A Guide to Change: Modifying Unhealthy Behaviors in Patients
AUTHOR
Ellen Feldman, MD, Altru Health System, Grand Forks, ND
PEER REVIEWER
Sary Beidas, MD, MBI, FACP, Associate Professor of Medicine, Florida State University, Sarasota, FL
EXECUTIVE SUMMARY
Motivational interviewing (MI) is an evidence-based, empathic approach to the patient interview incorporating techniques that encourage patients to self-reflect and voice reasons for change, while recognizing underlying ambivalence.
- Nearly 40% of visits to primary care providers are for treatment of a chronic condition, which often includes recommendations for lifestyle modification. About 20% of visits require an element of behavioral counseling, especially in young to middle-aged adults and children.
- The transtheoretical model of change presents six stages: precontemplation, contemplation, preparation, action, maintenance, and termination/relapse.
- Perhaps the simplest method to gauge a patient’s position regarding readiness to change quickly and efficiently is using a “readiness ruler” or, alternatively, simply asking the patient to consider a scale of 1-10.
- There is moderate quality evidence supporting the use of MI in reducing binge drinking, reducing the frequency of alcohol use, reducing the overall quantity of alcohol use, addressing substance use in individuals with dependency, stopping smoking, and increasing physical activity. However, there is moderate quality evidence of no effect of MI for changing unsafe or risky sexual behaviors.
- A useful framework for counseling patients involves the Five A’s: ask/assess, advise, agree, assist, and arrange.
It is 10 degrees below zero in Churchill, Manitoba, Canada. Howling winds outside the lodge and a bleak landscape of snow and ice stretching for miles make me rethink my decision to embark on this journey — was I even going to see polar bears through frozen eyelids? Was my outerwear adequate for a hike in these conditions? The cushiony sofas and relative comfort of the lodge was looking more appealing by the minute. “Maybe I could just stay here,” I think, “and wait for better conditions later in the week.”
Our guide, striding confidently into the room, addresses my ambivalence almost immediately. “Let me introduce myself,” she says, “but, more importantly, tell me about you: Why you are on this trip, and your top hope for the journey as well as your main concern.” She continued, “I have the knowledge to lead you safely, but make no mistake, your ideas and needs set the path.”
Facing the unknown can be tough. As providers, our close relationship with the terms and processes involved in the practice of medicine may interfere with our ability to understand that, in many cases, we are asking patients to venture along an unknown path. While we may feel best suited to lead the journey, in most clinical encounters our job is to guide our patients; we are not the decision-makers. This mindset or way of thinking becomes particularly important when addressing lifestyle changes with patients.
Diseases related to unhealthy lifestyles, such as drinking, smoking, taking drugs, overeating, not exercising, and medication non-compliance, factor into at least 40% of the deaths of Americans every year and represent a growing global public health concern.1
Although on the surface it appears that motivating patients to change these habits is a relatively clear-cut solution, most primary care clinicians are acutely aware that addressing unhealthy behaviors is not as simple as prescribing a pill; there are no known “magic bullets” or easy remedies to enhance behavioral change. However, there are some techniques and strategies that have been proven to work in office settings to help patients become motivated about change and make progress toward a healthier state.
This paper presents approaches recommended for use in a primary care office when the clinical interview indicates a need for behavioral change. A framework or model can be used to understand the process of change. Keeping this model in mind helps providers determine where their patients are in terms of readiness to change. This understanding then can guide the provider toward a specified interview technique or style, several of which are reviewed in depth here. Notably, providers adopting these approaches often report an improvement in work satisfaction and reduction in symptoms of burnout while patients often experience improved outcomes.2,3
Clinical examples included within the text are used for illustrative purposes.
