19: Behavior Change

Many of the common contemporary health problems such as diabetes, heart disease, and cancer, are related to patients’ lifestyles and specific behaviors. To treat patient’s health issues, clinicians must encourage reduction or elimination of destructive behaviors (e.g., smoking and alcohol dependence), promotion of healthier behaviors (e.g., weight control, regular exercise, stress management, safer sex), and adherence to medical regimens intended to treat acute or chronic illness (e.g., taking medications, dietary restrictions, checking blood glucose). Clinicians are hardly alone in their influence on patients’ behavior. Patients’ social networks, their personal histories, genetics and life circumstances, as well as the media and broader societal forces also shape behavior. Not everyone’s vision of the good life involves careful attention to healthy behavior. Many patients prefer a medication or procedure over behavior change to ameliorate a problem. All this can leave clinicians unclear about how much they are supposed to be pressing for behavior change and what are the limits of their influence in the brief context of the patient encounter.

Fortunately, work done in the field of behavioral medicine in the past 30 years has great practical application for clinicians and patients alike. In this chapter, we will incorporate the contributions from the most researched approaches to behavior change: the Stages of Change Model, Motivational Interviewing, Self-Efficacy, Social Influence, Willpower, Goal Setting, Mindfulness, Self-Monitoring, and Contingency Management. The objective is to use this research as the basis for a practical approach to influencing patients that respects both the complexity of human behavior and the resources and limitations of the medical encounter.

The Stages of Change Model introduced the idea that people move through a succession of five relatively distinguishable stages in making changes in behavior (in addition to Relapse if they revert to old behaviors after an initial period of success). Quickly determining the patient’s stage of change with regard to specific behaviors allows the clinician to focus where further discussion or assistance would be most valuable. Many of the other behavior change models and strategies work well when integrated into this framework. The stages are outlined in Table 19-1.

The following descriptions and examples more fully illustrate each of the stages of behavior change:

• Precontemplation: The patient gives little thought to the problem and how best to solve it (e.g., adolescent drinks heavily, but is apparently oblivious to consequences).

• Contemplation: The patient thinks about the problem and the potential methods, costs, and benefits involved in trying to address it, but makes only inconsistent stabs at changed behavior (e.g., dietary changes that last only a few days before relapse).

• Preparation: The patient now commits to a specific course of action and timetable (e.g., patient decides to join Weight Watchers this month with a girlfriend from work).

• Action: A plan is being carried out on a regular basis with relatively clear goals and strategies being pursued (e.g., walking at least 30 minutes in the morning or evening 5 days a week).

• Maintenance: Successful changers begin to incorporate Action stage behaviors into a “new normal” way of living. Ongoing effort continues, but now feels less like a temporary alteration of familiar and normal behaviors and more incorporated into a sustainable lifestyle and identity (e.g., alcoholic with 5 years of sobriety).

• Relapse: There is a consistent return to problem behaviors and attitudes after an initial period of successful change.

Clinicians typically associate behavior change with the action stage, yet fewer than 20% of patients report readiness to take action on a health behavior change in the next 30 days (e.g., quit smoking or start a weight loss program). Clinicians can increase patients’ readiness to take action, as well as improving the action they eventually take, by encouraging them to contemplate, choose, and then commit themselves to a specific plan, carry through and modify the plan when needed, and incorporate new behavior into healthier lifestyles or recover from relapse and get going again. Moving from contemplation to maintenance in smoking cessation, for example, has been shown to take years on average. The goal of each clinician–patient conversation is to catalyze movement through the stages, and most of the patient’s work is done outside the visit, as they think about, plan, commit, and then carry out the new behaviors with the guidance and encouragement from their clinicians. The indented examples that follow illustrate ways in which the clinician can converse with the patient in various stages, beginning with precontemplation.

People typically start out in the Precontemplation stage. They already have the problem (e.g., drinking excessively, smoking, gaining weight, elevated blood sugar), but appear unaware or unconcerned about it. Awareness often builds in response to some “bad news” (e.g., physical symptoms, clothes that do not fit, restrictions on smoking, media focus on a health issue, a routine blood pressure check, or laboratory test). Any and all of these may prompt patients to start thinking more about the problem and weighing the pros and cons of trying to address it, moving them into the Contemplation stage. The clinician prompts this movement into contemplation by asking open-ended questions that require exploration and self-reflection by the patient or family in the office and later at home.

Depending on the specific problem, there may be validated screening questions that fit in nicely here, for example, CAGE or MAST (Michigan Alcohol Screening Test) screening for alcohol, brief screening inventories for depression such as the Patient Health Questionnaire (PHQ-9) or anxiety, or the SOAPP (Screener and Opioid Assessment for Patients with Pain). Providing normative data is a potent stimulant for further contemplation and helps patients in weighing the pros and cons of change.

Contemplators often make inconsistent efforts to change, lacking the planning and determination needed to sustain them. Unfortunately, they often come to the wrong conclusion about why change has not followed (e.g., “I guess I don’t have the willpower”). Over time they may either get stuck in ambivalence and procrastination, or move forward to become increasingly committed to a specific plan, goal, and timetable. To help, the clinician can encourage contemplators to come to a conclusion from their self-reflection.

Although making a commitment is essential, the plan must be put into action to produce the desired dividends. In the Action stage, people are “doing it” on a regular basis (e.g., walking a mile five times a week, closely following a diet plan, adhering to a medication regimen). To succeed they must keep their specific plan and intentions front and center and muster sufficient resolve and willpower to overcome moment-to-moment temptations to slip back into old behaviors. Recent research about willpower has brought some objectivity into what has in the past been either overvalued or dismissed as an artifact. Willpower can be thought of as the energy, focus, or commitment that fuels the capacity to make the previously determined choice in challenging situations. Willpower grows by mindfulness, clarity of intentions, anticipation, and preparation for challenges, as well as by modifying one’s environment when not in the throes of immediate temptation (cool situations) to avoid overtaxing one’s capacity for self-control in more tempting (hot) situations.

Contrast this kind of contemplation, anticipation, and commitment planning to the “New Years Eve Resolution” marked by good intentions, but lacking the underpinning for adherence in the face of even mild temptation. Such failure is often misattributed to “a lack of willpower,” when actually it was a failure of clear intention and plan clarification and preparation that left the person unprepared at the first hint of temptation.

The initial conversion of Preparation into Action is usually a time of high effort and little payoff. Think about the first week of exercising after a long layoff. Patients do best when they have anticipated this and have a ready response that can head off second thoughts (e.g., “Pain is the weakness leaving my body. My decision to exercise is already made, and I am not going to remake it every morning!”). On the other hand, it is common to discover that some intensification of effort or the addition of other behaviors to the mix must be made to the action plan if desired results are to be attained (e.g., walking a mile a day will lead to some improvement in fitness, but without reducing caloric intake it is unlikely to lead to significant weight loss). Self-monitoring research points to the importance of patients tracking the data carefully (about their actions and their results) and using that information in moments of choice and when reevaluating their action plan if desired results are slower in coming than expected.

Contingency management research has always highlighted the importance of having rewards lined up for the accomplishment of intermediate and larger milestones to motivate the initial and continued efforts at change. People may come up with these rewards naturally (e.g., “When I have lost 15 pounds I will buy myself some new outfits.”). It can also be helpful for the clinician to anticipate and encourage the patient to build rewards into their action efforts.

In the Maintenance stage patients try to incorporate their Action stage behaviors into a sustainable new lifestyle. Depending on the problem they are addressing, maintainers may be able to reduce some of the frequency and intensity of action stage effort (e.g., attending fewer Alcoholics Anonymous [AA] meetings, or allowing previously forbidden foods back into their diet in a controlled manner) and still hold onto improvements they have made. This is a challenging transition. Patients may have secretly been hoping that the intensive efforts of the Action stage would be time-limited, but many behavior and lifestyle changes must be maintained indefinitely if improvements are to be sustained. In the Maintenance stage, those behaviors tend to come more naturally if people increasingly identify with the new lifestyle and can remind themselves to enjoy the improvements their efforts have produced. It is also necessary for their immediate social network to adapt or be reconfigured to support the new behaviors and routines (e.g., Long-term sobriety depends on building associations with people and activities that do not encourage drug and alcohol use. Family members must learn to not inadvertently encourage overeating, and the changer must learn how to gracefully say “no” to well-meaning offers of unnecessary food.). Self-monitoring is very important as the path to relapse often begins with a series of slips that are not recognized and not recovered from swiftly (e.g., a cigarette or two after putting the kids to bed, giving oneself permission to exercise less as winter weather sets in and the outdoors is less inviting).

Unfortunately, any single attempt at behavior change offers a high risk of Relapse (e.g., weight regained, exercise abandoned, substance use renewed, etc). Relapsers may feel discouraged and stuck, or alternatively may remain committed to change and primed for another try. The clinician can help by reframing relapse as a time for regrouping, taking the lessons learned and planning the next action.

In the examples above, each stage of readiness to change has been addressed in a different way by the astute clinician. Appropriate clinician strategies for each of the stages are summarized in Table 19-2.

Research in motivational interviewing, intrinsic motivation, and psychological reactance has revealed that people are inclined to resist coercion and have trouble maintaining behavior changes that do not meet internalized values and goals. Unfortunately, typical attempts at influence (by doctors, parents, teachers, etc) are often limited to “pushing” types of interactions involving lecturing, explaining, exhorting, criticizing, inspiring, or threatening dire consequences if change does not occur. Much of this can feel like unwanted external pressure and coercion to the patient. Researchers have found little support for the sustained effectiveness of a heavy-handed, coercive or even inspirational approach. On the contrary, reactance theory shows how people, who might otherwise have admitted their concern over a problem, may instead feel compelled to defend their behavior when criticized, pressured, or coerced. The rhetorical question is an example of such a thinly described “push” (e.g., “Don’t you think … ?”). Motivational interviewing has shown instead how “pulling or attracting” by eliciting the patient’s ideas, values, feelings about the problem, and potential solutions produces greater change with less strain in the clinician–patient relationship than the “pushing” strategies clinicians typically used. The clinician’s role is to help the patient gather the relevant data from which to weigh the pros and cons of change, determine the importance and urgency of change, and then commit themselves to a reasonably effective course of action when they are ready.

This motivational approach is accomplished through an interview style that encourages expressions of empathy for the challenges at each stage, curiosity about feelings and ideas, and respect for the patient’s ownership of the problem and autonomy in deciding when and what to do next. Listening for and highlighting “change talk” (in which patients themselves are providing the arguments for change and exploring how it might be accomplished) can be very effective. Expressing concern instead of control, and curiosity rather than command, are the hallmarks of this approach. Although the clinician is often the one providing the worrisome information that precipitates the behavior change conversation, pulling rather than pushing is usually the best way to promote patient self-reflection and to build internal (and therefore sustainable) motivation to consider change. Using the rhythm of provide–elicit–provide keeps the patient active in the conversation, rather than a passive recipient of a “push” lecture. This strategy works when the clinician offers succinct pieces of information or feedback and then immediately elicits the patient’s response before deciding what next to provide.

The clinician is not abdicating responsibility to provide information, guidance, and set limits when a patient’s request or ongoing behavior is unsafe. On the contrary, behavior change is sometimes catalyzed when clinicians, and other important people in the patient’s life, have made clear the limits of what they can support or tolerate.

Self-efficacy theory predicts that for the individuals to become more motivated for a change they must become sufficiently convinced both that the change is in their best interest and also that the specific change being considered would be effective in meeting their objective (e.g., “Is losing weight really necessary for me? And If I were able to follow a Mediterranean or low-fat diet, etc, would I really lose significant amounts of weight?”). Self-efficacy research also reminds us that people must feel sufficiently confident that they can reliably perform the changed behavior before they will commit themselves to action. The effective clinician is not just working to help the patient feel convinced that change is needed or desirable, but also helping the patient create manageable and achievable steps that can be embraced with confidence. Ultimately, the change must strike the patient as sufficiently important that it feels worth all the effort, which for many behavior changes is considerable! These are continuous variables (more/less/sufficiently) rather than all or none. Increased conviction that the change is important and necessary, combined with building confidence that the specific steps are doable, ultimately results in the tipping point being reached where the patient is willing to commit to a course of action.

