The Process in Your Clinical Practice

The encounter for lifestyle change opens with the establishment of rapport and trust with your patient. You are assisting the patient to be in control of the encounter and trying to establish a partnership for what needs to be done, which only the patient can decide. Your role is to assess the patient's level of healthy lifestyle activity, educational needs, emotional state, and readiness to embark on change, and to reflect these back to the patient as they become clear.

A good way to open the discussion is to present a list of options (a "menu") that you and the patient might work on together for the encounter. Ask if this is acceptable. You can identify a patient's readiness for behavioral change simply by asking the patient about the positive aspects of the patient's current behavior and then listening. Follow this up with a similar question, What are the negative aspects of this behavior? To assess the current state of the tension between the positive and negative aspects, using a motivational "ruler," ask the patient how important it is to change the current behavior, on a scale of 1 to 10. If the patient rates the importance of change as only a 2 out of 10, you can ask, "Why isn't it a zero or a one?" If it is a 6, you can ask, "What would it take to make it a seven?" The goal of this interaction is simply to understand the patient's readiness for behavioral change and to facilitate the patient's recognition of his or her own ambivalence.

The uncovering of ambivalence is a useful step forward, not a failure on the physician's part. Ambivalence must exist, or the behavior would have changed already. Ambivalence is the reason for the encounter. The physician must try to understand what creates the tension that results in ambivalence. Ambivalence can be addressed; a clear "no" cannot. If the patient turns out not to be ready for change, the patient is probably right. Only the patient fully understands all the competing values in his or her life. Acknowledge that directly, asking such questions as, "Where does that leave you now?" or "What are you thinking/feeling at this point?"

If the patient is ready for change, you want to find out how much and how fast. Let the patient be in charge. A good question is, "How can I help?" If the patient does not have a specific task for you right now, you can always just offer information from a clinical perspective. Ask if this is acceptable. Try to reach mutual clarity about what to expect. "How confident are you that you can cut your smoking in half this week?" On a confidence scale (1-10), physicians are seeking a level of 7 out of 10, to indicate that the patient is really confident about making a change. If the answer is less than 7, you can gently suggest considering a lower goal. For example, "Well, if you only feel a confidence of 5 about cutting your smoking in half, how confident would you feel about reducing your smoking by two cigarettes a day this week?"

When you have a firm degree of confidence (>7) about a mutually agreed goal, you are ready to close the encounter. Affirm the effort the patient is making to enhance the quality of his or her health. Affirm that you will be there for the patient at each turn on this path to lifestyle change.

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