February 2000 • Volume 6 • Number 2
Tool helps physicians break through to resistant patients
BY JANE STOEVER
"We need to learn how to change from a 'fix-it' to a motivational role."How many times have you tried to get Patient X to quit smoking/lose weight/start exercising/reduce stress?
Patients who resist changing their risk behaviors create obstacles to their own health care, leaving their physicians stymied -- and frustrated. However, family physician Richard Botelho, M.D., of Rochester, N.Y., says he's had success working with patient resistance using a tool he calls the "decision balance."
"We need to learn and understand how patients perceive and value the benefits of their unhealthy behaviors," says Botelho, who presented the decision balance concept during a preconference workshop at the recent Conference on Patient Education in Austin, Texas. "We're trained to focus on disease, not the perceived benefits of unhealthy behaviors. Patients and practitioners have differences in values and perceptions about health behavior change. To use our differences to make a difference, we need to learn how to change from a 'fix-it' to a motivational role."
The decision balance tool explores a patient's perceptions about change, asking him or her to list the benefits and concerns of changing, as well as the benefits and concerns of not changing. The patient then ranks his or her resistance to change and motivation to change on a 0-10 scale.
Using individualized interventions (often over several office visits), the physician can help lower the patient's resistance score and raise the motivation score.
Botelho tells of a hospitalized patient who went from smoking one pack of cigarettes a day to two packs when her family nagged her to quit. On the decision balance, she said a benefit of smoking was that it hid her feelings. Upon further questioning, she revealed that smoke created a protective screen around her.
"Probing patients' perceptions and feelings can help you address their reasons for resistance," Botelho says.
But probing for perceptions is not what most doctors do. They tend to "hammer away" at a patient with information and advice, treating risk behavior as a "nail." However, Botelho says, if you think of the risk behavior as a nut rusted to a bolt (the patient), "hammering away at the patient may make the situation worse and even damage the threads of the bolt so the nut never comes off."
Implementing the decision balance involves three steps.
Step One
First, clarify the patient's issues about change without imposing any judgment. Ask the patient whether he or she is thinking about changing the risk behavior. Then, propose filling out the decision balance, using a stage-specific rationale. For example: "You just told me that you're not interested in quitting smoking. Would you mind if we filled out a decision balance form together? It can help me understand better why you don't want to quit." Work with the patient to fill out the form, then obtain and discuss the resistance and motivation scores.Step Two
Review the patient's comments on the form as you try to lower his or her resistance through nondirect interventions, such as:Probing priorities to create general ambivalence. "So what do you like most about smoking? What concerns you most about quitting?"
Using double-sided reflection to summarize ambivalence. "On one hand, you said that smoking helps you relieve stress, but on the other hand, you are concerned about how smoking stresses your heart. What do you think about that?"
Using time-line questions to understand patient perspectives about risk behaviors. "What was your heart like five years ago compared to now? What do you think your heart will be like in five years?"
Wrap up the discussion by asking whether the resistance and motivation scores have changed.
"It takes practice to discuss risk behaviors with patients without nagging or passing judgment."
Step Three
Use direct interventions to enhance the patient's motivation to change. Some options:Back-to-the-future questioning. "Suppose you quit smoking and never had another heart attack, then would it have been worthwhile to quit smoking?"
Benefit substitution. "In what kinds of stressful situations do you smoke? How could you relieve stress instead of smoking? Could you write down ways of relieving stress for each situation and bring the list in next time?"
Clarifying values. "What is more important in your life than smoking? Is smoking more important than your health? If you say that your health is more important than smoking, then you're saying one thing and doing another. What would convince you to do what you say?"
Wrap up by seeing whether the patient's resistance and motivation scores have changed.
It takes practice to discuss risk behaviors with patients without nagging or passing judgment, Botelho says.
Feel free to e-mail Botelho at rick_botelho@urmc.rochester.edu for more information.
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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