Consultations about changing behaviour

Introduction

Health threatening behaviours are the commonest cause of premature illness and death in the developed world, affecting the sustainability of our health services and society.1 Almost every healthcare worker interacting with almost every patient has an important opportunity to change health behaviour. Examples include a general practitioner talking to a patient about smoking or exercise, a health visitor engaging a mother about her child's diet, an accident and emergency house officer talking to an injured patient about alcohol, a renal nurse discussing fluid intake, and a dental hygienist discussing flossing. These consultations can be difficult to navigate, however, and practitioners often make a cursory attempt to satisfy external guidelines or end up avoiding the subject altogether. Here, we consider how the flexible use of a guiding style could make health promotion more satisfying and effective.

Skilfulness makes a difference

The challenges of changing health behaviour have parallels in everyday life. For example, the more we raise the stakes in telling a child to do something, the more likely conflict will follow. “Please get into the bath, now!” is often followed by, “But I am not dirty!” In the more polite confines of the consulting room, weariness is a common reaction.Doctors feel pressure to do more to prevent the effects of health compromising behaviourson their patients. Yet, doctors say they are not social engineers, cannot dictate the lives of their patients, and were trained primarily for diagnosing and treating medical conditions not monitoring and modifying their patients'behaviour. When they raise health behaviour, clinicians usually default to a directing style of interacting with their patients.

It is not difficult to distinguish discussions that go well from those that go badly. When the discussion goes well, the patient is actively engaged in talking about the why and the how of change and seems to accept responsibility for change. When the discussion goes badly, the patient is passive, overtly resistant, or gives the impression of superficially agreeing with the practitioner. These reactions are measurable, predict outcome,2 and are influenced by the behaviour of the practitioner; confrontational interviewing, for example, predicts high levels of patient resistance.3 Therefore, practitioners might have greater potential to raise or lower patient resistance than many assume. If this is true, skilful consultation about behaviour change, like the skilful and compassionate breaking of bad news, is worthy of every effort to give patients the best quality of care possible.

Try guiding instead

Credit: MGM/THE KOBAL COLLECTION

The process of changing behaviour

Just telling people they are at risk of developing a disease is rarely sufficient to change behaviour.4 People change if they come to believe that it is both of value and achievable.5 Maintaining change is not easy, and successful change often requires multiple attempts.6 Decisions about change can be finely balanced and linked to other behaviours, as with the smoker who gets irritable and puts on weight each time she quits. Information about risk is but one of several influences on this process. We can help patients weigh up the value of change and set realistic targets, but ultimately the patient must decide whether to change and how.7 8

This rather obvious conclusion probably accounts for the enthusiasm with which motivational interviewing has been adapted from psychotherapy into healthcare settings.9^–12 Since patients often feel ambivalent about change, they are sensitive to well intentioned efforts to persuade them one way or the other. Resistance and denial are common reactions, but these can be overcome, and outcomes improved, if the practitioner elicits the case for change from the patient rather than imposes it.

Directing or guiding?

So, how might everyday healthcare practice be improved? It is useful to contrast at least two styles of consulting about behaviour change. When practitioners use a directing style, most of the consultation is taken up with informing patients about what the practitioner thinks they should do and why they should do it. When practitioners use a guiding style, they step aside from persuasion and instead encourage patients to explore their motivations and aspirations. The guiding style is more suited to consultations about changing behaviour because it harnesses the internal motivations of the patient. This was the starting point of motivational interviewing,9 which can be viewed as a refined form of a guiding style.

Core skills

Asking, informing, and listening can be thought of as core tools or skills used by practitioners in different combinations and in the service of either directing or guiding. Asking involves the use of questions. Paying careful attention to choice of words, timing, tone of voice, and the ambiguities and contradictions often elicited in replies will engage patients more actively. Informing involves providing information, advice, feedback, or a demonstration. Focusing attention on clarity, evidence, purpose, and congruence with patients' needs is likely to achieve efficient use of time and reduce the likelihood of resistance. Listening involves hearing what patients say and ensuring that their meaning is understood. Responding appropriately, sometimes by conveying understanding through empathic or reflective listening, engages patients constructively. The box shows the use of these three core skills in the service of either directing or guiding.

