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It is clear that many contemporary health problems, such as diabetes, heart disease, and cancer, are related to patients’ lifestyles and specific behaviors. As a result, the clinician must cultivate the skills to influence patient lifestyles, including the reduction or elimination of destructive behaviors (e.g., smoking and alcohol dependence), promotion of healthier behaviors (e.g., weight control, regular exercise, stress management, and safer sex), and increasing adherence to medical regimens intended to treat acute or chronic illness (e.g., taking medications, dietary restrictions, and checking blood glucose). Yet not everyone’s vision of the good life involves careful attention and effort toward the healthiest behavior. Many patients prefer either to live with a risk (e.g., smoking or obesity) or prefer a medication or procedure over behavior change to ameliorate a problem. Much of clinical practice, particularly with limited visit time, conforms to a “find it and fix it” approach. The clinician assesses and identifies the problem and tells the patient what needs to be done about it. Sometimes this works. Often however, the “fix” requires patients to be convinced of the necessity of burdensome behavior changes which they must commit to, carry out, and maintain for years to come. How to best promote this kind of change is the objective of this chapter.
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Fortunately, work done in the field of psychology and behavioral medicine in the past 40 years has clarified the most effective approaches to successful behavior change. In this chapter, we will incorporate the contributions from the most evidence based approaches: the Stages of Change Model, Motivational Interviewing, Self-Efficacy, Harm Reduction, Communication Theory, Social Support/Influence, Willpower, Goal Setting, and Behavior Therapies.
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BEHAVIOR CHANGE MODELS
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The Transtheoretical Model (TTM) (see Prochaska and DiClemente) is perhaps the most researched and applied of all comprehensive approaches to behavior change. It describes the stages through which change progresses as well as the change processes (e.g., insight development, self-reevaluation, behavior modification strategies like changing settings and stimuli and using rewards to encourage constructive behavior) that prove effective at each stage. The Stages of Change (SOC) aspect of TTM describes how people move in a spiral manner through a succession of five relatively distinguishable stages in intentional behavior change. The succession is “spiral” because patients rarely move in a linear path through the stages but instead linger and often relapse into prior stages before eventually achieving maintenance of healthier behaviors. Some critics have found this forward and backward aspect of patients’ time courses to undermine the validity of the SOC approach. For most clinicians, however, the value of being able to assess the patient’s stage of readiness for changing a specific behavior lies in focusing discussion or assistance where it is most efficient and effective. Many of the other behavior change models and strategies we will discuss ...