How to reach a shared management plan with a patient whom you want to change their

behaviour

Maggie Eisner, October 2012

Think of a patient whom you tried to help to change

What did you try? What worked? What didn’t work? Any ideas about why it worked/didn’t

work?

Change isn’t a simple discrete event, it’s a process

Sometimes a crisis can precipitate a sudden change

Change usually involves loss as well as the perceived gain

Stages of Change – precontemplation, contemplation, change

Traditional advice-giving isn’t useless but absolutely depends on timing

Need to understand the behaviour’s meaning for the patient - how do they see the benefits and problems of the change?

Help patient prepare for change Encourage to experiment with small

steps Provide information when the patient is

receptive Accept that people have relapses (and

help patient accept this too)

A video from the USA

We need to enable the patient to Believe that change is important Have confidence in their ability to change

Dancing vs wrestling Start positive

The dinner plate, to choose which behaviour to change first

Scaling questions (1-10 scale) How important is this change to you? How confident are you that you can change?

Find out – suggest – find out more (Elicit – Provide – Elicit) What do they know/want to know? What do they see as their options? What might their family and friends think? What do they think?

Help them set realistic goals/targets which they think will work – concentrate on the next small step

Patients Helplessness

Agree it’s hard, empathise

Help them recall past successes

Resistance Summarise what

they’ve said (instead of getting into an argument)

Clinicians Lecturing

Go back to asking questions about the patient’s point of view

Cheerleading Bring the focus back

to the patient

Can you think of how you might have been more effective?

Help patient believe change is important Help them get confidence they can change Start positive Dinner plate Scaling questions Find out – suggest – find out more Help patient set realistic target – what’s the

next small step? If pt helpless, empathise, remind of past

success If pt resistant, summarise what they’ve said Stop lecturing and get back to pt’s point of

view Stop cheerleading, get back to pt’s point of

view

Scenarios for groups of 3 (doctor, patient, observer) – preferably Mixed ST years People you don’t know well

Patient – study scenario and get deeply into role Observer – note specific things the doctor did well or

could have done better Feedback – doctor first (How did you think you did? What

did you do well? What do you think you would have liked to do better?), then patient, then observer

Feedback should help the doctor – either affirm what they did well, or specific ideas about what they could do differently (Without specific suggestions, you were really good is as unhelpful as you were rubbish)

Have you ever wanted to change your behaviour?

What helped/hindered you?