Depending on the patient’s stage of change, the clinician could promote further contemplation of the problem and potential solutions, encourage commitment to a specific course of action already contemplated, help tailor the patient’s current actions to accelerate desired outcomes, or assist incorporation of successful actions into the patient’s ongoing lifestyle. Assessing and building conviction is usually the place to start, since a patient who is not sufficiently convinced that the problem is important is unlikely to think much about how to solve it or what the challenges might be.

Clinicians can help increase the confidence of individuals who feel that even a desired change is impossible for them. For the Contemplation or Preparation stage patient, clinicians can encourage thinking about or researching or imagining the specifics of a plan they are reasonably confident the patient could carry out. Making this a thought experiment often can catalyze the process.

For the Preparation stage patient, the clinician is encouraging a choice or commitment in the face of inevitable uncertainties about how things will actually go. Contemplation can become prolonged when the patient is searching for certainty about the “best way” rather than accepting that consistent adherence to any reasonable plan is better than the endless search for the perfect plan.

Asking patients to rate their conviction, confidence or the importance of a change on a 1–10 scale can add clarity. It is helpful for deciding whether offering data that might help convince the patient of the importance of change would be most helpful, or instead helping them to build a plan they feel more confident they can carry out is the better use of time.

For the Commitment stage patient, the clinician probes for the readiness to move into action in the foreseeable future. Research in goal-setting highlights the value of setting specific targets and timetables as one moves into action and keeping regular track of both the actions themselves and their desired outcomes. Publicly announcing a commitment to specific behaviors and outcomes has also been shown to impact outcomes more powerfully than private commitments, and so can also be encouraged.

For Action stage patients, the clinician inquires about challenges to their consistency and helps them either adjust to a more manageable action plan (i.e., one in which they have more confidence they can persist) or intensifying or including more elements in their current action plan if desired results are not coming quickly enough.

Here is an example involving smoking that incorporates some of the elements described above:

Recent research is highlighting the extent to which an individual’s behavior is influenced by and even comes to match those in their social networks. For example, heavy drinkers often associate with other heavy drinkers for whom this level of drinking is normal. We see similar effects in smoking, other drug use, weight issues, effort at schoolwork, sexual behavior, etc. It is useful for patients to reflect on and plan for (contemplation work) the challenges that will come if they begin to express desires and behaviors in contrast to peers. On the positive side, a change in the behavior of a person in the patient’s social network can be expected to promote contemplation of change by the patient. The clinician can inquire about the behavior of people in the patient’s social network as a way to encourage emulation of healthy behavior, or as a heads up that the patient must prepare for some disapproval if starting a behavior change challenges the status quo of those they associate with most closely.

Sometimes clinicians feel they are shirking their duty if they do not take a strong prescriptive stance about their patients’ unhealthy lifestyle and behavioral issues. The key is to integrate the responsibility to advise and encourage, with an empathic, concerned, and curious demeanor, drawing patients into a more active exploration and ownership of the problem. Here are some examples of how a clear recommendation for behavior change can be made empathically rather than judgmentally within a collaborative, rather than clinician-centered framework.

Expressing increasing levels of concern is another way that clinicians can meet their obligation to alert patients to potential health consequences while not provoking either the embarrassment or reactance, which could fuel resistance.

People almost always feel two ways about behavior change. Ambivalence is normal. Patients see discomfort and disruption of their familiar routines in the short term, balanced against the hope of desirable outcomes in the longer term. The effective clinician asks about and empathizes with this ambivalence by inviting the patient to talk about the resulting stalemate and its effects. This is better done with open-ended rather than rhetorical questions (e.g., “Don’t you think that …?”). Here is an example of exploring ambivalence:

Clinicians can translate their sense of urgency into an expression of concern that the patient’s goals may not be met unless the ambivalent impasse is resolved and a tipping point is reached in favor of change. Using the language of “I am concerned” emphasizes the desire to be helpful over the tone of judgment that people so easily hear and resent.

