Behavior Change
Using techniques that promote
empathy and behavior
change
Behavior Change is Key…
Why Do Our Patients Struggle?
(“strong” endorsements by physicians)
poor self-discipline
poor will-power
not scared enough
not intelligent enough
53.2%
50.0%
36.9%
16.3%
Polonsky, Boswell and Edelman, 1996
The Overarching Approach
The patient must…
 BELIEVE SELF-MANAGEMENT IS
WORTHWHILE: The patient must feel
there is hope and benefit in doing a
good job (GOALS)
 KNOW WHAT TO DO: The patient
must have a clear and achievable
plan for self-management (ACTION
PLANS)
Persuasion Techniques
• Agree that patient should make the change
• Explain why the change is important
• Warn of consequences of not changing
• Advise patient how to change
• Reassure patient that change is possible
• Disagree if patient argues against change
• Tell the patient what to do
• Give examples of others (other patients,
peers, celebrities) who have made similar
healthy changes
How does that feel?
The Overarching Approach

GOALS: BELIEVE SELF-MANAGEMENT
IS WORTHWHILE: The patient must
feel there is hope and benefit in
doing a good job.
FACTS AND FICTIONS
1. Diabetes is the leading cause of adult
blindness, amputations and kidney failure.
True or false?
________________________________________
A. False. Poorly controlled diabetes is the leading
cause of adult blindness, amputations and kidney
failure.
Feelings Can Fuel Change
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What are the patient’s feelings?
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Think of a patient you’ve seen recently
Have you ever asked how he/she feels about
his/her diabetes?
What “bugs” that person the most about his/her
diabetes???
What is working for that person in their current
lifestyle? (what is the function in the
“dysfunction”)
ASK! (then listen)
Behavior Change Strategies
1. Begin with your patient’s interests
• Agenda must be personally meaningful
for the patient
• Start with questions, not information:
• “What questions should we make sure to
address today?”
• “What’s been driving you crazy about
your chronic condition?”
Behavior Change Strategies
1. Begin with your patient’s interests
2. Believe that your patient is motivated
to live a long, healthy life
• You are both on the same side
The “Journalist” Intervention
1.
2.
Zero in on an area for behavior change
Get the details
•
3.
Explore relevant beliefs (4 “importance”
questions)
•
4.
Be a journalist, listen carefully, limit questions
“Your current score? Why not lower? Why not
higher? How to bump it up?”
Summarize and feed back the total story
DO NOT OFFER ANY HELP OR ADVICE
Importance
“How do you feel about exercise now? If ‘0’
was not important, and ‘10” was very
important, what number would you give
yourself?”
0_________________________________10
not important
very important
“You rated exercise importance at 4.”
Why isn’t it a 3? (listen for the benefits)
“And what would it take to make it a 7 (listen for ideas to
overcome barriers)a 6 or 7?” (listen for the obstacles)
Rollnick et al, 1999
Listen Well and Summarize
“It sounds like you’re inclined in two different
directions. On the one hand, you’re somewhat
worried about the possible long-term effects of
your illness if you don’t manage it well – it’s
pretty scary to think about such things. On the
other hand, you’re young and you feel fairly
healthy most of the time. You enjoy doing
what you like to do, eat what you like to eat,
and the long-term consequences seem far
away. You’re concerned, and at the same
time you’re not concerned.”
How does that feel?
Behavior Change Strategies
1. Begin with your patient’s interests
2. Believe that your patient is motivated
to live a long, healthy life
3. Help your patient determine exactly
what they might want to change
The Overarching Approach
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BELIEVE SELF-MANAGEMENT IS
WORTHWHILE: The patient must feel
there is hope and benefit in doing a
good job.
