alcohol Use

Part A. Key Facts about Excessive Alcohol Use Part B. Reducing Alcohol Risk and Harm

     16. Tobacco Use

Part A. Key Facts about Tobacco Use Part B. Helping Resistant Smokers Quit

     17. Facilitating Self-care of Diabetes

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.

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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?

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CHAPTER 2
CONTRASTING THE FIX-IT AND MOTIVATIONAL ROLES

FOR REFLECTION

How do fix-it and motivational practitioners differ in helping their patients change?

OVERVIEW
The fix-it role is most effective in treating injuries and diseases caused by risk behaviors, providing instant gratification for the patient and rewards for the practitioner, if it is successful. In this role, we typically wait until patients have developed complications before advising them to change their behavior. This approach has a limited impact on patients, however, and is often frustrating for them and for us. The purpose of this chapter is to compare this traditional method with a new approach to behavior change and to highlight some differences in how these two roles affect the process and outcome of health care. This comparison deliberately focuses on the limitations of the fix-it role, which is effective in addressing immediate medical problems, and emphasizes the strengths of the motivational role, which is helpful in addressing health behavior change over time. The purpose of this comparison is to enhance your understanding about how
different roles work for different health issues.

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CHAPTER 3
ADAPTING YOUR ROLE TO PATIENTS' NEEDS

FOR REFLECTION

What different roles can you adopt to best meet your patients' particular needs?

OVERVIEW
You are more likely to help patients change if you adapt your role to meet their changing needs over time. The fix-it role is effective and highly appropriate in addressing injuries and diseases caused by risk behaviors. In this role, we typically wait until patients have medical complications before advising them to change. The fix-it approach is based on the assumption that patients will only change when they are sick. This advice-giving approach, even if repeated over time, is of limited effectiveness. But you can intervene earlier and identify at-risk patients before such complications occur. In the preventive role, you educate and provide advice in patient-centered ways. When this tailored approach does not work or loses its effectiveness, you can adopt a motivational role and develop an individualized approach whether or not your patients have any complications. The motivational role helps you work more effectively with so-called resistant patients over time than using the fix-it or preventive role.

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CHAPTER 4
BECOMING AWARE OF ASSUMPTIONS

FOR REFLECTION

How do different assumptions from practitioners, patients and their families help or hinder the prospects of promoting patient behavior change?

OVERVIEW
Many training programs do not provide adequate time, preparation, and opportunities to reflect on and understand implicit assumptions that affect the practitioner-patient-family relationship. This chapter may help you become aware of how assumptions either facilitate or hinder the process of motivating patients to change. Culture, values, beliefs and attitudes powerfully shape the assumptions that you and your patients make about behavior change. Both you and your patients can benefit from identifying how assumptions can positively and negatively affect your relationship in working together. Facilitating assumptions enhance the prospect of motivating patients to change. Stumbling-block assumptions are self-limiting, self-defeating and/or self-fulfilling prophecies.

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SECTION II
UNDERSTANDING INDIVIDUAL CHANGE

Section II describes how theory and research evidence can provide insights into and guide your work with patients. To enhance your understanding of behavior change, Chapters 5-7 address how
     • Four vectors affect the force of change toward a positive or negative outcome
     • Different perspectives can each contribute toward insights about resistance
     • Theories and models provide different ways of understanding motivation
Chapter 8 provides an overview of the six-step approach using the Ladder of Change as a conceptual framework for helping you address the large gaps between the best theories and research evidence and the complexity of working with individual patients over time. This framework can help you work with some of the limitations of
applying scientific evidence to individual patients.

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CHAPTER 5
FORCES OF CHANGE

FOR REFLECTION

Change can be threatening, involve risk and create discomfort.

OVERVIEW
The Forces of Change model provides a framework to help you think about how to intervene to help patients change. The individual vectors for and against change are motivation and resistance; the system vectors for and against individual change are supports and barriers. Motivation and supports generate a positive force toward healthy outcomes, while resistance and barriers generate a negative force toward unhealthy outcomes. The relative strengths of these opposing forces influence whether individuals engage in healthy or unhealthy behaviors. Your challenge is to understand these opposing forces of change so that you can help patients reduce the negative force and increase the
positive force for change.

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CHAPTER 6
UNDERSTANDING RESISTANCE

FOR REFLECTION

What is your understanding of the word resistance?
What assumptions do you make about patient resistance?

OVERVIEW
Patient resistance is an expected and normal part of the change process.1 Different concepts and models provide different ways of understanding it. These different perspectives can also help you understand how you may unintentionally contribute to such patient resistance. A surefire way to evoke resistance is to advise patients to change when you assume they are ready but they are not. For example, a simple, open-ended question about smoking may inadvertently evoke resistance in some patients. You need to recognize both the subtle and blatant forms of resistance in order to work effectively with patients. Otherwise, your relationship with them will feel like a tug-of-war. The following aphorism about patient autonomy captures the rationale for working with rather than against resistance.

Patients become more willing to consider change if you acknowledge their choice to behave in "unhealthy" ways and if they think that you really understand their reasons to stay the same.

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CHAPTER 7
UNDERSTANDING MOTIVATION

FOR REFLECTION

What is your understanding of the word motivation?
What assumptions do you make about patient motivation?

OVERVIEW
Selected concepts, models, theories and clinical approaches are highlighted to provide different perspectives on motivating behavior change. The concepts of self-efficacy and outcome expectancy address whether patients have the confidence and ability to change and whether they think they can achieve their goals for change, respectively. Self-determination theory addresses why patients change, that is, what kinds of motives are more likely to maintain change for life. The transtheoretical model (stages of change) helps to understand patients' readiness to change. Motivational interviewing and relapse prevention approaches help patients initiate and maintain change, respectively.

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CHAPTER 8
OVERVIEW OF THE SIX-STEP APPROACH

FOR REFLECTION

How can you negotiate with patients and motivate them
to work through the change process?

OVERVIEW
The six-step approach to change1 is a mental map to help you negotiate with your patients to take charge of their health over time. This model can help you assess where your negotiations with patients were particularly effective, as well as where and why they broke down. The Ladder of Change provides a conceptual framework that combines the six-step approach with the Stages of Change model: precontemplation, contemplation, preparation, action and maintenance. Each rung on the ladder represents a stage of change-starting with the bottom rung, which represents the first stage of change, and going up. The six-step approach helps patients move up the Ladder of Change.

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SECTION III
HELPING PATIENTS CHANGE:
A SIX-STEP APPROACH

The six-step micro skill approach is designed to help you negotiate with patients about behavior change in a single encounter or during multiple encounters over time. A chapter is devoted to each step: building a partnership, negotiating an agenda, assessing resistance and motivation, enhancing mutual understanding, implementing a plan for change and following through. By moving back and forth between these steps with patients, you can learn how best to motivate them to change.

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CHAPTER 9
STEP 1: BUILDING PARTNERSHIPS

Patients ultimately determine the goal and pace of behavior change. However, your partnership-building skills can significantly accelerate your patients' progress. In this three-part chapter, you will learn about three sets of skills that will enable you to develop effective partnerships with patients.
      Part A: Develop empathy to understand patients' perspective
      Part B: Relate to patients appropriately and accommodate their preference
      Part C: Clarify roles and responsibilities (separate and shared) with patients
Empathic relationships enable you to form effective alliances with patients (see Figure 3.3). Good relationships with your patients have intrinsic worth and value for both parties, but this relational process may not always lead to improved outcomes. What the process can do is lay the foundation for developing effective partnerships with your patients so that you can address your differences in perceptions and values about behavior change (discordance) with them before building common ground (concordance). Effective partnerships can help you work through patients' emotional dis-ease, heightened ambivalence, conflicts (intrapersonal and interpersonal) and even enhanced resistance that can be produced by discussing your differences. To weather patients' emotional storms created by the prospect of change, you may need to strain your relationship (or even allow it to temporarily worsen) so that they can improve their health care outcomes. If you successfully help patients navigate through and move beyond these storms, you can strengthen your relational bond with them and work more effectively together on any other health behavior and/or issue.

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CHAPTER 9 Part A
DEVELOPING EMPATHY

FOR REFLECTION

How do you empathize with patients who resist changing their risk behaviors?

OVERVIEW
Empathic relationships provide the foundation for promoting behavior change, even though empathic skills alone may not be sufficient to help patients change their behavior. To develop such relationships, you can use a variety of communication skills to understand patients' thoughts and feelings about their risk behavior. Such relationships enable you to work from their persective and enhance their prospects of change.

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CHAPTER 9 Part B
USING RELATIONAL STRATEGIES

FOR REFLECTION

Which relational strategies can best help patients change?

OVERVIEW
A relational map can help you better understand how to develop effective partnerships with your patients. Understanding this map helps to clarify how your patients can relate to you in three ways:
      1. The patient one-up/practitioner one-down position
      2. The one-to-one position (egalitarianism)
      3. Practitioner one-up/patient one-down position (paternalism or autocracy)
You can select one of three relational strategies to help patients take charge of changing their behavior by
      1. Elevating them to take the one-up position
      2. Deliberately taking the one-down position
      3. Establishing complementary relationships
When you elevate patients to take the one-up position, you assume that patients know what is in their best interest and how to change, if they choose to. When you take the one-down position, you do not assume you know what is best for your patients or how they could best use your expertise, if at all. With complementary relationships, you accept patients at whatever relationship level they are at but also address the underlying factors that could prevent or detract from taking the one-up position. For example, you can boost the patient's confidence by acknowledging strengths and past successes at
behavioral change.

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CHAPTER 9 Part C
CLARIFYING ROLES AND RESPONSIBILITIES

FOR REFLECTION

What factors affect your roles and responsibilities in working with patients?
How do you clarify your roles and responsibilities with patients?

OVERVIEW
The following factors can shape and change your and your patients' roles in working together:
     • Your patients' perceived confidence and ability to change (self-efficacy)
     • Your patients' motives
     • Your patients' autonomy
     • Your use of authority, influence and control
     • The balance of responsibilities between you and your patients
Clarifying your roles and responsibilities can help you enhance the effectiveness of your partnerships with patients over time. The process may activate patients to take charge of their own health care.

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CHAPTER 10
STEP 2: NEGOTIATING AN AGENDA

FOR REFLECTION

How do you address risk behaviors when patients may not want to talk about them?

OVERVIEW
There are two sets of agendas at the beginning of practitioner-patient encounters, yours and your patient's. The following continua can help you characterize a patient's agenda:
     • Single item-multiple items
     • Urgent-nonurgent
     • Orderly-chaotic
     • Explicit-implicit
     • Simple-complex
Your agenda for clinical encounters often differs from that of your patients. Many patients are not even thinking about health behavior change when you think they should be. Your task is to acquire the necessary skills to understand the patient's initial agenda and then negotiate toward a shared agenda for addressing behavior change using either a problem-focused or a prevention-focused approach. Such agenda-setting skills serve several important functions: they clarify differences in priorities for the clinical encounter; build common ground about the need to address health behavior change, or at least help you better understand your differences with patients; and use time with patients more efficiently and effectively. In particular, your agenda-setting skills prepare patients
to participate actively in assessing how their behavior affects their health.

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CHAPTER 11
STEP 3: ASSESSING RESISTANCE AND MOTIVATION

FOR REFLECTION

How do you assess patient resistance and motivation?

OVERVIEW
This chapter will help you learn how to assess patient resistance and motivation. You will also learn how a disease-centered assessment differs from a motivational assessment. A motivational assessment can be a disarming and positive experience for patients because you first try to understand how they benefit from their risk behavior. This assessment also prepares patients to confront themselves about whether to change, so that they decide why, what and how much to change. To conduct such an assessment, you can use any of the following options:
     • Ask about readiness to change
     • Itemize benefits and concerns about the status quo versus change
     • Use a decision balance
     • Assess resistance and motivation based on how patients think and feel
     • Explore motives for change
     • Inquire about competing priorities and energy to change
     • Assess confidence and ability to change (self-efficacy)
     • Ask about supports and barriers to change
Ultimately, behavior change is an individual responsibility, but one that is influenced by many external factors. The first part of this chapter provides an individual perspective on change, while the last part addresses the social, community and cultural
factors that can act on individuals in positive and negative ways.

