CHAPTER 3

COMMUNICATION AND HEALTH BEHAVIOR CHANGE COUNSELLING

Claire Lane

INTRODUCTION

As was highlighted in chapter 2, the task of changing behavior is often complex and varies between individuals. Thus, the challenges raised concerning health behavior change affect both patients as well as clinicians.

There is often an assumption in clinical practice that if patients are not doing what is “good for them,” then they must be lacking in knowledge. Although information and advice does have a place within many behavior change consultations, it is often patients’ inner feelings about what change might mean for them that create perceived barriers to change, rather than a lack of information alone (Department of Health 2004). This signals a phenomenon known as ambivalence—having mixed feelings about change, and in turn feeling unsure or indecisive. Many people can think of a time in their lives when they have struggled to make a decision—where they have felt a sense of inner conflict about which course of action is the best choice, or a sense of hopelessness when neither path seems better than the other.

Many clinicians consult with ambivalent patients on a daily basis. It is often obvious that certain behaviors are damaging patients’ oral health. Perhaps it is smoking or their diet that is causing most of the problems. Perhaps the patients are not following the oral hygiene regimen that has been recommended. Despite the number of times you have told them what they need to do, they never seem to do it. This may lead to the clinician feeling a number of different emotions—ranging from worry and concern, through to frustration and helplessness.

The main question we are left with then is how can the dental clinician address the complex task of health behavior change in a way that engages the patient to think about the issue, without triggering tension and resistance during the dental visit?

Traditionally, patients are passive recipients of information regarding how and why they should change their behavior. Individuals often feel more reluctant to think about change if they perceive their freedom is being compromised (Brehm 1966). So perhaps if the clinician is able to create an environment of understanding and respect for the patient’s autonomy, a patient may feel more comfortable in discussing health behavior change.

Good, skillful communication is the key to creating this kind of environment. Communication is a process by which we allocate and convey meanings in an attempt to create shared understanding with others. To that end, the choice of language, tone of voice, nonverbal cues, and gestures we use are important in ensuring the right message is conveyed. As highlighted in chapter 2, the way in which the patient is spoken to can make the difference between feeling that the clinician is helping him or her to change or feeling that he or she is being pushed into something the patient is not happy with. If the dental clinician can accurately select the most appropriate style of communication to employ in a given consultation, and utilize communication skills that make the patient feel respected and in control of any changes to be made, this will create a setting where a productive discussion about change can take place.

THE RELATIONSHIP BETWEEN THE CLINICIAN AND THE PATIENT

The first initial step in any consultation about health behavior change should be to create a good “rapport” or “constructive relationship” with the patient. A good rapport will encourage the patient to be open and honest in the consultation. In contrast, a bad rapport may result in the patient just telling you what he or she believes you want to hear. Rapport is important to consider, as previous research has shown that the quality of the relationship between the clinician and the patient correlates with patient behavior change outcomes (Najavits et al. 2000).

Take a few moments to think about a person in your life with whom you feel at ease to talk. What is it about him or her that makes you feel comfortable? What kinds of things does he or she do?

In addition to your own ideas, there are some suggestions below that you might find helpful to consider when thinking about how to create a good rapport with your own patients.

Smile and welcome patients into appointments:

• Do they feel comfortable coming into the surgery?
• Have you seen them before?
• Do you know their names?

Think about the non-verbals:

• Have you taken off your mask, so patients can see your face when you are talking to them?
• Are patients sitting up when you are speaking to them?
• Are you giving patients your attention when they are speaking?

Think about when you ask questions:

• Can patients respond to you?
• Are you assuming what patients’ responses would be?

Take some time to listen to patients:

• Why have they come along to see you today?
• What do they understand about their oral health?
• How do they feel about treatment?
• How do they feel about things they need to do to maintain their oral health?

Make them feel comfortable enough to come back in the future:

• Do you tell patients you look forward to seeing them again?
• Do patients feel they will be “told off” if they do come back?

Good communication reflects a good clinician-patient relationship, and in turn creates a good relationship. Selecting the right style of communication for a given consultation is often the key to creating and maintaining a good rapport.