Directing and behaviour change

In the directing style, informing is usually the dominant mode. This is appropriate in many circumstances—for example, when a patient has acute appendicitis. However, to be effective in changing health behaviour this style requires a particularly well timed and personally relevant quality. More often, the directing style manifests in a rigid routine in which, for example, the first question to a smoker, “How much do you smoke?” is followed by a series of closed questions before the delivery of advice to quit. Informing then becomes telling patients what they already know (or have considered, tried, and rejected) and presenting them with a single, apparently simple solution. Resistance is a common reaction, and this dysfunctional interaction can leave practitioners blaming the patient for lacking motivation or being in denial.

Perceived lack of time is a common explanation for the almost reflex use of a directing style when trying to change behaviour. Contractual obligations to discuss certain subjects may lead to a raw, number crunching approach that loses sight of individual needs. Similarly, guidelines may also unwittingly reinforce an oversimplified approach by encouraging practitioners to advise patients about lifestyle change in an unhelpful manner.

Guiding and behaviour change

The three core skills are also used in the guiding style, but here asking often involves eliciting from patients why or how they might change and listening is used to convey understanding of their experiences and to encourage further exploration. Even the use of informing is different. Informing is combined with asking to encourage choice and promote autonomy rather than to tell the patient what to do (see box). Challenges for the practitioner include being restrained, conveying the conviction that solutions lie within the patient, and handing over responsibility about decisions to the patient while retaining control over the time and overall direction of the consultation.13

The style being used can be reflected in small things like the phrasing of a question, the offering of an invitation to consider change, or the seating arrangement. Everyday life provides other examples. Parents commonly use both styles. Directing seems essential and appropriate in some situations but quickly generates resistance if clumsy or wrongly timed. To avoid resistance, parents and teachers use scaffolding or guided participation, adjusting the level of support according to the needs of the individual. This occurs consistently across cultures and predicts later success for the learner.14 15

Everyday practice

Shifting from a directing to a guiding style requires doctors to change their attitude about who is responsible for solving the problem and how the momentum and the direction of the discussion are controlled. One practitioner described it thus: “It's a shift from ‘Do this, do that’ to ‘Nudge, listen, summarise; nudge, listen, summarise.’” The ability to switch between the skilful use of these styles, even within the same consultation, is a marker of good practice.

Giving advice is often viewed as the delivery of expertise within a directing style,16 and characterises much of what is known as brief intervention in addiction and elsewhere.17 18 However, by integrating skilful informing with listening and asking, a guiding style could be used to deliver brief interventions. This approach seems in tune with wider developments—for example, the recent white paper Choosing Health, which encourages the move from “advice from on high to supportfrom next door.”19

Patients themselves are probably the best teachers when it comes to learning how and when to use the directing or guiding styles. For example, if a patient shows resistance in response to directing it might be a signal for the practitioner to shift style. Conversely, impatience or other evidence of lack of progress with a guiding style may lead the practitioner to switch to directing.

The guiding style can also be used to change practitioner behaviour, avoiding the didactic approach assumed in evidence based guidelines and incentivised targets.20 21 The goal is to enable practitioners to adjust their routine approach to talking about behaviour change and engage the patient more in decision making.22 Despite the subtlety of processes, it seems possible to measure skilfulness,23 24 to identify improvements associated with training,25 and to identify ways of maintaining changes in practitioner behaviour.26 While motivational interviewing itself might take time to learn, the guiding style on which it is based is well within the reach of busy healthcare practitioners.

Moving forward

Effective brief interventions in routine clinical care have enormous potential to improve public health. Research into consultations that aim to change behaviour is therefore likely to be worth while, and the box on bmj.com provides a list of sample questions. We already know that adaptations of motivational interviewing are generally more effective in changing single behaviours than no or minimal interventions, and they are usually as effective as more intensive alternatives.10^–12 It is now worth testing the hypotheses that brief interventions informed by the guiding style result in greater change than directive advice across multiple behaviours.

Helping patients change health threatening behaviour could be a routine component of most healthcare consultations. Given the scale of potential health gains, pressure is increasing to do more of this work.1 Enhancing motivation and encouraging change is a complex task that demands skilful consulting, and practitioners might benefit from refining their existing skills, particularly in the use of a guiding style. Patients deserve a sensitive response to difficult decisions about behaviour change. At the very least, we should be sure that we are doing no harm with our well intentioned interventions aimed at changing their behaviour.