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CHAPTER 12
STEP 4: ENHANCING MUTUAL UNDERSTANDING

FOR REFLECTION

How can you address differences in understanding, perceptions and values
about health behavior change with your patients?

OVERVIEW
You and your patients will usually have differences in understanding, perceptions and values about health behavior change. You will be more effective in helping your patients to change if you first understand these differences before trying to address them.1;2 To work toward this goal, you may also need to address your differences in role expectations, agendas and assumptions with your patients. Then you can use these differences to enhance mutual understanding and make a difference.3 Four essential skills can help you motivate your patients to change their behavior.
1. Educating patients about risk behaviors and the benefits of change can help develop a
     common understanding with them about the need for change.
2. Using nondirect interventions can clarify how you and your patients perceive and value
     the benefits and concerns about behavior change differently. These interventions help
     you explore why patients do not want to change, are ambivalent about it or indifferent
     to it. This process can lower patient resistance to change.
3. Using direct interventions can help patients change their perceptions and values in ways
     that motivate them to change their behavior.
4. Addressing perceptions about patients' confidence and ability to change can identify
     impediments to implementing a plan. After patients have rated their confidence and
     ability to change, you can consider and act on whether you agree with their self-
     assessment.
You can use these skills to make a successful transition from conducting an assessment to implementing a plan.

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CHAPTER 13
STEP 5: IMPLEMENTING A PLAN FOR CHANGE

FOR REFLECTION

How can you help patients develop and implement an appropriate plan for change?

OVERVIEW
Many factors affect whether patients develop an appropriate plan for change. This chapter will describe how to
     • Evaluate commitment toward a plan of change: Your level of commitment as well as
        that of your patients may vary when addressing different health behaviors.
        Furthermore, patients also have different competing priorities, levels of energy and
        motives that affect their level of commitment to change.
     • Decide about goals for change: The range of goals for implementing a plan may exist
        along the following continua: stages of change (contemplation-preparation-action),
        short-term to long-term goals and pragmatic to ideal recommendations. Either you or
        your patient may select the goals for change unilaterally. Alternatively, you may
        negotiate with patients about the goals for change.
     • Work toward solutions: A focus on solutions rather than on problems may help some
        patients enhance their prospects of implementing a plan for change.

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CHAPTER 14
STEP 6: FOLLOWING THROUGH

FOR REFLECTION

How can you best arrange follow-up for your patients?
How can you help your patients ensure change and prevent relapse?

OVERVIEW
Appropriate follow-up arrangements can help you enhance the prospects of patients initiating and maintaining change and preventing or addressing relapse. You can best arrange such follow-ups by
     • Providing a rationale, purpose and reasons for follow-up appointments
     • Setting the timing, duration and frequency of follow-up appointments
     • Using various methods to ensure change and prevent relapse

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SECTION IV
SPECIFIC BEHAVIORS

Chapters 15, 16 and 17 address the subjects of excessive alcohol use, smoking, and self-care of chronic diseases respectively. Chapters 15-16 are broken down into two parts; part A discusses facts and issues specific to the particular behavior, while part B provides options for developing learning skills based on the six-step approach. Each chapter reinforces how you can adapt this approach to address other risk behaviors. Whatever your time limitations and the number of patient contacts, you can individualized these options to help motivate patients to change their risk behaviors.

KEY FINDINGS AND SPECIFIC ISSUES
Chapter 15 describes the notion of a risk continuum, the concept of harm reduction and the use of uncertainty to assess alcohol problems. Any reduction in risk and harm is worthwhile, particularly when patients cannot abstain and achieve the ideal goal. This problem is also relevant to other risk behaviors such as dietary adherence and weight reduction. Chapter 16 addresses the need to integrate behavioral interventions with treating nicotine dependence in order to decrease smoking rates. Combining behavioral counseling with medical treatments is also relevant to helping patients overcome other drug addictions. Chapter 17 addresses self-care of diabetes and the need for patients to juggle multiple agendas. This issue is also applicable to other patients who have multiple risk factors, whether or not they have a chronic disease.