STYLES OF COMMUNICATION

In our daily lives there are a number of different styles we use when communicating with others. Rollnick and colleagues describe a simple three-style model for understanding how health care clinicians might communicate with their patients in daily practice, using either a directing, guiding, or following style (Rollnick et al. 2007).

Directing

A directing style involves the delivery of expert advice and help. This has traditionally been the dominant approach within health care settings. Directing is best employed where there is a good rapport between the clinician and the patient. The information should be well-timed, personally relevant, and delivered in such a way as to engage the patient.

Following

A following style utilizes listening skills and occurs in situations where sensitivity is required (such as when a patient is upset). The goal of a clinician using a following style is not to solve the patient’s problem immediately but to provide support and encouragement (for example, when breaking bad news to a patient).

Guiding

The third, more complex style described by Rollnick and co-workers is guiding (Rollnick et al. 2007). In guiding, the clinician and patient work together to help the patient identify his or her own goals and how he or she might best achieve them. This style is most appropriate when talking to patients about making health behavior changes — especially with those who may be ambivalent about changing.

It is important to note, however, that skilled judgment is required by the clinician in order to select which style is most appropriate for each situation. Consider what the consequences of sticking with one style might be. Consider also what might happen if the wrong style is used with a particular patient. Skilled clinical communication is about being able to effectively identify which styles of communication are best suited to a given point during the dental visit and being able to switch flexibly between those styles during the interaction.

When it comes to behavior change issues, some patients may require “direction”—particularly those who have stated that they want further information or advice. Others may have more pressing concerns—for example, after receiving some bad news during an examination—and need to be “followed.” However, those patients who appear to know what they need to do but have not managed to do it yet may be more receptive to a “guiding” style (Rollnick et al. 2007).

A helpful exercise to consider which style might be more appropriate (directing, guiding, or following) is provided via the examples below:

It is important to be sensitive to the patient’s reaction to a particular style of communication. If the rapport between you and the patient seems to be breaking down (the patient seems uncomfortable, disengaged, confused, or maybe resistant), this should be a sign that a particular style does not appear to be working. This can serve as a signal to the clinician that one might need to switch and try another style to get the rapport back on track.

KEY SKILLS FOR COMMUNICATING A BOUT HEALTH BEHAVIOR CHANGE

There are four main communication skills that can be used to implement a guiding style of communication with patients. These are summarized by the acronym OARS, which stands for “open questions,” “affirmations,” “reflective listening,” and “summarizing.” These may be terms that you are familiar with. Alternatively, you may not have encountered them before.

To effectively use a guiding style, it is important to incorporate OARS skillfully when communicating with patients about health behavior change. Using these skills helps the patient to feel understood, supported, encouraged, and able to get his or her point across. This is useful for the clinician, who can effectively do less, yet understand more about the patient’s motivations for change.

In chapter 6, you will learn more about how OARS can be further refined during Motivational Interviewing to draw out a patient’s intrinsic motivation. For now, however, we shall concentrate on using OARS to maintain a good rapport, have a productive discussion about health behaviors with a patient, and understand the patient’s perspective on change.

There are six broad questions that need to be considered in relation to communicating about health behavior change. These are addressed in turn in the sections below, and illustrations of individual OARS skills, commensurate with a guiding style, are provided.

Question 1: Is the patient happy to talk with you about behavior change?

There are a number of consequences associated with talking with a patient who is not ready to engage in a discussion about his or her health behavior. At best, patients may simply decide that they will ignore what they are told; at worst, they can be argumentative or resistant. Individuals may even be at different stages of readiness to change different aspects of one health behavior (Rollnick et al. 1999). They may have a pressing issue that is more important for them to talk about that is affecting their readiness to change. To this end, the dental clinician should always ask permission to discuss health behavior with a patient, rather than just telling the patient that there will be a discussion about his or her health behavior. This can be achieved through asking a simple question, such as:

Within clinical consultations, it is often the case that there is more than one health behavior affecting the patient’s oral health. Achieving small changes can make a patient feel more able and confident to make other changes (Bandura 1995). In these situations, it is important to start where the patient feels most comfortable and encourage him or her to suggest what area he or she would like to talk about, rather than simply selecting what the dental clinician feels is the most pressing issue. Again, this can be addressed through a question such as: