Counseling patients on lifestyle modification and psychosocial problems is a fundamental competency for family physicians.^1–4 Approximately 40% of primary care office visits are for chronic illness⁵ in which psychosocial factors play a major role in etiology and disease progression.⁶ Counseling patients about health risk behaviors and health education is a core component of 18% of all primary care office visits.⁵ Although counseling regarding weight management, diet, smoking, and alcohol use is an important part of clinical practice, a survey found that only between 31% and 56% of primary care physicians rated themselves as having significant expertise in counseling about these issues.⁴

In the past decade, primary care counseling strategies have been refined,^7–10 and some have been empirically evaluated.^10–12 This article describes practical counseling strategies typically requiring no more than five to 10 minutes that can be integrated into a typical office visit^1,3,9,13,14 (Table 1^3,15 ). Research and clinical guidelines suggest that smoking cessation can be effectively addressed in three minutes, problem alcohol use in five minutes, and dietary fat consumption and lipid levels in eight minutes.¹³ These strategies may also be adapted to multiple patient contacts. For example, the U.S. Preventive Services Task Force guidelines¹⁶ and a recent Cochrane review ¹⁷ for addressing alcohol misuse suggest that several 10- to 15-minute counseling appointments are most effective for reducing alcohol consumption.

Transtheoretical (Stages of Change) Model

The stages of change model (Table 2^3,15,18–20 ), originally developed from studying successful smoking cessation techniques,^18,19 recognizes that many patients are currently unmotivated or ambivalent about habit change. The stages of change model provides a framework for assessing the patient’s degree of commitment to change, and can guide physicians in choosing from counseling strategies such as the five A’s, FRAMES, or motivational interviewing. By asking questions assessing the patient’s motivation, and determining his or her specific stage in the change process (i.e., precontemplation, contemplation, preparation, action, maintenance), physicians can move the patient toward initiating action or support ongoing health behavior change.^15,18,19

Patients in the precontemplative stage pose a particular challenge. If a patient appears unconcerned about health risks, the physician may be tempted to emphasize the consequences of a behavior such as continued smoking or excess alcohol use. However, aggressive education may increase resistance and has the unintended effect of reducing patient openness to physician input.^{3,15,16,18,19,21}

In precontemplation, the cons of changing outweigh any perceived benefits.¹⁸ Therefore, counseling at this stage should emphasize the benefits of change. Achieving “decisional balance” involves eliciting the patient’s stated pros and cons for changing his or her behaviors. To move the patient from contemplation to action, the physician should address obstacles to change. Studies of multiple health behaviors conclude that moving through these stages involves a cross-over, with an increase in the pros and a decrease in the cons of changing behaviors.¹⁸

In the action and maintenance stages, patients contend with possible lapse and relapse. When a lapse occurs, patients are more likely to relapse to their former habit when they attribute the lapse to internal causes such as personality, genetics, or lack of willpower. Patients attributing their lapse to external factors such as peer pressure or work-related stress are less likely to relapse.²⁰ Physicians should frame lapses and relapses as learning experiences and help patients recognize formerly unanticipated challenges as well as develop a plan for preventing future episodes.

Although the stages accurately predict health-related behaviors, the effects of specific stage-matched interventions are unclear.^22,23 For example, the stages of change are useful in approaching smoking cessation counseling, with precontemplative patients responding best to a brief motivational intervention accompanied by written information.²³ Patients in the preparation or action stage benefit most from a combination of focused advice, written guidance, and prescription medication when indicated.²³

The Five A’s

The five A’s (ask, advise, assess, assist, arrange; Table 3^{3,10,15,24,25} ), is a stepwise protocol for primary care physicians to efficiently assess and counsel patients about smoking cessation,^3,10,15,26 alcohol intake,^3,19 and weight loss.^24,25 Whenever possible, advising and assessing should link the patient’s presenting problem (e.g., gastrointestinal distress, knee pain with a body mass index above 30 kg per m²) to objective, factual standards (e.g., safe vs. unsafe levels of alcohol use, recommended daily caloric intake). Patients are likely to respond more favorably to “I” statements (“I recommend…”) rather than “You” statements (“You should…”).³

In one study, using some of the five A’s in a brief emergency department intervention required a median of seven minutes that included screening, describing the relationship between alcohol and the patient’s presenting problem, enhancing patient motivation, and goal setting. This physician-delivered intervention, when assessed during a six-month follow-up visit, was associated with an average of 3.3 fewer binge episodes in the previous 28 days compared with 1.5 fewer episodes for patients receiving standard care.²⁷