KNOW WHAT TO DO. The patient
must have a clear and achievable
plan for self-management
Behavior Change Strategies
1. Begin with your patient’s interests
2. Believe that your patient is motivated
to live a long, healthy life
3. Help your patient determine exactly
what they might want to change
• Identify and respect ambivalence
• Present the bouquet
4. Develop a reasonable, detailed action
plan
The “Action Plan”
Intervention
1. Don’t tell patients what to do
2. Negotiate what changes to focus on
blending your expertise and patients’
desires
3. Focus on 1 – 2 concrete actions to start
Not attitudes, numbers, or actions to stop
Not “lose 5 pounds in 2 weeks”
Instead…”Walk briskly 20 minutes 3 x/ week,
Monday, Wednesday and Friday after
lunch”
The “Action Plan” Intervention
4. Start with changes that are
achievable
even if “physiologically silly”
5. Selected actions must be personally
meaningful
6. Do the first step right away
“What does this mean you’ll do tomorrow
AM?”
How does this feel?
Behavior Change Strategies
1. Begin with your patient’s interests
2. Believe that your patient is motivated
to live a long, healthy life
3. Help your patient determine exactly
what they might want to change
4. Develop a reasonable, detailed
action plan
5. Stay alert for common obstacles
Patient Self-Management Barriers
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Social devastation (poverty,
homelessness, lack of access to health
care services, etc)
Lack of information
Cultural disconnect
Low functional health literacy
Relative lack of life skills
Anxiety/disease-specific
distress/depression
Address Health Literacy
• Assess patients’ recall or
comprehension of recommendations
(aka “close the loop”)
• D. "So . . . let's make sure. What
medications are we going to change?"
• P. "I think we're going to stop this one (is it
metformin?) . . . and I'm going to take
glipizide twice a day. . . I think that's the
green one.“
• Develop strategies to overcome this barrier
(case management, phone contacts, etc)
Schillinger et al, 2003
Food for Thought…
Depression
• “Depression significantly increases
the overall burden of illness in
patients with chronic medical
conditions…depression is associated
with a 50-100% increase in health
services use and cost.”
Simon, Gregory E. “Treating Depression in Patients With Chronic Disease”.
Western Journal of Medicine 2001:175:292-293
PHQ-9
• 1-4 normal – repeat PHQ 2 annually +
PHQ-9 if 2 question screen positive
• 5-9 minimal symptoms of mood
disorder/disease-specific distress – group
visits/chronic disease self-management
program (CDSMP) if applicable;
counseling if worsening
PHQ-9
• 10-15 dysthymia/disease specific distress
– counseling + group visits/CDSMP if
applicable
• >15 major depressive disorder –
medication + counseling + CDSMP when
improvement seen; close follow-up
• >20 severe depression—high risk for
hospitalization/suicidality - medication +
counseling (+ psychiatric evaluation if
not rapidly improving)
Sources of
Mood Disorders
Unresolved Trauma(s) or trauma(s)
Biochemical: NT imbalance
Behavioral Model: Learned Behavior(s)
Spiritual/Emotional Crossroads (Existential Crisis)
Risk Factors: Obesity
“Recent research indicated that obese individuals
have a significantly increased risk for developing a
mood, anxiety, personality, and alcohol risk disorder.
In this survey of 41,000 adults, the elevated risk applied
to both men and women. In turn, individuals who are
depressed may be more likely to become obese or
have other poor health outcomes.”
http://www.surgeongeneral.gov/library/publichealthreports/sgp1242.pdf
The Often Hidden Driver:
Adverse Childhood Events
ACE Score = 1 point each for positive responses to 10
questions inquiring about exposure to:
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Physical abuse
Emotional abuse
Sexual abuse
Physical neglect
Emotional neglect
Divorce/separation
Domestic violence in the home
Parent that used drugs or alcohol
Parent that was incarcerated
Parent that was mentally ill
From: www.acestudy.org
ACE Events
Please take the ACE privately, and
add up your “yes” answers to
determine your score.
How do ACE play out later in life?
• Increased smoking:
– Greater the likelihood of current smoking
• COPD:
– ACE score of 4; 2.6 x more likely to have COPD than a person
with an ACE score of 0
• Hepatitis:
– ACE score of 4: 2.4 x more likely to have hepatitis than a person
with an ACE score of 0
How do ACE play out in later life?
