Consultations about changing behaviour
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7522.961 (Published 20 October 2005) Cite this as: BMJ 2005;331:961
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The case illustration, explaining what constitutes ‘directing or
guiding ‘ principles in the context of behavioral changes in a particular
“health threatening” clinical situation is very apt indeed. Further, as
the authors state, “Resistance and denial are common reactions, but these
can be overcome, and outcomes improved, if the practitioner elicits the
case for change from the patient rather than imposes it...changing the
style of consultation could improve the experience for doctors and
patients “
Many consultation models tailored to achieve ‘skilful consultation about
behaviour change’ are illustrated in the literature; but the one that is
concise, effective, and applied to any ‘problematic’ clinical situation is
the one described by Pomm H A et al – “The CALMER approach”(1), consisting
of six steps; several of which only take moments to complete. These six
steps are:
1) Catalyst for change.
2) Alter thoughts to change feelings.
3) Listen and then make a diagnosis.
4) Make an agreement.
5) Education and follow up, and
6) Reach out and discuss feelings.
Although these steps are self-explanatory, (some have been covered in the
‘core skills’ in the article), their detail explanation can be obtained at
the reference below.
Incidentally, the ‘directing style’, may also be termed as ‘doctor
centered consultation’, and the ‘guiding style’ as ‘patient centered
consultation’.Thanks.
Ref. – (1) - PommHA et al. The CALMER approach: Teaching learners six
steps to serenity when dealing with difficult patients. Fam Med 2004;
36(7): 467 – 469.
Competing interests:
None declared
Competing interests: No competing interests
This is just to acknowledge a strident omission in the paper I wrote
on behaviour change with colleagues in the communication field. Our first
sentence places the context for the paper in the developing world, as if
the far more widespread poor health and associated behaviour problems in
the developing world are of less significance. The effects of poor
housing, social upheaval and other forms of deprivation manifest
themselves widely in the consulting rooms of practitioners in the
developing world, placing a huge burden on them to help patients as best
they can.
Having made this mistake, there is not much else that needs be said
about the potential of a guiding style in behaviour change consultations
in developing countries. Its clearly relevant and, I believe, adaptable
across cultures. In fact, given my impression of quite widespread morale
problems among over-burdened practitioners in the developing world,
skilfulness in using a guiding style can help them to feel less
responsible for solving health behaviour problems they encounter every
day. As for the listening component, I am yet to come across a
practitioner from a culture or language group who does not affirm the
value of listening to patients.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR- Changing ones behaviour is indeed extremely difficult, we
only have to look at ourselves and we soon realise that there a few things
in life we would like to change about ourselves, a telling off from
someone else usually doesn’t work.
Altering the style of consultations in order to change a patients’
behaviour has been in the making and is now an evolving practice. The new
method of teaching at medical school, Problem Based Learning (PBL) has
great emphasis on communication skills. Many medical schools have now
shunned the directing and parental approach to patient care and teach the
guiding style as described by Rollnick et al.1
Although doctors may not be able to dictate the lives of their
patients, as a medical community we are social engineers1 in that we have
modified skills in which to attempt to alter ones behaviour. It is true
that when a discussion goes badly, patient resistance increases and is
difficult to decrease this negativism in the patient. Subsequent change in
behaviour is then almost impossible. However, the change in style of
consultation may not be fruitful in changing behaviour in all patients.
For example with our ever growing obese population, although a patient who
is obese and newly diagnosed with diabetes mellitus knows it is bad to eat
unhealthy foods, the stimuli of freshly cooked pie and chips is much more
appealing than that of bananas, what happens, the patient gives in and the
tremendously hard work gone into the consultation to attempt to change
behaviour is fruitless. Modern technology can become a disadvantage to
directing or parental medical consultations. A diagnosis of cancer can
allow a patient to look up many details on the internet, conflicting
knowledge with a clinician can result in immediate resistance. On the
contrary, increased patient knowledge can be an advantage in the guiding
style of consultations as it can bring about effective discussion and
clear misunderstandings.
It should be agreed that at times a directive approach should be
reverted to in acute settings such as appendicitis as described.1 In
everyday practice a guiding approach is ideal in the ideal patient,
however “support from next door” will not always work, as there will
always be some patients who would like “advice from on high”,1 and this is
enough to change their behaviour.
To effectively change behaviour, it is agreed the archaic method of
consultation style should be changed and it has. We are currently in an
evolutionary process whereby in the near future most clinicians will use
this method. This change will make someone better.
1 Rollnick S et al. Consultations about changing behaviour. [Editor’s
choice]. BMJ 2005;331. (22 October).
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
“It is well said that bad habits are often easy to cultivate and
difficult to change.”
Every discussions aimed at changing behavior can end up good or bad,
depending upon how the clinician play the game and how much the patient is
involved in each discussion. There are several factors which influence the
outcome and just informing the patients about risk is not sufficient. As
the author describes the core skills used in different combinations can
lead to a healthy conclusions. Guiding patients to look into their own
behavior and letting them to choose is often sufficient in the first
interview, but moving them forward in the change requires multiple
attempts by the patients and often the clinicians as there are multiple
occasions even after a good discussion, the patient do not comply with the
change, due to their psychosocial beliefs and constant stimulus which
influences their behavior.
Competing interests:
None declared
Competing interests: No competing interests
Motivational facipulation
Having learned the technique during a primary health care masters
degree 5 years ago, I feel very disconcerted by the application of
motivational interviewing as a method. I don’t doubt that it is more
effective than confrontation or other methods, for enabling behaviour
change at least in substance use - not least smoking. My problem is not in
its public health utility. Rather, my problem is primordial: in its being
utilitarian. I question the very roots of such a public health. By what
rights, I ask myself, do I set out in advance to change someone else’s
behaviour (without the conflict of whether that person is harming someone
else in the process)?
My experience of participatory learning and action (PLA) with drug
users suggests that motivational interviewing is a grotesque shadow of
what it could be: providing information and developing motivation for
change within a context of a client becoming fully conscientised to the
factors affecting their behaviours and relationships - their substance use
only being a subset of these; taking a role as ‘facilitator’, not in pre-
determined (societally) targeted goals as a ‘guide/ manipulator/
facipulator’, (let alone ‘director’ as this article suggests) but in
enabling self-motivated and controlled change based on fully empowered
choice. Hence, sustained substance use may not count as failure, where
other factors of causal import, or which lend confidence in a belief in
self-efficacy, are being effectively acted on by a previously marginalised
person. Indeed, they may even be spontaneously sharing these lessons of
growth with their peers prior to any substance use change.
For me, the root issues relate to empowerment. Motivational
interviewing is in my opinion a paternalistic, covertly political health
distortion (which incidentally, I apologised for inflicting on my ‘client’
after my obligatory practicum was over and have avoided using since).
Competing interests:
I am a perpetual and ardent supporter of authentic, politically relevant primary health care and participatory development, as opposed to traditional public health and community development.
Competing interests: No competing interests