Some evidence suggests that depending on the clinical context and problem, the impact of the specific A’s may vary.^24,25 For example, when the five A’s impact on dietary change was assessed at the three-month follow-up, weight loss of 3.3 lb (1.5 kg) occurred only when the intervention included the “arrange” step, whereas small, statistically significant self-reported changes in fat and fiber intake occurred with the first four A’s alone.²⁵

FRAMES

FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of options, empathy, self-efficacy enhancement) is a precursor to motivational interviewing, and was originally developed to address alcohol misuse. However, it has been applied to other health issues such as reducing stroke risk²⁸ (Table 4^3,15,27,28 ). To facilitate collaboration, the physician obtains the patient’s permission before providing information. By granting permission, patients maintain control, implicitly demonstrate interest, and are less likely to experience a threat to their independence.^{3,15,21,29,30} How open the patient is to change will usually be evident by his or her answer to the responsibility statement that emphasizes the patient’s autonomous choice to address health risk behavior. Specific, individualized feedback is presented in a factual, nonjudgmental manner. For some patients, seeing numerical data, such as blood pressure readings or body weight, in the context of normal values, may be adequate for eliciting motivation to change.^3,15,27

The FRAMES strategy incorporates elements of motivational interviewing²¹ and patient-centered care’s emphasis on understanding patients’ values and preferences.^29,30 The menu of options step reflects the growing importance of shared decision making in clinical practice—particularly when there are several therapeutic options.^3,15,30 Research has shown that providing choices increases patient adherence and satisfaction.²⁹

Although abstinence remains the standard treatment for excessive alcohol use, reduced consumption has health benefits and diminishes risk of harm.³¹ In a randomized controlled trial, FRAMES was associated with 40% to 50% lower alcohol intake with a corresponding reduction in alcohol-related arrests and automobile crashes.³¹ A recent application of FRAMES to French primary care patients found reductions in cannabis use among patients up to 18 years of age at the six-month follow-up, whereas use increased among adolescents receiving routine care.³²

Motivational Interviewing

Motivational interviewing has been successfully adapted to a range of behaviors including medication adherence, dietary change, and safe sex practices.^33,34 Motivational interviewing was developed from the observation that substance abuse counselors who communicated empathy, understanding, and objective information were more successful in reducing patients’ substance use than those relying on confrontation.²¹ In the past decade, this strategy has developed further and its evidence base, particularly in primary care, has grown.³³ A meta-analysis of outcomes across multiple medical conditions found that compared with usual care, motivational interviewing strategies resulted in an average of 10% to 15% added benefit in patient outcomes such as alcohol consumption, blood pressure readings, body weight, and human immunodeficiency virus viral load.^33,35

Similar to the stages of change model, motivational interviewing assumes that patients are ambivalent about change^21,34 and are more likely to change if they consider and explain their own reasons for new behavior.²¹ In the context of a supportive relationship, physicians ask Socratic-style questions that help patients articulate their own reasons and goals for addressing health risk behaviors^21,34,36 (Table 5^3,15,21,30 ).

The initial stage of motivational interviewing focuses on understanding the patient’s concerns and developing rapport (Table 6^{21,34,36–38} ). Effectiveness is optimized when physicians maintain a ratio of two reflective statements per question.³⁸ When providing information, the physician should demonstrate a neutral, objective tone: “The amount that you reported drinking is at the 95th percentile for your age and sex, which means that you drink more than 95% of men your age in the United States.”³⁹ In focusing the conversation, the physician emphasizes the patient’s own reasons for and against change: “After learning about your blood pressure, you are concerned about the overall effect that drinking is having on your health and that drinking beer is the way that you relax after work. Do I have that right?” The use of “and” rather than “but” is deliberate; “but” is likely to increase defensiveness.^38,39

Patient values are a key component of developing an effective treatment plan (Table 7^34,38 ). Asking the patient about his or her ideas for habit change and continuing to ask permission before presenting options further the patient’s investment in change. This approach is also more likely to result in patient adherence. Although motivational interviewing techniques can be learned, maintaining the overall spirit of this strategy is more demanding.²⁷ In primary care settings, benefits have been demonstrated with one to three 15- to 20-minute sessions.³⁵ Descriptive reviews of motivational interviewing training for primary care physicians report a median of nine hours of training time⁴⁰; however, basic skills have been acquired with two hours of training.⁴¹

