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Therapy of the word
Communicating for behavior change.
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Hippocrates, the father of medicine, acknowledged that along with diagnosing and prescribing treatment for diseases, the “therapy of the word” was just as important a factor in providing medical care. It was just not what you told patients they need to do, but how you engaged them in the conversation about what they needed to do. Listening to their concerns was part of their medical care.
As frustrating as it may be for all of us, patients don’t always follow medical advice and often exhibit behaviors that are harmful to their overall health and well-being.
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We see patients who don’t take their medications as prescribed, don’t get enough physical activity, don’t monitor their blood sugars and who continue to smoke, eat unhealthy foods (too high in calories, fat, sodium, etc) and engage in other unhealthy habits that we, as health care professionals, want them to stop immediately.
We recognize that there may be serious health consequences if they don’t and we feel somewhat responsible. After all, didn’t they come to us for medical advice, so why don’t they follow it?
Telling patients what they should or shouldn’t do is not enough when it comes to changing behavior. Behavior change requires more than knowledge (what the medication is for) and competent skills (how to give an insulin injection). Behavior change occurs only when patients want to change their behavior. Patients, consciously or unconsciously, weigh both the advantages and disadvantages of changing or continuing a current behavior.
Helping with behavior change
For patients to adopt a new behavior, the reasons or motivation for changing the current behavior have to become more important than the reasons for staying the same. The reasons to change or adopt a specific behavior must become a priority for change to occur.
In the process of deciding whether or not to adopt a new behavior or change a behavior, ambivalence occurs. Exploring this ambivalence is a core skill in motivational interviewing. Motivational interviewing is a “directive communication method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” Application of motivational interviewing skills and communication techniques has been found to be especially effective in facilitating behavior change.
Research has provided strong evidence that physician-patient interactions can influence patient adoption of health-promoting behaviors. These interactions are the basis of what commonly is known as a collaborative patient-centered model of care as compared with the traditional compliance model of care.
Essential skills
Two essential communication skills used in motivational interviewing are asking open-ended questions and listening reflectively. These communication techniques form the basis of understanding the patients’ ideas, attitudes and feelings about changing a behavior.
Open-ended questions are a communication skill that can be effectively used to explore motivation. The goal of open-ended inquiry is to obtain the patient’s story. The goal is to be curious and to try to understand the experience of the person and the meaning that the person attributes to that experience. This may be very different from our training where we were taught to gather information and facts.
To elicit the patient’s story, start with simple requests. For example, “Tell me about how often you check your blood sugar at home.” “What” and “How” questions are also effective, especially as a follow-up question. For example, “How difficult is it for you to check your blood sugars at work?” “Why” questions aren’t as effective, since they may evoke defensiveness from the patient. For example, “Why don’t you check your blood sugars more often?”
After you receive a reply, affirm the patients by validating their thoughts and feelings. For example, “I appreciate your honesty in telling me your concerns about checking your blood sugars at work.”
Listening reflectively is not just parroting back to the patient what you have heard. You rephrase the patient’s statement to reflect what you think you heard and what you think the patient meant. For example, “If I understand what you are saying, you don’t like people at work knowing you have diabetes and that you need to test your blood sugar, is that correct?” This allows the patient to affirm or correct your understanding of what they said.
At the end of the conversation, summarizing key points is helpful in addressing discrepancy. Discrepancy exists when there is a conflict between patients’ beliefs or behaviors and their actions. For example, “So I hear you saying that managing your diabetes is very important to you, but that not checking your blood sugar at work is more important.”
Another effective communication skill is expressing empathy. The evidence for the effect of empathy as a communication tool for change is strongest. Empathy helps develop patient rapport without being judgmental, critical or blaming. Empathy stems from a sincere appreciation of the patients’ struggles and a genuine desire to understand their experience. For example, “I can understand how taking your blood sugar at work may not be easy at times, but I know you are interested in improving your diabetes management.”
Most health care providers are not trained in communication skills and techniques to encourage patient behavior change. These techniques require study and a lot of practice. The following resources provide an excellent introduction to behavior change and motivational interviewing.
Mary M. Austin, MA, RD, CDE, is Owner and President of The Austin Group, LLC in Shelby Township, Mich., and is an Endocrine Today Editorial Board member.
For more information:
- Rollnick S, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners. New York: Churchill Livingston; 1999.
- Rollnick S, Mason P, Butler C. Motivational Interviewing in Health Care: Helping Patients Change Behavior.New York: The Guilford Press; 2008.