• Depression:
– ACE score of 4: 4.6 x more likely to have depression than a
person with an ACE score of 0
• Suicide:
– There was a 12.2 x increase in attempted suicide between
these two groups
– Between 66-80% of all attempted suicides could be
attributed to ACE
Trauma
“Adverse Childhood Experiences
(ACE) are common, destructive,
and have an effect that often
lasts for a lifetime. They are the
most important determinant of
the health and well-being of our
nation.”
--Vincent Felitti, MD, co-chair of study
Adverse Childhood Experiences
(ACE Study)
www.acestudy.org
www.cdc.gov/ace
The Patient is a Whole
Human Being, Seeking Balance
Play/
Leisure
Physical
Financial
Emotional
Vocational
Cognitive
Spiritual
Social
Sexual
Trauma Informed Care: EMDR
• Eye Movement Desensitization and Reprocessing
(EMDR)
– developed in the mid-1980’s by Francine Shapiro, Ph.D.
“EMDR is a complex, eight-phase
method of treatment for individuals
who have undergone Traumas/
traumas.”
Consensus on EMDR
• World Health Organization (2013). Guidelines for the
Management of Conditions That are Specifically
Related to Stress. Geneva, WHO.
“Trauma-focused CBT and EMDR are the
only psychotherapies recommended for
children, adolescents and adults with
PTSD.”
Consensus on EMDR
American Psychiatric Association (2004). Practice
Guideline for the Treatment of Patients with Acute
Stress Disorder and Post-traumatic Stress Disorder.
Arlington, VA: American Psychiatric Association
Practice Guidelines.
“EMDR therapy was determined to be an effective
treatment of trauma.”
Consensus on EMDR
• Department of Veterans Affairs and Department of
Defense (2004, 2010). VA/DoD Clinical Practice
Guideline for the Management of Post-Traumatic
Stress. Washington, DC.
“EMDR therapy was placed in the "A" category as
“strongly recommended” for the treatment of trauma.”
What EMDR Seems To Do
• Being an essentially non-verbal therapy, patients
don’t have to talk about their trauma in order to
heal
• Speeds processing of the unconscious and
conscious material, integrating the trauma with
current awareness
• It takes away the pain but not the content
Case Study
• 49 year old divorced,
morbidly obese (274#)
woman who is diabetic with
complications, smokes, and
has had major depression
most of her life.
• Baseline status:
– ACE score of 8
– PAM: Level 3
– PHQ-9: 17
• on SSRI
– A1C: 9.5
• Hadn’t checked
her own glucose
in 2 years
Case Study (Continued)
Current status: February 2014
• PAM: Level 4
• PHQ-9: 5
• Weight: 259
• A1c: 8.2
What made the difference?
The patient has worked on the trauma of losing her
father and is working on the physical abuse she
suffered at the hands of her mother.
Ambivalence to Action Plan
• The healing is done within the context of a
relationship
• Patient worked with everyone on the SCC team
except for the physical therapist
• It’s not been easy for her—she threw up, twice, in
admitting that she’d been physically abused by her
mother.
Ambivalence to Action Plan
• Examining and helping the patient to change
his/her self-talk, particularly negative cognitions, is
the key to motivational change.
• Leading a “life worth living” is what traumatized
people can only dream about. They often don’t
see a future for themselves. Why take care of their
health?
Ambivalence to Action Plan
• Use small, incremental steps
• Meet the patient where he/she is at
• Be respectful of how the “status quo” has been
protecting them, sometimes for years, whether it be
excess weight, non-compliance with medical care,
smoking, etc.
• Do not try to take away their defenses. They may
not return.
“...and the time came when the risk
it took to remain in a tightly closed
bud became infinitely more painful
than the risk it took to blossom.”
Anaïs Nin (1903 - 1977)
Take-Home Messages
• Almost everyone would prefer to live a long,
healthy life
• Our patients are not unmotivated to selfmanage effectively
• The problem is that self-care is tough
• Our patients face many obstacles to good
self-care
• Simple behavior change strategies are likely
to help for many
• “Stuck” patients may be victims of their
early experiences which need to be
addressed to sustain improvement