“The Paradigm’s a Changin”: Patient-centered Approaches to Behavior Change

Friday, August 12, 2005

Breakout Session

Reported by Joelle Escoffery, PhD

The traditional approach to patient education and behavior change includes many inaccurate assumptions, including: 1) the patient ought to change, 2) a tough approach is always best, 3) the healthcare provider is the expert, so the patient must follow his/her recommendations, 4) the patient’s health is the prime motivator, and 5) patient motivation is dichotomous (eg, either present or absent). In contrast to that model of education provision, the Chronic Care Model promotes active patient involvement in order to create a more productive interaction with healthcare providers. In this model, self management is a collaborative agreement of goals between the healthcare provider and patient. This agreement is based on a patient’s confidence in his/her ability to change a given behavior. The primary responsibilities of the healthcare provider are to assist with problem solving and arrange for specific follow-up care. Self-management support does not include didactic education, finger wagging, passing judgment, or waiting for patients to ask for help.

One specific strategy that has proved beneficial in providing self-management support is motivational interviewing. Motivational interviewing is a client-centered approach for enhancing intrinsic motivation for change by exploring and resolving ambivalence. Specific motivational interviewing tools and strategies include agenda setting, the “typical day” strategy, the hypothetical “look over the fence” approach, exploration of costs and benefits, quantifying importance and confidence of factors related to behavior change, and appropriate information exchange.

When attempting to make a behavior change, patients are often resistant. When dealing with patient resistance, one common trap is to tack control away from patients and attempt to solve their problems for them. An alternative and more patient-centered approach is to emphasizes personal choice. Clinicians may also misjudge patient importance or confidence, in which case a more detailed assessment of these factors may be required. A very common approach is to meet resistance with more resistance, when a more appropriate approach is to back off and view the situation from the patient’s side.

This approach demonstrates how traditional education (ie, the provision of didactic information) is necessary, but insufficient for optimal diabetes self management. Patients also need self-management support provided in a culturally-specific manner to improve their self-efficacy.