Giving the patient just information and knowledge about behavior change is not enough. Many patients find it hard to stick to the change for long. We can utilize several tools, techniques, and interventions to help the patient adhere to the new behavior over a long period. The most effective tools to help patients make health-related changes and stick to them are communication and motivational interviewing.

Communication as a tool

In a session with the patient, we have limited time, and we have to utilize this time effectively to convince the patient to adhere to the change. The most effective tool in this regard is communication. The outcome depends on how well we communicate the benefits and advantages of behavior change. So, if our communication is efficient, we can influence the patients’ behavior for the time being they are on their own without direct supervision.

The motivation model

The motivation model involves the importance of the new behavior for the patient and his confidence in adopting that behavior. The higher the importance and confidence of the patient in new behavior, the higher the chances of patients adopting the new behavior.

The figure below illustrates this concept clearly. If the patient thinks that the new behavior is important and is confident in adopting that behavior, he has a higher chance of success in sticking to that behavior.

Reproduced from TrustMe-Ed lecture

We should communicate the importance of new behavior with the patients and boost their confidence to help them adapt to the behavior change.

Motivational interviewing

Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.

(Miller & Rollnick, 2013)

In our current healthcare setting, we focus on the direct approach to patient behavior change. The direct approach involves giving the patient advice and telling him what to do and what not to based on our knowledge and experience.

The novel approach of motivational interviewing puts forward the guidance approach. According to the guidance approach, we support, motivate and empower patients to make behavioral changes. This approach emphasizes asking the patient about his goals, his ideas to make the changes and supporting him in implementing these changes. Motivational interviewing involves patients telling why the change is important for them and not telling them why they need to change.

Processes in motivational interviewing

Motivational interviewing involves four processes. We will discuss these processes one by one:

Engaging

Engaging is how you connect to your patient. You communicate with the patient and inquire about his goals and the plan he has to achieve these goals. The energy of the conversation indicates the patient’s involvement in the change process. During the conversation, the patient acts as an active participant and shares his ideas regarding what he wants to accomplish and how. You show interest in the patient to get to know him better. Engaging is a crucial process in motivational interviewing and should not be neglected.

Focusing

Focusing involves agreeing with the patient on a common agenda. The therapist and the patient decide what to talk about. It usually involves choosing a topic that interests the patient and taking his remarks on what changes he wants and why, and how he plans to make these changes.

Evoking

Evoking is asking the patient open-ended questions and using the reflections from answers to motivate the patient to talk about his goals and what he would like to achieve. Instead of telling the patient, we encourage him to tell us what he wants to do and why he wants to make changes.

Planning

Planning is the process utilized after going through the above three phases, and the patient is ready to make the changes. We then agree on what, how, when, and where to practice these changes. The planning process involves a mutual agreement between the therapist and the patient.

Skills for motivational interviewing

The skills to utilize in motivational interviewing involve the following

Open-ended questions

Asking patients open-ended questions will prompt them to think and ponder and answer what they consider the best answer. The patient cannot respond with a yes or a no to an open-ended question. It encourages them to think. The questions may start with what, why, how, when, and where. It does not have to be a question at all. We can ask a question followed by saying, “Tell me more about it.” By involving the patient in open-ended questions, we ensure the patient is thinking and talking.

Reflections

Reflections involve repeating, rephrasing, and guessing what the patient says. This way, you convey to the patient that you are listening to the patient and understand what he is trying to say. It builds the flow of the conversation and removes any ambiguity in the conversation. The patient talks more openly, knowing that you are listening and understanding. Reflections make the conversation more clear and error-free.

Affirmations

Affirmation involves appreciating the patient’s strengths, efforts, and past successes. It makes the patient feel a bit proud of his past doings and strengthens his belief in himself. It gives the patient the courage and confidence to make the changes he wants. Affirmations can give the patient the “I can do it” attitude.

Summarizing

Summarizing is an effective skill in motivational interviewing. You stop during the conversation and summarize to the patient what he has said so far. This way, the patient may agree to what you are saying, or he may add to it. It will make the conversation move forward.

The structure of a session

The start of a session

You should start your session by asking the patient open-ended questions, like what does the patient want? Or why has he come to you? What problems does he have for which he is looking for a solution? Open-ended questions will make the patient open up and share his problems and thoughts about making a change.

