Supporting patient values in behavior change

Photo Cred: Polina Zimmerman/Pexels

By Integrative Practitioner Staff

The first health and behavior coaching visit can be overwhelming for both the provider and the patient. The patient may or may not be fully aware of their current health status or have recently received a confusing or serious diagnosis. Once the patient has had all their questions answered and feels ready to proceed, the initial step is to conduct an inventory to establish the patient’s baseline level of awareness and identify in which areas they could improve their health.

Most researchers in the field include the following categories in their models of integrative health and wellbeing:

• Physical
• Emotional
• Spiritual
• Social
• Recreational
• Intellectual
• Financial
• Environmental

The purpose of this health inventory is for the patient to reflect on where they are now and where they would like to be. It is important to open a non-judgmental dialogue with the patient and engage them in a candid conversation.

Throughout this conversation, the provider will evaluate the patient’s readiness for change using open-ended questions to understand the patient’s health experiences, including challenges and how they perceive their current state of health. At this point, the conversation is less about treatment and more about obtaining an awareness of their health risks, experience with a current illness or any symptoms they’re experiencing. The patient is welcome and encouraged to express their emotions openly.

Motivational Interviewing

• Motivational interviewing is a method of communication designed to encourage individuals towards a direction of change. The spirit of motivational interviewing can be described through qualities such as:
• Establishing collaboration with patients as opposed to establishing an expert role
• Focusing on eliciting patients’ own motivations for change versus educating them about why they should change
• Honoring patients’ autonomy to decide to change, as opposed to assuming the authority to tell them how to change.

According to William Miller, PhD and Gary Rose, PhD, authors of Motivational Interviewing: Preparing People to Change Addictive Behavior, there are five main principles of motivational interviewing:

• Express and show empathy towards patients
• Support and develop discrepancy between where the patient is health wise and where they want to be
• Avoid argumentation while rolling with resistance
• Support self-efficacy
• Develop autonomy
• Transtheoretical Model

The Transtheoretical Model was developed by researchers in the 1970s and uses stages to facilitate behavior change. These stages include:

1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
6. Termination

This model posits that individuals move through the six stages of change. Termination was not part of the original model and is less often used in application of stages of change for health-related behaviors. For each stage of change, different intervention strategies are most effective at moving the person to the next stage of change and subsequently through the model to maintenance, the ideal stage of behavior.

In precontemplation, patients do not intend to take action in the foreseeable future. They are often unaware that their behavior is problematic or produces negative consequences, and often underestimate the pros of changing behavior and place too much emphasis on the cons of changing behavior.

For the contemplation stage, patients are intending to start the healthy behavior in the foreseeable future, or within the next six months. People recognize that their behavior may be problematic, and a more thoughtful and practical consideration of the pros and cons of changing the behavior takes place, with equal emphasis placed on both. Even with this recognition, people may still feel ambivalent toward changing their behavior.

During preparation, sometimes called determination, patients are ready to take action within the next 30 days. They start to take small steps toward the behavior change, and they believe changing their behavior can lead to a healthier life. This step is followed by action, when the patient has recently changed a behavior and intends to keep moving forward. From there, the maintenance stage, where the patient has sustained their behavior change for more than six months and intends to maintain the behavior change going forward. People in this stage work to prevent relapse to earlier stages.

Use motivational interviewing techniques from the transtheoretical model. Allow time for the patient to express their concerns. Ideally, the provider uses a 2:1 ratio of reflection and feedback, so the patient feels heard and acknowledged. Permit the patient to discern what they’d like to change about their current health status based on what they see as the most important given their vision and values.

Some questions to support autonomy include:

1. What would being in charge look like?
2. How can you decide not hand control over to someone else?
3. What would it be like to have peace with the past, show appreciation for its lessons?
4. What would it look like to forgive yourself for the past while taking charge of the present and future?

Values

During initial conversations, providers can encourage the patient to identify their values. Values are a general expression of what is most important for an individual. Values are formed starting in early childhood and are later consciously reevaluated and may change. Understanding personal values allows the patient to get clarity and build self-awareness to make intelligent decisions and keep balance in life.

There are hundreds of core values and several resources offer predetermined lists. However, avoid using such templates with patients, as values should not be selected, but rather discovered and revealed. That said, if a patient is not familiar with values, it may be helpful to offer some examples, such as family, friendship, health, love, or success.

To help patients uncover their own values, a provider may ask guiding questions:

• What is more important in your life: beyond basic human needs, what must you have in your life to experience fulfillment?
• Consider a meaningful moment: what was happening to you and what values were you honoring?
• Consider a time when you were angry or upset: what were you feeling and, if you flip those feelings around, what value is being suppressed?

Providers work with the patient to brainstorm a master list of personal values. Group values under related themes and select a word that best represents each group of values. Next, help the patient refine the list by determining:

• What values are essential to their life?
• What values represent their primary way of being?
• What values support their inner self?

Work with the patient to select between five and 10 core values and rank them in order of importance. This may occur over a couple of visits if the patient needs more time. For some patients, it may also be beneficial to identify negative values, or those items that are unimportant to them. Once values have been selected and ranked, have the patient craft a value statement for each. A value statement can be positioned as an affirmation. For example, a value statement for health might be, “to thrive with energy and vitality every day,” whereas a value statement for family might be, “to prioritize quality time with loved ones.”

Note, as the patient grows and becomes more self-aware, their values may change. The provider can use this information to tailor action steps and help the patient make decisions based on their core values.

Editor’s note: This article features an excerpt from A Six-Step Approach to Health and Wellness Coaching: A Toolkit for Practice Implementation.