Talking with your patients about health behavior change

By Julie Luzarraga

Health behavior change is one of the most accessible and simple interventions at a provider’s fingertips. Research shows that following a healthy lifestyle is associated with a 66 percent reduction in mortality. Habits such as smoking, excessive eating, and high stress all have significant impact on physical and mental health.

Something as simple as eating less or reducing stress can have a positive influence on physical, mental, and emotional health. However, these seemingly simple behavior changes can feel insurmountable, both for the patient and for the provider initiating the conversation.

Negative health behaviors often stem from an emotional and neurochemical cycle of trigger, behavior, and reward. The first step is understanding this cycle as it applies to the individual patient. The unhealthy habits we want our patients to change typically create a feeling of happiness, provide distraction from something uncomfortable, and have deep meaning rooted in how someone has learned to manage discomfort. There are two components to most unhealthy behaviors, the story or meaning behind the behavior and the physical experience the behavior creates.

Take for example my patient Sarah who has recently decided she was ready to reduce her sugar intake. She has known for some time this would help with both necessary weight loss and chronic pain, but has been unsuccessful in making significant changes.

Working together, we identified that when she feels overwhelmed, she soothes herself with something sweet. Growing up, her grandmother was one of the few nurturing adults in her life, and would often bake with Sarah. This became a treat or reward that meant something beyond the sugar. In addition to the psychological meaning of Sarah’s reward cycle, eating a cookie when she was stressed created dopamine. In her cycle, Sarah’s trigger is feeling overwhelmed, the behavior is eating something sweet, and the reward is that real physical feeling of contentment.

Like anything that makes us feel good, we begin to want more of it, despite the fact that too much may be unhealthy or even harmful. It can become stressful when we use less healthy external options to soothe or regulate our mood.

Once a provider understands this cycle of trigger, behavior, and reward in the context of psychological meaning and the neurochemical response, it is easier to start the conversation with a patient. I work with both providers and patients on how to have these conversations. Providers often struggle with addressing sensitive subjects like weight, smoking, diet, stress, and other behaviors that can evoke shame. The outcome can be that a provider comes off as too clinical, harsh, or they do not address it at all.

I’ve had many patients over the years come to an appointment with me after their annual exam feeling disappointed that their provider did not bring up their increased cholesterol or other issues related to their health behavior. They are afraid to talk with their providers but desperately want support.

Using the cycle of reward helps providers to have these conversations without shaming patients. In fact, many patients have no idea why they cannot stop doing something that is unhealthy for them. Explaining to them that there are legitimate reasons that make it hard can be incredibly empowering for the patient.

In addition to coming to the conversation from the perspective of the reward cycle, motivational interviewing skills help guide how we talk about health behavior change. Motivational interviewing is a patient-centered counseling approach used to help patients make positive behavior change by identifying the path between their current behaviors and their desired outcomes. Essential components of motivational interviewing are empathy, reflective listening, use of open-ended questions, and ongoing assessment of a patient’s readiness to change.

In health behavior change, the success of the intervention is contingent upon a person’s readiness. The stages of change model ranges from pre-contemplation, contemplation, preparation, action, and maintenance. Health behavior change can always be discussed, but the conversation shifts based on which stage of change a patient is at. When a patient is in pre-contemplation, meaning they are not able to look at the need for change or defend against the idea of change, it is best to ask open-ended questions and present facts and references. Creating safety and planting seeds is the goal in the very beginning. Any referrals or encouragement to change will not be helpful and may even feel shaming or scolding to a patient.

Once a person is in the contemplation stage, a provider can begin to learn more about the meaning behind the behavior, barriers, and a patient’s anticipated timeline for starting to change. At this point some patients will be able to take recommendations and move forward on their own. Maybe they’ve already started a weight loss program or joined a support group. Other patients will need more support. The stages of change is a long process for many and maintenance can often be the most important stage.

Incorporating a therapist or integrative health coach can be very beneficial for patients who are ready and need more support. In my clinic, a referral to a health coach is almost always made. We have learned that even the patients who appear to be self-motivated and have lots of resources start to struggle at some point. Having an existing relationship with a health coach can prove beneficial when challenges arise. An integrative health coach can work with the patient to identify barriers, develop strategies, and create positive behaviors to replace old negative ones. They are able to meet with the patient more frequently and use tools to support motivation and sustainability.

Retiring a habit can bring up a lot of emotional and physical challenges. For some, the behavior may have been related to how someone coped with trauma as a child. Others may not have the support of their family or socioeconomic barriers to resources and tools. If there is a comorbid psychiatric condition, a therapist can help support the patient during the process. In some situations, several providers form a team, creating a solid support system that can help the patient as they work through the stages of change.

Health behavior change while simple is not easy. It requires dedication and commitment from both the provider and the patient. In my clinic, we have seen amazing results. We have had people decrease and discontinue medications, lose weight, get pregnant, and improve their overall quality of life. Change requires support and time, but having the conversation, holding the space, and providing the ongoing support for health behavior change is one of the most valuable interventions an integrative practitioner can offer.

References

Loef, M. and Walach, H. (2012) The combined effects of healthy lifestyle behaviors on all cause mortality: a systematic review and meta-analysis. Preventative Medicine. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/22735042