THE CHALLENGE OF BEHAVIOR CHANGE
Key Points of This Chapter
- Behavior change is complex and can seem like a struggle for both the patient and the clinician.
- Patient behavior change happens outside the treatment room within the context of your patients’ lives.
- There are ways of approaching the challenge of health behavior change that make it less stressful for the clinician and with a greater potential for effecting results in a brief period of time.
- There are limits to what you can achieve with advice alone: research suggests that the conversational environment in which the advice is given makes a significant difference to how that advice is received.
- Ambivalence—or “feeling two ways about something”—is a normal part of the change process.
- How you communicate with your patient makes all the difference: evidence has shown that the expression of empathy is perhaps the most important factor in facilitating patient behavior change.
- It will be the patient’s task to say how and why he or she should or might change. The clinician’s role is to elicit these arguments for change from the patient.
- For patients facing the need for a number of changes to be made, involving them in the process of decision making at the beginning is important. The use of a specific skill, agenda setting, and agreeing on priorities canfacilitate this process.
- There are many different models and theories of behavior change that can help guide ways of thinking about practice.
Behavior change requires effort. It involves consciously making different choices or adopting new habits and lifestyle patterns and is seldom comfortable, easy, or convenient. Consider the case of Mrs. K, a 38-year-old mother of three children. She comes home from a recent appointment with her dentist with a firm resolve to follow the self-care advice given. As the weeks pass, however, she loses momentum and one evening while halfheartedly flossing her teeth, she notices her gums bleeding more than usual. She feels guilty about this and so considers cancelling her upcoming dental hygiene appointment, not wanting to explain the increase in the bleeding of her gums to her hygienist.
We may agree that the worst step Mrs. K can take at this stage is to cancel her dental hygiene appointment. A basic understanding of the progression of gum disease would indicate that doing so is counterproductive. So, what happened to Mrs. K that she was considering taking a step like this? And further, how can dental clinicians encourage patients to make better decisions in support of the oral care they need?
Questions about how and why people act in certain ways in relation to their health have absorbed clinicians and behavioral scientists alike across many disciplines for years. Within the study of health behavior, many theories have been proposed and numerous studies conducted in an attempt to develop and evaluate effective interventions promoting behavior change. Theories vary in their philosophy of which factors determine behavior change. Some place greater emphasis on individual factors such as cognitions or emotions, while others include environmental factors such as socio-economic status or the influence of the family. However, the evidence to date suggests that behavior change is a challenging task and no single approach guarantees success.
In this chapter, we will focus on the challenge of addressing behavior change with patients at an individual level. First we will highlight some key concepts related to behavior change illustrated from both the patient’s and the clinician’s perspectives. We will then provide an overview of popular theories and models as ways of understanding behavior change.
This is a book for clinicians. The challenge of behavior change we will focus on lies within the oral health care environment. Clinicians say things like, “I repeat the same information every time I see this patient, what part of it doesn’t he understand?” Patients say things like, “I’ve smoked for 25 years and now even my dentist is telling me to quit. Give me a break!” And the struggle continues.
So what is it about behavior change that gives rise to these challenges? One way to approach this question would be to have a look at the process of change itself and identify some key concepts. The following case example is an illustration of one man’s struggles to improve his health. The story may have obvious paralels with patients you see in your practice. We will use this example to highlight some key concepts in working with behavior change in the clinic.
Behavior change is complex and can seem like a strug1gle for both the patient and the clinician.
The patient’s perspective
Consider a 65-year-old man receiving treatment for periodontal disease. This man is mostly compliant with his oral hygiene routine and attends his appointments regularly. However, despite repeated information and advice given to him by his dental clinician and others, he continues to smoke forty cigarettes a day. He is also slightly overweight and, on assessment, admitted he had a high sugar diet with little intention of changing this.
Several years into treatment the man returns for an appointment having lost a significant amount of weight. His dental clinician notes an improvement in his disease progression and asks the man what has changed. She learns that the man had started walking daily with his wife, who had recently retired. Encouraged by the success of losing some weight, he had made some small changes to his diet and had been steadily cutting down the amount he was smoking.
Clearly, stopping smoking and making some dietary changes significantly improved this man’s general health as well as his periodontal condition. Of course the dental practitioner knew this and had been wanting him to make these changes for some time. However, this patient’s perspective tells a different story. The man knew the benefits of quitting smoking but, despite efforts made in the past, he had not managed to succeed and had lost the confidence that this was something he was able to do. He would then try changing his diet. Results here were familiar too. He would start with the best intentions and then old habits would creep back in. Although he knew these changes would make a difference to his periodontal disease, he focused his efforts on his oral hygiene routine and attending visits and felt he was doing all he could to manage his oral health. His decision to start walking had very little to do with improving his oral health and more to do with joining his wife for walks, then feeling motivated by the effects of this activity. The man was encouraged by his dental clinician’s response to these changes and this strengthened his resolve to maintain the changes further.
What does this simple story illustrate about behavior change?
Change can happen naturally in everyday life
It is now generally accepted that in many different contexts, positive change occurs relatively frequently without more formal intervention. One way of understanding behavior change interventions, therefore, is to see them as ways of facilitating this naturally occurring process (Miller and Rollnick 2002). Reflecting on this patient’s story, we see that this man made changes at a time that made sense to him and in a way that made the effort seem worthwhile. A simple conclusion is this: that all patients have the potential to make changes despite the struggles that so frequently characterize this task. Reminding yourself of this potential can encourage you to approach the challenge of behavior change with optimism and curiosity, thereby creating a conversational environment more conducive to talk about change.