Behavioral Change in Primary Care
Why is it useful for primary care providers to think about and understand behavioral change? Consideration of some statistics presents compelling reasons. Almost 40% of visits to primary care providers are for treatment of a chronic condition, and most often addressing these conditions includes recommendations for lifestyle modification.4 Additionally, almost 20% of all visits to primary care require an element of behavioral counseling, and this number is even higher when looking at children and young to middle-aged adults.4 Looking from a different perspective, the top causes of morbidity and mortality in the United States include cancer, heart disease, stroke, chronic lower respiratory disease, and diabetes, all of which have potentially modifiable behavioral risk factors or predecessors.4-6
In fact, the American College of Cardiology and the American Heart Association note that the most important factor for prevention of heart disease is lifelong healthy lifestyle.7 The American Cancer Society notes that maintaining a healthy lifestyle (focused on body weight, activity level, and diet) is second only to smoking cessation as the most important prevention intervention.8 Along these same lines, the American Diabetes Association promotes intensive lifestyle intervention to reduce the risk of type 2 diabetes.9
However, counseling patients to change behavior is different fundamentally from motivating patients to change behavior. Medical training and practice have struggled with this basic discrepancy for years. Studies in the 1980s focused on counseling patients regarding tobacco use, while investigations regarding counseling patients to increase their physical activity gained momentum shortly thereafter, in the 1990s. Some of these earlier studies seem to equate counseling with simply giving advice, and there are few detailed descriptions of a recommended overall approach to help patients make changes.10,11
There has been a shift in the focus of the literature over the last 10 to 20 years as the concept of “lifestyle medicine” has developed. Lifestyle medicine refers to a growing body of evidence that the prevention, treatment, and, in some cases, reversal of noncommunicable chronic disease can be managed by a comprehensive and intensive change in lifestyle factors, such as nutrition, exercise, management of stress, and sleep. Examples of such diseases include coronary heart disease, type 2 diabetes, obesity, and hypertension. The importance of effectively and efficiently communicating with patients in a manner that maximizes the likelihood of patient motivation and action increasingly is recognized, studied, and taught to providers at all stages of training and practice.12-14
To understand approaches most likely to motivate patients to make behavioral change, it first is useful to explore and develop an understanding of the concept of change as it applies to human behavior.
Stages of Change: A Model
“Our dilemma is that we hate change and love it at the same time; what we really want is for things to remain the same but get better.” — Sydney J. Harris
This quote from journalist Sydney J. Harris highlights the conflict that many individuals feel about change in general. In medicine, inherent ambivalence often interferes with efforts to improve health behaviors that are problematic.
Readiness to change is best viewed as a moving target. That is, an individual may feel varying degrees of motivation to change or modify a behavior depending on circumstances. However, to engage in dialogue with a patient about change it is essential to gauge where the patient is on this spectrum.
Although there are multiple models proposed to understand the process of change, the transtheoretical model of change (TTM; also known as stages of change) most often is used in medicine for this purpose. This model, developed in the 1970s based on studies of smokers’ experiences in stopping tobacco use, postulates that changing habitual behavior generally occurs along a continuum, with an individual passing through various stages of readiness to change in a non-linear fashion. Understanding and accepting that there is ambivalence to change is a core principle considered to be one of the backbones of TTM. The model presents six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination/relapse. See Figure 1 for more details about each stage.15,16
Figure 1. Stages of Change |
 |
An individual eventually may reach a sixth stage, “termination,” when motivation to resume problematic behavior is extinguished. Often, however, relapse to a different stage occurs during the maintenance stage; this generally is viewed as a natural part of the progress toward change. Likewise, shifts between any of the levels, in no particular order, occur during this process. Notably, a patient can use the change in level of readiness or relapse as an opportunity to self-examine motivating factors and triggers.15,16
Consider the following:
Alana is a 45-year-old professional, a mother of two who presents for a recheck of hypertension. She is on her fifth month of lisinopril 20 mg daily. Her blood pressure in the office today is 139/85 mmHg, pulse 78 bpm, and her weight has increased to 194 pounds from 189 pounds six months ago. At her last appointment, her provider had informed her about the importance of exercise and weight control in blood pressure treatment. Today Alana states, “I cannot believe I gained five pounds. I really need to watch what I eat and get back to the gym!”
In thinking about conversations regarding changing behavior, it is helpful for the provider to have a mechanism to gauge the patient’s position regarding readiness to change quickly and efficiently. In many cases, while still thinking about behavioral change, it is important to proceed with an appropriate workup to rule out any nonbehavioral or organic etiologies for the identified problem (such as weight gain in this clinical example).17
When focusing on changing behavior, perhaps the simplest method to assess the patient’s stance regarding change is to use a “readiness ruler” or, alternatively, simply to ask the patient to consider a scale of 1-10 (with 10 being most ready) and respond to the question “How ready are you to make a change?” The readiness ruler is a visual form of this question, often color-coded and divided into three graded sections representing “not wanting to change,” “unsure about change,” and “ready to change.” Although these simplified tests may not capture the nuances of the patient’s thinking, they do provide a ballpark estimate with clinical utility.18,19
A second useful question is “How confident are you that you can make a change?” Again, a visual prop, such as a “confidence ruler,” can be shown to illustrate the question.18,19
Thinking about the stages of change, the provider says to Alana, “Let’s look at this a little differently today. I hear you identifying that there are changes you would like to make with your eating and exercise. On a scale of 1-10, with 10 being most ready, where would you rank yourself in terms of wanting to make the change? And where would you rank yourself in terms of how confident you are that you can make these changes?” Alana replies, “Seven for wanting to move on this, and about three for confidence that I can.” Alana’s reply shows that she really wants to look at changing her eating patterns and exercise but is not sure she can follow through. “What makes you rank your confidence at a three rather than one or two?” her provider asks.
