Intended for healthcare professionals

Practice Competent Novice

Motivational interviewing

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1900 (Published 27 April 2010) Cite this as: BMJ 2010;340:c1900

The different dimensions of working with behaviour change. Exploring internal and external influences

‘Giving up smoking is easy. I’ve done it 100s of times’ Mark Twain

Most people who have given up smoking will probably be familiar with this well-known quote. We all will have made behaviour changes. Some are so effortless we may not even be aware we have made them. Others can fill us with dread. New Year’s resolutions we know will probably be ‘thrown out of the window’ by February.

People who work with behaviour change often use models to help them work in a more appropriate and time-efficient manner. One of the most commonly known behaviour change models is the ‘stages of change’ by Prochaska and DiClemente. Within this model people usually transition through six stages (pre-contemplation, contemplation, preparation, action, possible relapse/ lapse) before they finally reach a more stable setting known as ‘maintenance’. This transition can happen at different rates and depend on many various external and internal factors.

My own work experience has enabled me to work with people in different situations and settings around behaviour change. Although people are generally going through the same process, understanding some of the different external and internal factors which influence this cycle may help a smoother and safer transition.

External factors

There are different external factors at play in behaviour change. It could be the intervention itself. Many people working with behaviour change use ‘motivational interviewing techniques’ to try to engage individuals in an appropriate way to their mindset. People can disengage quickly if they are in pre-contemplation and are pushed into action.

Services based in locations where the individual was not expecting to receive an intervention are much more likely to have a client population in pre-contemplation. In domestic abuse services, these could be health-based workers who pick up on a problem following a consultation, or in pre-diabetes, a general health check may have unexpectedly found elevated blood sugar levels. Some services are approached by people already in ‘contemplation’ or ‘action’. Having an understanding which ‘stage’ an intervention or service may predominantly receive, can help provide appropriate responses and support.

Interestingly, it is sometimes when people exit the model that risk often increases. In domestic abuse, there is a much higher chance of homicide at this point. It is also when trauma and mental health support can become increasingly prominent. In people experiencing alcohol problems, a sudden change in consumption at ‘action’ can lead to death, and with drug addiction, the risk of overdose can increase at ‘maintenance’ if there is a lapse.

Person-centred support, rather than an authoritarian approach with consequences and pressures, will almost always reap better results. Sometimes policy can influence the model. A shift from ‘harm reduction policy’ towards ‘abstinence’ could increase the risk of relapse for people with drug and alcohol addictions. Inappropriate interventions, unsupportive systems or lack of joined-up and cohesive support could be holding someone back from making the changes that they want to make.

Internal factors

Internal factors often play a part in ‘the cycle of change’ process. Sometimes people can believe they have an ‘all or nothing’ personality which is more likely to lead to relapse. In diabetes prevention work encouraging (all or nothing) patients to make some realistic and sustainable changes could obtain more achievable lasting results.

If people have addictions the chances of relapse are likely to be increased. Relapse prevention is often incorporated into drug and alcohol work. If trauma and attachment issues come into the picture, then an appropriate trauma-informed intervention would be an essential part of the work.

Bridging the gap between service intervention, systems and policy

I’ve had the privilege of working in some fantastic services, which have used multi-agency working, flexible and appropriately timed interventions as part of their support plan. The changes people can make in supportive and realistic environments are sometimes astounding. And if people don’t want to make any changes at that particular time, then obtaining knowledge of what is available if they do change their minds, can play an important part in the intervention. In a ‘tick box culture,’ it can be easy to miss or dismiss what is not overtly visible.

A move towards a person-centred approach, which is realistic, congruent with supportive policy and service interventions, and acknowledges both the internal and external factors involved in an individual’s journey through this process is vital. Understanding the external factors which may be rooted in systems and policy beyond an individual’s control, can move away from a culture of blame and guilt to more productive interventions. This is particularly relevant for those experiencing additional challenges, vulnerabilities and complex situations.

Competing interests: No competing interests

26 September 2019
Sarah Blake
PhD student at Bristol University. Researching impact of Electronic Patient Health Records on potentially vulnerable patients.
Knowle