Clinicians often wonder how best to shift the discussion toward behavior change for a patient who is not bringing up behavioral and lifestyle contributors to health issues (common in Precontemplation). A natural lead-in is to make statements linking the patient’s concerns to their behavior as the clinician’s reasons for pursuing the behavioral issue. For example, if a female patient asks for birth control, the clinician can use her concern about pregnancy as a basis for asking how else she had been protecting herself when having sex. This may lead naturally to a discussion about using condoms with new partners, an issue that was not on her agenda for this visit. If a patient comes for his annual physical it makes sense to ask, “Is there anything you have been doing which you think has inadvertently gotten in the way of your being more healthy?”

A discussion of smoking cessation with a patient hospitalized for chronic obstructive pulmonary disease (COPD) is an example of how bridging between symptoms and behavior can come about naturally:

As mentioned earlier, the self-efficacy construct offers a very helpful diagnostic and planning metric for the clinician in deciding what to pursue next in the limited time of the encounter. The clinician can ask the patient to rate himself from 1 to 10 on how convinced he is that his smoking is a problem at this time (or stated differently, how convinced he is that quitting smoking would be helpful right now). If the patient is barely convinced that the change is valuable at this time (e.g., “I don’t see how that would really help.”), then exploring his understanding of the impact of smoking on his COPD will be the place to start. If the patient is already convinced that the change would be very valuable (e.g. “I know that smoking is killing me, but I have never been able to quit for more than a few days.”), then the clinician’s time is best spent talking about ways to enhance confidence that the patient can accomplish it.

These same open-ended and scaling questions about conviction, confidence, and importance can be used with almost any health behavior. Here are more examples of questions to assess conviction, confidence, and importance:

Although clinicians are convinced that behavior change would be helpful in many patient conditions, they often lack confidence in their ability to influence patients’ behavior in brief medical interviews. The goal of this chapter has been to map out pragmatic approaches that can be utilized in even the briefest encounters to have a positive influence on the patient’s behavior. Assessing a patient’s Stage of Change promotes a more focused examination or hospital room conversation by pointing up where the patient’s next efforts would most productively be directed to promote movement toward behavior change. Motivational interviewing teaches the demeanor of empathic and respectful curiosity that acknowledges patients’ autonomy while exploring the ambivalence that marks all difficult choices. The clinician learns to pull from the patient self-motivational thoughts and feelings rather than push at the patient with lectures, threats, and inspiration. Reactance theory reminds the clinician of the natural urge to resist coercion, and research on intrinsic motivation makes clear that for change to be initiated and sustained individuals must relate the effort and outcome to their own goals and values, ultimately deciding if the effort is sufficiently important. Research on goal setting emphasizes that the most effective actions are ones in which the patient has clearly identified goals and monitors both behavior and outcomes on a regular basis. Willpower is a necessary but limited commodity in the patient’s life. It is built on the underpinning of careful contemplation of the problem and ways to overcome it, a clear commitment to a specific course of action, mindfulness and anticipation of temptations to slip and relapse, and modification of the environment to make the right choices easier and the wrong choices harder. Social Learning Theory teaches that behavior changes when both conviction and confidence cross a threshold that tips toward action. At each stage of change the clinician must understand what is affecting patients’ conviction that the problem requires attention as well as their confidence that success is possible. The principle and reality of patient autonomy reminds us to respectfully inquire about, thoughtfully attempt to influence, and ultimately accept the patient’s decisions about how important a change is for them. We must accept that a patient’s behavior is affected by many forces and influences, one of which is us. The more clinicians can link up with and build upon the broader array of motivators and resources for healthier behavior and lifestyle, the more they will enjoy this fundamental aspect of effective patient care.