Intrinsic motivation affects patient behavior
There is a difference between motivation that arises from an internal source (intrinsic motivation) versus that which is prompted from an external source (extrinsic motivation). Take a moment to think about your own experience of change. There is a difference between your doing something because you decide it is a good idea and your doing something to receive a reward or to avoid punishment.
Intrinsic motivation is related to individual experiences of confidence, vitality, and self-esteem, and these factors are unique to each individual (Deci and Ryan 1985). Gaining an understanding of what these factors might be for your patient contributes to knowing how best to tap in to his or her positive potential for change.
Let us return to the story of the patient described above to illustrate this. The man in the example developed an inner sense of satisfaction and well-being not only due to the health improvements he was noticing but also as a result of the quality time he was spending with his wife. These internal factors reflect the man’ s intrinsic motivation to sustain the positive changes he had made and even begin to provoke some small changes in other areas of his life.
People change when they are ready
What happened to inspire the man in the case study to cut down on his smoking and change his diet? One way of answering this question would be to say that he simply reached a point when he was ready to make some changes. This concept of readiness was introduced with the Stages of Change model (Prochaska and DiClemente 1983) and plays a central role in helping us understand how it is that some patients seem “more motivated” to make changes than others. Motivation is a dynamic concept. At any one moment in time, patients may be at varying points of readiness to change a particular behavior. Additionally, they will be at different points of readiness for different behaviors. From the case study above, we can see that the man first made changes to his oral hygiene routine, then to his physical activity levels, to his diet, and, finally, to his tobacco use. From a “readiness” perspective, it seems clear that the man was “more ready” to comply with his oral health routine than with smoking cessation advice. Attempts by the clinician to influence his smoking behavior may therefore have been unsuccessful. And this would not have been because the man is generally “difficult” or “unmotivated.”
Ambivalence is part of the process
Perhaps one of the greater limitations of behavior change theories proposed thus far is an over-reliance on logic or linear processes when approaching the change process (Ryan and Deci 2000). Behavior change appears, by nature, to be irrational. Attempts in this area are typically characterized by periods of success and then reverting back to familiar habits. Rather than being pathological in any way, this kind of process is both familiar and to be expected. Moreover, it can be captured succinctly with the concept of ambivalence.
Ambivalence is an internal process where a person feels two ways about doing something. Most people will experience a certain amount of ambivalence throughout the process of change (Rollnick et al. 2007; Ryan andDeci 2000). The man in this case study clearly knew the reported health benefits of stopping smoking. His inability to quit smoking was not linked to a lack of information but rather to an internal “tug of war” where one part of him felt it important to do something about his smoking, that is, his early attempts to quit, but another part of him felt the task was too difficult. In addition to this, the man may have experienced some benefits to smoking. He may, for example, have felt that cigarettes helped him relax. No matter how illogical this may seem from the outside, when it comes to behavior, it is the patient’s perception that counts toward what choices he or she will make.
Change happens in the context of our patients’ lives
This story illustrates a final key point: that patient behavior change happens outside the treatment room within the context of our patients’ lives. Clinicians who take time to engage with their patients, listening closely to understand their life context, are certainly more likely to influence some of the decisions and choices their patients may make when leaving the consulting room.
Patient behavior change happen outside the treatment room within the context of our patients’ lives.
The clinician’s perspective
The clinician working with the man described above may tell a very different story. Every time they met the clinician would raise the subject of the patient’ s tobacco use, giving him information leaflets and a helpline number to help him with the recommendations provided. The man would sit and listen to the advice and take the leaflet home with him, but he seemed reluctant to talk about his tobacco use in any detail. At times he seemed irritable and sullen whenever the topic was brought up again. The clinician felt frustrated by this, as it was clear the man was making good attempts with his oral hygiene routine. It seemed impossible to understand why he couldn’t grasp the improvements he could make by simply cutting down his tobacco consumption. The clinician would also give the man some information regarding diet but felt tobacco cessation was the greater priority.
This type of experience is fairly common in routine clinical practice. As a dental clinician, in any consultation, you may have as little as 5 or 10 minutes to speak with your patient about changes they could be making to improve their oral health. The frustrations expressed by the clinician working with this man are therefore understandable. However, there are ways of approaching this challenge that make it less stressful for the clinician and with a greater potential for effecting results in a brief period of time. The challenge remains to use the time available to maximum effect and to make the “window of opportunity” you have available count (see chapter 5).
There are ways of approaching the challenge of health behavior change that make it less stressful for the clinician and with a greater potential for effecting results in a brief period of time.
Limitations of giving advice
A familiar approach in addressing oral health-related behavior change has been to give advice or to try to persuade patients toward a particular course of action. However, the limitation of this approach becomes clear when considering the psychological theory of reactance (Brehm 1966; Brehm and Brehm 1981). When someone feels pressured to accept a certain view or attitude, his or her immediate emotional reaction is to argue for the opposite. This reaction occurs when individuals perceive a freedom, or choice, is to be taken from them. As a result, trying to persuade a person to adopt a particular course of action frequently elicits the exact opposite result to the one you are trying to achieve.
This goes some way to explain why it is that traditional educational interventions have not proved effective in promoting patient behavior change (Renz et al. 2007). This is not to say that clinicians should not give advice or information to patients. However, research suggests that the conversational environment in which the advice is given makes a significant difference to how that advice is received (Salter et al. 2007). This finding complements research by Najavits and co-workers that emphasizes interpersonal interaction as the single most important factor in influencing motivation and behavior change (Najavits et al. 2000).
Another way of saying this is that it is the way in which we communicate with our patients that affects behavior change outcomes (Rol/>