BATHE

At least one-half of all mental health encounters occur in primary care,^1,3,42 and patients with psychiatric conditions are twice as likely to be treated by primary care physicians than by mental health professionals.⁴² The BATHE (background, affect, troubles, handling, empathy) strategy is a structured set of questions and statements created specifically for the primary care setting and its inherent time constraints to address a range of psychosocial problems^3,9,43 (Table 8^9,43,44 ). Compared with usual care, the BATHE technique has been associated with improved patient satisfaction in several medical settings.^9,45

The background question deliberately encourages the patient to focus on a specified present topic or event since the most recent office visit. It is not usually productive or practical to pursue a detailed history, and physicians should generally avoid the psychotherapist’s, “Tell me more about that?” query.^3,19

Affect is the next step. Nonverbal cues such as tone of voice, posture, and facial expression can be clues to emotional states that the physician can encourage the patient to consider, because some patients may have difficulty articulating their feelings.^9,15

The troubles question is particularly useful with patients who are overwhelmed or are responding to a major life stressor, and it provides focus for the remaining queries. The physician should not assume that he or she knows what is most troubling to the patient.^9,15 For example, if a patient’s spouse has just announced that she is filing for divorce, the key concern may not be loss of the relationship but financial worry about how to survive on a single income.

Handling is primarily an issue of coping. When there are specific actions that would render a situation less distressing, a problem focus is most helpful (e.g., learning about available treatment options for newly diagnosed cancer). However, for uncontrollable situations such as the death of a loved one, emotion-focused coping may be associated with less distress.⁴⁶ In this approach, the patient is encouraged to consider activities that can help him or her get through an emotionally difficult period. An expression of empathy closes the interview.

Approach to the Patient

These counseling strategies should be implemented in a stepped care model.⁴⁷ For patients who respond to direct physician advice, the five A’s and FRAMES are likely to be effective. When patient motivation is a factor, the stages of change can guide counseling. Motivational interviewing techniques for increasing patient awareness of risk and resolving ambivalence are indicated for patients who are not interested in addressing health risk behavior. For patients with psychiatric conditions and broader psychosocial issues, the BATHE technique is a useful starting point.^3,15

A common dilemma is how to proceed when patients exhibit comorbid problems such as smoking and excessive alcohol use. Historically, physicians were advised to target one behavior at a time.⁴⁸ Recent research suggests that this limitation may not be necessary.⁴⁹ In a recent study clinicians used transtheoretical model–based counseling to address three weight-related behaviors simultaneously (e.g., reducing fat intake by less than 30% of overall calories consumed, increasing exercise to 30 minutes at least five times per week, and reducing daily food intake by 500 calories). Patients progressing to the action or maintenance stage with one behavior were twice as likely to move to the action or maintenance stage with a second behavior during a 24-month period compared with a usual care group.⁴⁹

Physicians capitalizing on the teachable moment, estimated to occur in 10% of primary care office visits, may have greater counseling success.⁵⁰ These moments are typically acute medical events or pregnancy that increase patients’ motivation for change.⁵⁰ For example, a patient presenting with acute bronchitis may be more open to discussing smoking cessation, particularly when the physician connects the acute symptoms to cigarettes.

Patients with psychiatric conditions or psychosocial stressors will benefit from the BATHE technique, combined with psychotropic medication when appropriate.⁵¹ These patients should be closely monitored to assess their response to this initial intervention. Patients demonstrating a minimal response to brief psychosocial counseling should be referred for subspecialty mental health care.

This article updates a previous article on this topic by the author.³

Data Sources: Search terms included counseling and psychotherapy paired with primary health care. Some of the counseling strategies described (five A’s, FRAMES, BATHE) were entered alone. Motivational interviewing and transtheoretical (stages of change) model were paired with primary medical care. The author’s previous articles (references ³ and ¹⁵) were reviewed for recent citations. In addition to Medline, searches were run in the Agency for Health Care Research and Quality database, Cochrane Database of Systematic Reviews, U.S. Preventive Services Task Force, and the Substance Abuse and Mental Health Services Administration. Finally, to search for applications of newer counseling approaches to the primary care setting, acceptance and commitment therapy, solution focused therapy, and positive psychology were paired with primary medical care in Medline. Search dates: October 2017 through January 2018, and April, May, and September 2018.