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Dr. Michael Evans Add to ...

If you're a problem solver you probably enjoy fixing things and giving advice, seeking out information and arguing for change.

These skills will serve you well if you're trying to help your loved ones fix a leak, but not if you're trying to fix them, research shows.

When you want someone to become more healthy or give up bad habits, simply doling out good advice and urging them on won't create change.

To truly increase your chances of influencing family and friends toward healthy behaviours, you need a crash course in motivational interviewing and the stages of change.

Developed by clinical psychologists William Miller and Stephen Rollnick, mostly in studies of heavy drinkers, motivational interviewing has now been applied in situations from water disinfection practices in Zambia to people's eating styles.

Its value in helping doctors was shown in research published in last week's Archives of Pediatrics and Adolescent Medicine.

The journal profiled research capturing the daily interaction of pediatricians with parents. It's a tricky thing to talk to parents about their obese children, and the doctors used the non-confrontational style inherent in motivational interviewing to make their case.

"What you want to do is get the patient to take responsibility for their behaviours," lead author Robert Schwartz of Wake Forest University School of Medicine in Winston-Salem, N.C., told Reuters News Agency.

The technique uses open-ended questions such as:

What worries you about your current behaviour?

What would be a small change that you could start with?

What would it take to make you feel more confident about changing?

Or even, sounds like you're not really interested in help right now.

In the lexicon of motivational interviewing, this is "change talk." It starts with where the person is rather than where you want them to be.

When I first became a doctor, I wanted to convert all my smoking patients to non-smokers right away.

Most felt that stopping smoking was a health priority. But most didn't quit.

Later on in my practice, I met a woman who was having unprotected sex with her HIV-positive husband once a month. I was shocked because it seemed to be a meditated decision.

I outlined the risk and she understood. She was smart, if sad. But, like the smokers, she didn't change.

To understand why people make health decisions that don't seem wise - and how motivational interviewing can influence them - it helps to understand more about why people change.

The rational thought would be that someone would change their health behaviours based on, well, rational thought. A cancer diagnosis should be a powerful predictor of whether a person is able to quit smoking, but the medical literature shows that it is not. What does predict success is having the benefit of a counselling style described by Carl Rogers, founder of client-centred therapy, as "accurate empathy" (skillful, reflective listening with a non-judgmental attitude), along with warmth and genuineness.

If you have these skills and attributes, you understand not only the importance of change but also of people's level of confidence and readiness to make that change.

Instead of a major event making up their minds, patients often describe a subtle personal moment - like hearing a comment from a grandchild - as their turning point.

As the psychiatrist James Gordon famously noted: "It is not that some people have willpower and others don't, it is simply that some people are ready to change and others are not."

The stages of change were developed by psychologists Carlo Diclemente and James Prochaska, again in the setting of addiction.

Taking one of my smokers, they would decide what mode the patient was in: "pre-contemplation" (not really thinking of quitting); "contemplation" (thinking about it), ready for "action" (setting a date to quit) or in "maintenance" mode (quit and trying to keep it that way).

Motivational interviewing is focused not on getting them to quit today, but on shifting from one stage to the next.

Counsellors use specific techniques that allow them to roll with the patient's needs. A good example is the "decisional balance," where a patient is asked to reflect not only on the pros but also on the cons of changing or not changing.

Traditional counselling tends to focus on the negatives of continuing a behaviour. But my own clinical success seems to come from the opposite.

Counter-intuitively, my experience is that when I ask patients to discuss what they like most about smoking, this appears to open the door to quitting.

We all know the downsides, but when we mull the upsides (taking a break, camaraderie, weight control) it gives us an understanding of how to take control and reduces the resistance to change.

For the woman who was having risky sex with her HIV-positive husband, her decision seemed more understandable after we discussed what she saw as the merits.

She said she felt less depressed after sex, that the act connected her to a world she felt largely disconnected to. She also said her husband had a history of violence, and that she felt the risk of HIV transmission was the lesser hazard.

It wasn't until we had a shared understanding of these factors that we could start working together.

With motivational interviewing, small successes are reinforced and built upon. The result is gradually picking up new patterns of behaviour, coupled with a better sense of the Holy Grail of sustaining a healthy lifestyle - self-efficacy. The feeling that you're capable of making changes in your life.

It's said that the conversation of motivational interviewing is a dance, not a wrestle. Are you ready to tango?

Michael Evans is an associate professor at the University of Toronto and staff physician at the Toronto Western Hospital


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