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Counseling for Behavior Change
F. Daniel Duffy
GoldmanCecil Medicine, 14, 5254.e2
Most medical care requires patients to change some behavior. For example, patients may need to
keep appointments, stop an addictive behavior, eat different foods, take daily medications, monitor
glucose levels, or increase their physical activity. The probability of effectuating change depends on
the skills and language of the counselor, recognizing that clinicians typically see patients during brief
and relatively infrequent visits for prevention and chronic care.
Behavior change counseling is talk therapy that engages patients in a partnership to execute a plan
for change. 1 Behavior change counseling delivered by trained counselors is efficacious in sustaining
healthy diets, increased physical activity, reduced alcohol and tobacco use, improved dental
outcomes, reduced body weight, and selfcare monitoring. Trained physicians who provide brief
officebased counseling using patientcentered motivational methods can help patients successfully
lose weight A1 and improve diabetes selfcare management. A2 Modest success has been achieved
with officebased counseling for medication adherence A3 but not for heavy drinking A4 or problem
drug use. A5
Motivational Interviewing
Motivational interviewing is an evidencebased therapy that has been adapted to the clinical setting
to counsel patients about behavior change. 2 Using this approach, clinicians avoid giving advice and
instead ask openended questions and then use “reflective listening” to uncover internal ambivalence
that may restrain change. The verbal behaviors of trained clinicians include listening carefully and
responding to patients' voiced desires, fears, and ambivalence about changing; using statements to
affirm patients' autonomy and ability; summarizing patients' selfarguments for and against change;
and helping patients intensify their motivation to make changes. With persistence, these
conversations can convert patients' ambivalence into the belief and confidence that they can and will
change. The overall advantage of motivational interviewing is about 50% greater than comparative
counseling methods. 3
Change counseling in medical care is based on the transtheoretical model of change ( Fig. 141 (f0010)
), which proposes that people change by moving through a cycle of five cognitiveexperiential stages (
Table 141 (t0010) ): precontemplation , contemplation , determination , action , and maintenance , 4
often with a sixth stage ( relapse ). Many people cycle several times before adopting a new habit. By
identifying a patient's stage along this continuum of change, a physician can select the most efficient
counseling approach.
FIGURE 141
Cycle of change stages.
TABLE 141
STAGES OF CHANGE CHARACTERISTICS
Pick start date Encourage social
support
Tell others
Become a role
model to
others
Call for help
Fitting Change Counseling Into Medical Practice
The goal of change counseling is to help patients do what they need to do to achieve their own health
goals. Physicians help but cannot make people change. Patients do the work, guided by clinicians
who evoke their internal motivation to make the change.
To learn what behaviors patients need to change, the physician starts by taking a history of active
problems, by performing an appropriate physical examination ( Chapter 7 ), and by ordering any
indicated diagnostic tests ( Chapter 10 ). To optimize motivational interviewing, the history should
rely primarily on openended questions so patients can tell their own stories. The physician's
periodic reflections, expressions of empathy, and summaries of what patients say help patients
believe they can and must change.
The AskTellAsk Approach
The process of change counseling helps patients focus on their role in achieving their own health
goals. In contrast to a paternalistic practice of making a diagnosis, ordering treatment, and giving
expert advice, it promotes a patient's motivation, autonomy, and responsibility for making changes.
Iterative asktellask cycles remind clinicians first to ask patients to engage; second to tell
information, answer questions, and correct misinformation; and third to ask patients to verbalize
their understanding and intentions.
To use the asktellask strategy to initiate a conversation about the diagnosis and treatment,
clinicians first ask permission to summarize their findings. Second, if patients agree, clinicians tell
their diagnostic impressions and health assessments using clear and simple language. Third,
clinicians ask an engaging followup question to clarify patients' understanding with a question such
as, What do you know about this situation? The third ask may take the form of a reflective statement
that invites patients to go deeper, affirm their courage, express empathy, or acknowledge nonverbal
expressions of emotion. Usually, people know more than expected, thereby reducing the time needed
for education of the patient.
To focus patients' attention on their role in making changes, clinicians might ask, What ideas do you
have about what you and I might do to improve your health? Generating a list of hypothetical
options may take several asktellask iterations. When a satisfactory list has been developed, the
physician should summarize the patient's voiced health goals and the shared list of options for
achieving them.
Clinicians then initiate change planning with a question such as, What are you willing to do?
Patients' answers indicate their readiness to take action to change their behavior. Clinicians should
guard against the “expert trap,” in which patients skirt their own ambivalence for change and shift
responsibility for change onto the clinician by stating, You are the expert, and I'll do whatever you
tell me to do.