DEVELOPING SKILLS
Chapters 15-17 provides a wealth of ideas and encourage you to use your clinical judgment in selecting interventions that will enhance your patients' readiness to change. If you provide continuity of care to patients, you will have multiple opportunities to intervene over time and to develop your professional skills. Your individualized approach can help patients
     • Think more about change
     • Reduce their resistance to change
     • Enhance their motivation to change
     • Prepare for change
     • Take action to change
Some options are used more than others. For example, you may use the decision balance more frequently than explicitly clarifying your roles with your patients. The important point is to select and use whatever options seem to work for your individual patient.

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CHAPTER 15 Part A
EXCESSIVE ALCOHOL USE

FOR REFLECTION

What is the alcohol risk-and-harm continuum?
How can you use diagnostic uncertainty to assess for alcohol abuse and dependency?

OVERVIEW
Brief interventions have been proven to have a positive effect on excessive alcohol intake. To understand the patterns of alcohol use, an alcohol risk-and?harm continuum lists them in descending order of severity, from alcohol dependence to abstinence. Both alcohol abuse and dependency can be classified from mild to moderate to severe. Definitions for each of these terms are provided in this chapter to assist you and your patients when negotiating about a diagnosis. When you are unable to make such a diagnosis, this chapter discusses how you can use diagnostic uncertainty to help patients assess their excessive use of alcohol.

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CHAPTER 15 Part B
REDUCING ALCOHOL RISK AND HARM

FOR REFLECTION

How do you deal with patients who do not respond to your advice to keep
below the low-risk drinking limit or to abstain from alcohol use?

OVERVIEW
About 20% of patients who drink excessive amounts of alcohol will respond to health education and advice to reduce alcohol consumption to below low-risk limits. Even when patients have alcohol-related complications, however, they will not respond to your advice to change. Furthermore, many patients are dependent on alcohol without your knowing about it. This section helps you learn how to deal with the full spectrum of resistant patients who have a hazardous, harmful and dependent use of alcohol; it can also help you work with patients who drink and drive, request sedative drugs and/or provide rationalizations to avoid dealing with their excessive alcohol use.

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CHAPTER 16 Part A
TOBACCO USE

FOR REFLECTION

How can you combine behavioral interventions with drug treatment of nicotine dependence to help your patients quit their tobacco use?

OVERVIEW
Traditional approaches to tobacco cessation involve practitioners providing education and advice to patients.1-5 These approaches, however, help only a small percentage of tobacco users (2-10%) to quit each year.6;7 Factors that enhance quit rates include the intensity and duration of smoking cessation programs and approaches that use multiple methods rather than single methods. For example, drug treatments for nicotine dependence can complement behavioral treatments and thus enhance quit rates among nicotine-dependent smokers. The key issue is how best to combine behavioral interventions with treatments for nicotine dependence to help smokers quit.

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CHAPTER 16 Part B
HELPING RESISTANT SMOKERS QUIT

FOR REFLECTION

How can you deal with a patient who does not respond to quit-smoking advice?

OVERVIEW
Health education and advice approaches prepare you to help 10-20% of smokers who are ready to quit. Most smoking cessation programs, however, do not adequately address how to deal with resistant, ambivalent or indifferent smokers. This chapter helps you learn how to motivate such patients to change over time. It discusses how the six-step approach can be used to motivate patients in different stages of the change process, and provides examples of specific questions you can use with your patients to help them quit smoking.

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CHAPTER 17
FACILITATING SELF-CARE OF DIABETES

FOR REFLECTION

How can you help patients adhere to multiple recommendations in order to
     • Lower hemoglobin A1c as much as possible?
     • Reduce the rate of diabetic complications?
     • Slow the deterioration rate of diabetic complications?
     • Lessen the impact of complications when they occur?

OVERVIEW
This chapter describes how you can develop individualized interventions to help patients take better care of their diabetes. You can negotiate with patients about whether and how to adhere to the diabetic guidelines and thereby work toward reducing Hb A1c levels, the complication rates and the impact of those complications.

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