The Change and the sustain talk and the agenda mapping

After asking the questions, like is he ready to make the changes, and what changes does he want to make? The path to change talk and agenda mapping begins. Change talk and agenda mapping will help us agree with the patient on the topic of the conversation.

The Change and the sustain talk

In a session, the patient has two options. He can sustain his old behavior and refuse to make changes, or he wants to do something different and change his behavior for the better.

The change talk

If the patient is looking to make some changes, we will ask the patient about the reasons for making the changes. It will help us determine how much the patient is motivated and confident in making the changes. The patient may respond by saying, “I will make the changes,” or “I am going to make changes.” It represents that the patient has already decided that he wants to change. The change talk can help us identify where the patient stands on the path of making changes.

The sustain talk

The patient may choose to sustain the behavior and not change it. In this case, the sustain talk will help us identify why the patient wants to continue the old behavior. If the patient is not ready to make the changes, we should not convince or force the patient to make changes because it will make him resist if you try to impose your decision on him. Maybe the patient is not ready yet, but after a session with you, he might think about the changes and decide to make the changes after some time.

The agenda mapping

Agenda mapping involves clearly stating the topics to talk about in the session. After the change talk, you and the patient agree on making certain changes. You and the patient should be clear about what will be the topic of the conversation.

The agenda can be simple, involving only a single aspect of the patient’s life, and sometimes it can encompass multiple aspects. Write down the areas you are covering with the patient during this session.

For example, if the patient wants to exercise, exercise is the behavior to discuss in the session. Sometimes the behavior change can involve multiple areas of the patient’s life, like diet, stress management, sleep, weight loss, and exercise. In this case, we will write down the possible topics of conversation and make it clear to the patient what we will be talking about. It is helpful to keep two or three empty spots for the topics that arise during the conversation that need attention.

The image below represents the agenda mapping for exercise alone and several aspects of the patient’s life.

Reproduced from TrustMe-Ed lecture

Additional tools after the change talk and agenda mapping

If the patient agrees to make changes, some additional tools can help increase the patient’s motivation. These tools include decisional balance and scaling questions.

Decisional balance

Every behavior has its benefits and costs. We should help the patient evaluate these benefits and costs. If the benefits of the new behavior are higher than the costs, the patient is good to go. But if the new behavior comes at a higher cost, we should help the patient minimize the cost to maintain a balance between the benefits and costs of the specific behavior.

For example, if a patient wants to add exercise to his daily routine, we can assess the benefits and costs of exercising regularly. The benefits include but are not limited to better health, better shape, more energy, and better cardiovascular stamina. The costs of exercise can include time consumption, may be boring, patient does not know how to do it, and patient doubt about succeeding.

If the patient is not ready to change the behavior, it might indicate whether the benefits are not enough or the costs are too high. We should help the patient reduce the costs so the benefits get higher and the balance shifts towards benefits.

Scaling questions

Scaling questions help us evaluate the importance of the new behavior for the patient and his confidence in adopting the new behavior. Scaling questions show the motivation of the patient. If the motivation is low, we can discuss the factors responsible for it.

We use a scale to evaluate how motivated the patient is. We can ask questions, like how important the new behavior is to you, and ask the patient to choose on a scale of one to ten. If the score is low, we can increase the importance and confidence of the patient to help him change his behavior.

If the patient gives a behavior a nine on a scale of one to ten, we can ask why the behavior is so important for him. It will help us further evaluate what he thinks about a specific behavior. If he gives a behavior a three on a scale of one to ten, we can help him reach an eight or nine by increasing his motivation for a specific behavior.

Planning

When the patient has decided to change his behavior, we plan what the patient will do, when, where, and how he will do it. The patient decides when, where, and how he will do it. The patient provides information on when he can have time and where to perform the task more effectively. Following a well-optimized plan can lead to the success of behavior change.

The Elicit-Provide-Elicit Model

In motivational interviewing, you cannot impose your decision on the patient regarding behavior change. The patient is free to decide whether he wants to adopt the new behavior or not. But we can provide the patient with relevant information to increase his motivation. Elicit-provide-elicit is an excellent model in this regard.

In the elicit-provide-elicit model, we ask the patient what he knows about the new behavior. We then provide relevant information and ask him again what this information means to him. This process will elicit the patient’s thoughts regarding a specific behavior and allows us to understand what the new behavior means to the patient.

If you want to learn more about communication and motivational interviewing, you can watch the complete lecture on Communication for Behavior Change by Andreas Lycke on TrustMe-Ed.