To avoid the trap, clinicians can estimate patients' motivational stages using a convictionconfidence
ruler ( Fig. 142 (f0015) ). Clinicians show patients a ruler with markings from 1 to 10 and ask, How
convinced are you that it is important for you to do what is needed from 1 (not convinced at all) to
10 (totally convinced)? They then ask, Using the same scale, how confident are you that you will do
it?
FIGURE 142
Motivational counseling aid.
Patients with low (0 to 2) scores are probably in the precontemplation stage. Midrange scores (3 to 7)
suggest the contemplation stage. A high conviction score (8 to 10) implies determination to change,
and moderate to high confidence scores (5 to 9) imply the preparation stage. High scores for
conviction and confidence indicate action or maintenance stages. In the relapse stage, patients may
have a low confidence score and, if very discouraged, a low conviction score as well. Scores of less
than 7 on either question may indicate insufficient motivation for success.
The convictionconfidence scale can clarify patients' convictions about the importance of changing by
asking, Why four on conviction (or confidence) and not lower? Or one might ask, What would it
take to raise your conviction (or confidence) score to a nine? Voiced answers to these question help
patients clarify their values and beliefs and see their strengths and resources to make needed
changes.
StageSpecific Change Counseling
A patientcentered change plan is far more comprehensive than a medical treatment plan, which
forms only one part of a person's health plan. For example, filling a prescription is one step in a
treatment plan, but remembering to take the medication several times a day, altering eating habits,
monitoring medication effects, and quitting a selfdestructive behavior are ongoing tasks in a change
plan. The most common error in medical care is treating lifestyle changes as a simple prescription
and being disappointed with the lack of patient adherence to recommendations. Nevertheless,
physicians often must first focus the change plan on ensuring that patients take their medications
before addressing more complex and timeconsuming lifestyle changes.
Precontemplation stage counseling encourages patients to seek information from reading material
and websites and to talk with family, friends, or others who have successfully made similar changes.
This process highlights the conflict between the risks of the status quo and the benefits of new
lifestyle behaviors. Precontemplation is not influenced by scare tactics, professional argument, or
debate.
Contemplation stage counseling, which is more difficult, requires time and training. Trained
physicians or counselors help patients explore and resolve the natural ambivalence that keeps them
from doing the work needed to change. A decisional balance table ( Table 142 (t0015) ) can contrast a
patient's reasons for sustaining current behaviors with the reasons for changing to healthier ones.
Clinicians or counselors listen to what patients say and verbally reflect a patient's ambivalence to
help patients begin to convince themselves to change. This approach helps patients “think out loud”
about their conflicting desire to change and their simultaneous wish to sustain the status quo.
TABLE 142
DECISIONAL BALANCE
When momentum stalls or patients backslide from doing their part, physicians often blame patients
for resisting change or label them noncompliant. More likely, the difficulty lies with insufficient
resolution of the natural ambivalence about change and evolving discord in the physicianpatient
relationship. Physicians and patients begin talking at cross purposes, become defensive, blame,
interrupt, and disengage. Physicians might resolve the relational discord with an apology, by
affirming patients' strengths, or by shifting the focus of counseling to empathy with the patient's
ambivalence and encouragement to believe that she or he can change.
Determination and action stage counseling reinforces a patient's confidence. Counseling might
begin with the question, What are you going to do and when will you begin? Picking a start date and
committing to other people generates accountability and social support. Because it is difficult to
change alone, asking Who or what might help you? encourages patients to solicit support from
partners or others who are making similar changes. Patients may use reminders and rewards to
reinforce the new behavior while avoiding situations that stir craving for the old behavior. To plan for
relapse prevention and recovery and to handle problems and side effects, clinicians might ask, What
problems might arise and how might you handle them? As with all change counseling, action plans
work best when patients identify the people, resources, and coping strategies themselves. When the
change involves quitting an addictive behavior, the plan also should include treatments to manage
withdrawal and craving ( Chapter 32 , Chapter 33 , Chapter 34 ).
Maintenance stage counseling is frequently ignored on the assumption that once patients take action
to change, the work is done. Moving from action to maintenance requires the new behavior to be
internalized and to become routine, requiring little thought or effort. Counseling bolsters the new
behavior when “change boredom” sets in, life stresses and competing priorities weaken commitment,
or old behaviors become attractive and their consequences forgotten. Maintenance counseling keeps
vigilance alive with questions such as, What is working? or Most people have difficulty; how has this
change gone for you? Physicians can talk about relapse with questions like, Many people begin to
think that after a while it's safe to . . . [return to the old habit] just one more time; if you have had
these thoughts, how have you handled them? To engage patients in creative problem solving,
physicians might ask, Who or what has helped you sustain your new behavior? Planning for
recovery after a lapse can be initiated by asking, Should you slip, what will you do, or who will you
call? A suggestion to call immediately tells patients that relapse is common and can be remediated; it
should not be considered a sign of failure. By reframing relapse as a learning opportunity, physicians
also help patients reflect on how to strengthen their action plan.
