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“Changing Behaviour-A Gamble, depends how each clinician play it.”
- Ranjit K Dhelaria (25 October 2005)
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Change something. Make someone better.
- Sandip Hindocha (25 October 2005)
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An omission: health behaviour change in the developing world
- Stephen Rollnick (26 October 2005)
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Changing Behaviour - The CALMER Approach
- Chandrakant Madgaonkar (30 October 2005)
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Motivational facipulation
- Ditch Townsend (12 November 2005)
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Ranjit K Dhelaria, Senior house officer South Tyneside District Hospital
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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 |
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Sandip Hindocha, House Officer North Manchester General Hospital, Crumpsall, Manchester. M8 5RB
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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 |
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Stephen Rollnick, Professor of Healthcare Communication Department of General Practice, Cardiff University, Llanedeyrn Health Centre, Llanedeyrn, Cardiff C
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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 |
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Chandrakant Madgaonkar, Family Physician Jaya Chamraj Nagar, Hubli - 580020, India.
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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 |
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Ditch Townsend, South East Asia Director - The Leprosy Mission International Singapore 199589
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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. |
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