++
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.
+
Clinician: Sounds like we are agreed that your cholesterol level is a worry, but taking into account the possible side effects, you would prefer not to start a medication now to try to bring it down. (patient nods) Well, here is a handout that describes the problems caused by elevated cholesterol and options for treating it. I encourage you to look through the section on diet and exercise and decide how much and what kinds of changes you are ready to commit to. Does that seem like the right step for you now?
++
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.
+
Clinician: What concerns do you have about your alcohol use? (Pause for response) Is there anything about it that worries you? (Pause for response) What is your wife most worried about? (Pause for response and empathize if contentious issue at home). What has happened to make this such a concern to her? (Pause for response) How important is her concern to you? (Pause for response). You may want to ask your family if there is anything about your drinking that worries them, as a way of helping you decide how important this really is. Is that something you would be willing to consider?
++
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.
+
Clinician: I have a brief questionnaire that can be helpful in determining to what extent depression is contributing to the constant tiredness you reported. Why don’t you take a moment to complete it and we will score it together and see what it suggests to us.
Clinician: Tommy is at the 95th percentile for weight for a 9-year-old at his height, Mrs. Mason. What do you and your husband think about that? (Pause for response) Have you noticed Tommy expressing any concern about this weight? (Pause for response). Tommy, I am wondering how you feel about your weight?
++
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.
+
Clinician: We have talked about the pros and cons of starting insulin for a few visits now. Given the laboratory results today and your readings at home, I wonder if you have come to your own conclusion about what must be done next to get you out of the danger zone?
++
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.
+
Clinician: So, as you plan for how to use your willpower to best effect, think about how your commitment not to buy high-calorie foods in the less tempting setting of the supermarket makes it easier to resist the urge to consume high-calorie snacks in the more tempting situation in front of the television that evening.
Clinician: What do you think you may need to change in your social life, if you are going to stay out of situations where the temptation to drink or use drugs could be really strong?
Clinician: You will need to be especially mindful of your intentions as you sit down to a meal. What ideas do you have for how to bring your intention to say “no” to seconds clearly into your mind at that crucial moment?
++
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.
+
Clinician: Sounds like you were hoping to have continued to lose weight at the same rate as when you started out, but you know about the body’s natural mechanisms to resist further weight loss. What changes in your action plan do you think you might need to make to continue burning off more calories than you are taking in, now that you seem to be experiencing some of those set point issues?
++
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.
+
Clinician: Be sure to reward yourself periodically for the efforts you are making. For instance, in addition to all the health benefits it will bring you, what do you thing would be a fitting reward for getting your hemoglobin A1c below 7?
++
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).
+
Clinician: Congratulations on all you have accomplished. Are these changes starting to feel like a better lifestyle for you?
Clinician: What have you noticed is the amount of exercise and calorie control you need to continue before your weight starts to increase again?
Clinician: How is your social life different, now that you are committed to staying sober?
++
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.
+
Clinician: So you were able to quit smoking when you were pregnant with Tommy but little by little slipped back into smoking in the year afterwards? Is it still clear in your mind that smoking will cause health problems for you and the baby? (Pause for response). How were you able to resist the urge to smoke for those 9 months? (Pause for answer) I wonder if some of those same strategies might work for you again if you decide that quitting is still best for you and your family. What do you think?
++
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.
+
Clinician: What went through your mind as I described your most recent lab values and blood pressure readings and the risks associated with them?
Clinician: What do you already know about the relationship between the extra weight you are carrying and the problems you are having with sugar control and high blood pressure? (The question suggests the connection while encouraging the patient to come up with the self-motivational evidence.)
Clinician: It sounds like you would love to lose weight, but at the same time you are pessimistic that you could keep the weight off based on your past experience (feedback and elicit response). Tell me more about that.
++
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.
+
Clinician: Having discussed this with you, I am starting to see that we have two problems to contend with here. One is that you continue to feel a great deal of discomfort and the second is that the narcotics are not the safest and most effective way to help you with that discomfort. I could not allow myself to continue to prescribe a medication that is likely causing more harm than good. Are you open to an alternative approach? (Clinician does not try to immediately push or sell alternatives, but instead allows the patient to participate in the discussion as a way to reduce the risk of reactance. While the patient is not being given the choice to continue to get narcotics from this clinician, the clinician is acknowledging the patient’s autonomy to work together on an alternative approach or seek a second opinion if desired.)
++
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.
+
Clinician: I am concerned that your hemoglobin A1c has gone up further. How worried are you about that? (Provide–elicit). What do you think might have caused that? (Pause for an answer). What do you think may be needed to turn that around? (Many patients already have a good idea what might be needed). How confident are you that you could start to make those changes today? (Pause for an answer).
Clinician: If you are reasonably convinced that change is needed, then let’s think about a plan that you feel reasonably confident you could start out with. What ideas do you have about that? (Asking the patient to start the exploration of specific behavior changes helps prevent the “yes, but” dynamic that can get triggered when the clinician is the one offering the ideas first.
++
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.
+
Clinician: If you were to decide to get more exercise, what are some ways you could imagine doing this that you feel most confident you could stick with? For instance, you might consider joining a health club, getting an exercise machine, finding a friend to jog or walk with? What can you picture about any of those alternatives?.
++
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.
+
Clinician: Sounds like you are not confident that you would be able to make time for exercise after you get home to your family in the evening. (Provide feedback and elicit). I am wondering when else you could fit in exercise? (Pause for patient’s ideas) For instance, some of my patients tell me that it is more possible to exercise some mornings before work, or on some lunch breaks, or to stop on the way home a few evenings each week, because they know they will not be able to get out again once they get home in the evening. What do you think of something like that for you? (A “Yes, but … ” response would signal that the patient needs to do more contemplation work before commitment is possible.) You may want to ask your family when it would be easiest on them for you to make time for more regular exercise and perhaps lay out for them why this is so important to you. Is that something you can imagine doing this week?
Clinician: Picture yourself cutting back the number of cigarettes you smoke from 20 to 15 a day for the next 2 weeks and then going down to 10 a day until we talk again in a month. Does that seem doable to you when you try to picture it?
++
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.
+
Clinician: On a scale of 1–10, with 1 being unimportant and 10 indicating that almost nothing is more important, where would you now place the importance of using protection when having intercourse? (Pause for response) Can you tell me a little more about why you rate it a 4 rather than a 2, for instance? (Asking the patient to indicate why the selected number is higher than a lower number can elicit the level of importance, however small, the patient attributes to the change. A follow-up question shifts the focus to further considerations that could strengthen the patient’s sense of importance.) What would it take to move your rating from a 4 to a 7?
++
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.
+
Clinician: If you let your family know your intention to cut down on the amount you are eating, they may be in a better position to serve smaller portions, not encourage you to finish up leftovers and perhaps they can support you in other ways without just nagging you.
Clinician: You will know that you are really committed to change when you don’t think of reminders as nagging, but instead see them as just-in-time prompts that can help you be more mindful of what you already intended to do in a situation. Like when your wife reminded you that you had decided to limit yourself to two drinks when you go out socially.
++
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.
+
Clinician: It sounds like you continue to believe that walking 2 miles every evening is the best plan for you, but then you find yourself re-making the decision to get going every evening. I imagine that the voice that says “But maybe not tonight?” is not unexpected and you could plan for that voice as well. You might simply remind yourself, “I already made that decision and always feel better for having done it!” and then just put on your walking shoes and go. Eventually getting regular exercise could feel like the normal way to live and you will wonder how you ever lived without it. Does that make sense? (Clinician listens for a “yes, but” which would call for switching from advice giving to pulling for the patient’s ideas.)
++
Here is an example involving smoking that incorporates some of the elements described above:
+
Clinician: Where are you now in your thinking about quitting smoking? (Determining current stage.)
Clinician: How convinced are you that stopping smoking will be necessary to help you breathe with less effort now and also slow down the progression of symptoms in the future? (Check conviction about value or importance of change.)
Clinician: Now that we have talked about the over-the-counter and prescription aids that can help to reduce those initial cravings for nicotine, how confident are you that you could get through those first few months without cigarettes? (Check confidence about a specific method of change.)
++
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.
+
Clinician: Do you know anyone who has successfully ——? Tell me more about that.
Clinician: As you think more about changing this behavior, who do you anticipate will be most supportive and where do you think you might expect some resistance? (Pause for response) How could you handle that?
Clinician: Many people do best when they have a companion to exercise and diet with. Is there someone you think is ready to take action with you, perhaps at home or at work, or a friend who is also concerned about this?
++
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.
+
Clinician: Probably the best things you could to reduce the chances of another heart attack would be to quit smoking and get your cholesterol under control. Tell me what goes through your mind as I say that to you?
++
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.
+
Clinician: I am increasingly concerned that your poorly controlled blood sugars are already doing damage and dragging you still closer to all the serious problems you told me earlier that you wanted to avoid. What do you think can be done to turn this around?
Clinician: I agree that no one is more concerned about your child’s well-being than you. I just worry that you could blame yourself if Caitlin gets a serious case of one of these illnesses that widely validated research tells us vaccination could have safely prevented. How concerned are you about that aspect of the risk of vaccinating or not vaccinating?
Clinician: I imagine that learning you are pregnant is a big deal all by itself. On top of that, here I am telling you that things like alcohol and cigarettes could really hurt your developing baby. Tell me what is going through your mind as you hear all that?
++
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:
+
Clinician: It sounds like you are weighing the burden of time and effort involved in exercising regularly against the upset you feel with yourself for not doing more to reduce your risk of another heart attack? How do you imagine you will ultimately decide what to do?”
++
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.
+
Clinician: I am just concerned that you will feel more and more like an invalid unless you can get yourself out of the house for some activity every day. But what do you think?
Clinician: I am just concerned that without restarting the home stretching and conditioning program, you will continue to feel limited by this back pain and perhaps end up choosing the surgery that you told me initially you wanted to avoid. (Pause for response.)
++
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:
+
Clinician: Let me ask you about a few behaviors that usually worsen COPD and create the kind of crisis that led to your admission. For instance, how do you think your smoking might be affecting this?
Clinician: I imagine it was pretty scary to feel that you couldn’t get a breath. How important is it to you to avoid another breathing crisis like that one? (Pause for response). Is that important enough to make the effort to quit smoking now? (Searching for the intrinsic motivation rather than over-relying on “doctor’s orders” or other “pushing” behaviors that we have described earlier.)
++
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.
+
Clinician: What aspect of quitting smoking has been the most difficult for you? (Pause for answer) Let’s see what we might have to offer to help with that.
++
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:
+
Clinician: How convinced are you that the medication is essential for keeping your moods from swinging so dramatically from depression to mania?
Clinician: How confident are you that you could calmly set clearer limits about your children’s behavior? (Pause) What affects your confidence that you can talk with them calmly when they are misbehaving? (Pause for answer). Knowing that managing your own anger is the biggest challenge for you, let’s think for a moment about what can help with that. Make sense?
Clinician: Well it sounds like you are already pretty convinced that smoking is bad for you and the grandkids, and it is very important for you to get to care for your grandchildren, but your daughter won’t allow that if you are smoking at home. Still, the idea of gaining even more weight is really putting you off. So to help you feel more confident that you could quit smoking, we would need to find some way to reduce that initial craving for cigarettes without your gaining a large amount of weight. Tell me what you already know about things that can help with craving, and I will fill in the blanks.
Clinician: How convinced are you that doing those stretching and strengthening exercises will reduce your back pain? (Pause for response). So, even though you do think they could help over the long term you are pretty worried that they will make the pain even worse with your back already being so irritated. That is understandable. Would it help you feel more confident if I demonstrate how you could start out doing the stretches in a way that would not make your pain worse?
Clinician: Being in the hospital allows patients time to plan for the lifestyle changes that will be essential for their recovery. What ideas do you have already about changes that will be important for you to make after discharge?” (Pull before push, ask before tell.)