Counseling Teamwork and Referral
Behavior change counseling helps patients move from precontemplation to maintaining new habits.
This counseling is not a single intervention but rather an ongoing process with longterm followup
at frequent intervals. Longer counseling visits are appropriate in the first few months for the
precontemplation and contemplation stages. Facetoface or telephone followup visits every week or
two are useful during the determination and action stages. For the maintenance stage, monthly brief
followup counseling in the office combined with almost daily contact with supporting persons or
role models works well. When intensive help is needed, physicians may refer the patient to education
classes, behavioral counseling professionals, or selfhelp support groups to augment the medical
treatment. Medical home primary care practices also can provide counseling for proactive prevention
and chronic illness care using multidisciplinary teams of nurse educators, nutritionists, physical
therapists, psychologists, and pharmacists. Changing of addictive behaviors usually requires referral
to a behavioral change specialist.
Review Questions
1. Which of the following statements best describes the purpose of change counseling in the
context of medical care?
A. To evoke patient selfmotivation and to resolve ambivalence about changing
B. To advise patients of the evidencebased changes that are best for their health
C. To affirm and to support the autonomy of patients regardless of whether they change
D. To make patientcentered arguments to convince patients to change
E. To create a safe supportive environment that encourages patient change
Answer: A The principles of change counseling emphasize the importance of goaldirected
counseling that ends in the patient's moving toward more healthy behaviors. The approach uses
conversational counseling methods that evoke the patient's motivation and resolve natural
ambivalence between the status quo and the effort needed to change. Therefore, A is the best
answer. B is wrong because counseling is more than giving advice. C speaks to supporting the
patient's autonomy, which is important, but not to making progress toward change. D is wrong
because argument is specifically avoided in change counseling and is a sign of dysfunction in
the patientphysician relationship. E is important for counseling, but it does not go far enough
in defining the goals of change counseling.
2. Which of the following motivational interviewing skills are most useful in helping patients
explore their ambivalence and talk themselves into changing?
A. Giving clear, simple explanations about medical conditions and the changes people can
make to reduce the risks to their health
B. Using open questions and statements of affirmation and reflection to guess a patient's
meaning and summarizing a patient's perspectives
C. Obtaining a complete assessment of risks, prior patient behaviors, and experiences
with making other changes in their lives
D. Using the convictionconfidence ruler to assess the patient's reasons for changing and
reasons for sustaining the status quo
E. Acknowledging nonverbal emotion caused by clinicians giving advice or telling patients
what to do
Answer: B B is the correct answer because it states the four skills that characterize
motivational and most patientcentered interviewing: open questions, affirmation, reflection,
and summarization. Although a health risk assessment is an important starting point for
change counseling, A is incorrect because it is limited to giving advice. C is incorrect because
obtaining an assessment, although important, is only part of the task. D is incorrect because the
purpose of the convictionconfidence ruler is to assess motivation, and D describes decisional
ambivalence. Acknowledging emotions is an important engagement skill, but E is incorrect
because the answer is limited to advice given by clinicians.
3. What is the purpose of a decisional balance tool in change counseling?
A. It shows the balance of risks of disease and benefits of treatment.
B. It documents the clinician's decisions for the changes patients need to make.
C. It tracks change in the patient's confidence during the course of counseling.
D. It demonstrates the patient's perceived importance of making a change.
E. It displays a patient's ambivalence between making change and sustaining the status
quo.
Answer: E E is correct. The decisional balance is a counseling tool that displays a patient's
ambivalence, showing the arguments for sustaining the status quo in one column and the
arguments for change in an adjacent column. It is a potential starting point for change
counseling in the precontemplation and contemplation stages. A is incorrect because the
decisional balance is not about the clinician's decisions. B is not correct; although putting the
decisional balance in the medical record documents its use and its results, decisional balance
displays the patient's ambivalence, not the physician's decisions. C is wrong because the
decisional balance displays ambivalence and does not track changes in commitment. D is
partially correct because the decisional balance documents the patient's reasons for change, but
it also documents the reasons for sustaining the status quo.
References
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