In this case, the provider quickly has identified that Alana is hovering in a gray area between contemplation and preparation: wanting to make a change, but not sure how to do so. This is a perfect area for motivational interviewing (MI), which the provider adeptly moves into by asking Alana to give voice to her thoughts about changing her situation. The idea of eliciting Alana’s own thoughts about even a slim chance of succeeding in her efforts reflects “change talk,” a central concept involved with MI.20
What Do Studies Say About Motivational Interviewing?
MI, developed and pioneered by psychologists William Miller and Stephen Rollnick in the 1980s, has its roots as an approach toward talking with individuals about substance use. At the time, this collaborative approach represented a monumental change from accepted techniques in use, such as shame and confrontation. A core concept of MI is that change is more likely when a person decides for themselves to change. The principles of this technique demonstrate respect and a desire to understand the patient’s ideas about behavioral change. The approach encourages a back and forth discussion that is goal-directed and geared toward motivating by encouraging the patient to voice their own arguments for change. During a clinical interview conducted via MI, the patient is encouraged to examine values, principles, fears, and hopes.21,22
MI in medicine has broadened in scope and evolved in nature from its earlier beginnings, with proponents recommending MI for a wide range of behavioral interventions associated with treatment of chronic diseases. For example, MI has been recommended not only for substance misuse but also a range of conditions, including gambling disorders, eating disorders, diabetes management, lifestyle changes in people with cardiovascular disorders, management of irritable bowel disease, and management of musculoskeletal problems.23 Unfortunately, there are few methodologically sound trials supporting widespread use of this approach. One major barrier to performing such studies is that MI training is not standardized, making it difficult to evaluate the effectiveness of this intervention in different hands.20,23,24
Recognizing these problems and looking for evidence supporting recommendations for the use of MI in specific disease states, in 2018 Frost et al conducted a comprehensive systematic review of studies involving the use of MI in medicine. Out of 5,222 studies identified, only 104 were of high enough quality to meet inclusion criteria. For purposes of the review, the studies were categorized into four domains as described in Table 1. Among these studies, most evidence was graded very low to low in quality, using a standardized quality of evidence scale ranging from “very low” quality of evidence to “low” to “moderate” to “high.” However, there was moderate quality evidence supporting the use of MI in reducing binge drinking, reducing the frequency of alcohol use, reducing the overall quantity of alcohol use, addressing substance use in individuals with dependency, stopping smoking, and increasing physical activity. On the flip side, there was moderate quality evidence of no effect of MI for changing unsafe or risky sexual behaviors.23
Table 1. Summary of the Results from a Systematic Review of Motivational Interviewing in Medical Settings |
||
Specific Outcomes |
Number of Studies/Participants |
|
Alcohol abuse |
Reducing consumption |
9/2,767 |
Binge drinking |
11/1,340 |
|
Frequency of consumption (short- and long-term) |
31/6,318 |
|
Peak blood alcohol concentration |
14/2,805 |
|
Quantity of alcohol |
50/9,353 |
|
Smoking |
Abstinence |
28/16,803 |
Substance abuse |
Decreasing use |
15/2,327 |
Increasing physical activity |
Any chronic health condition |
8/921 |
One notable problem in the field is the paucity of long-term studies regarding the effect of MI. A 2020 Danish study by Morten et al reported results of an eight-year randomized clinical trial of individuals diagnosed with diabetes or at high risk for diabetes who received either treatment as usual (control group) or one of two intensive treatments, one of which included MI with physicians trained in this approach. At the end of the eight-year period, the risk of cardiovascular disease (CVD) was the same in the two intensive treatment groups and the risk of all-cause mortality was the same in all three of the groups. There was no evidence that MI was effective in reducing either of these risks.25
However, there was an additional finding from this study when looking at a subgroup of people with high risk factors for diabetes who were screened into the study but were normoglycemic upon admission. Although the intensive treatment arm of this subgroup showed a risk reduction for CVD when compared to the control group (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.86-1.03), the group randomized to receive intensive treatment and MI showed a more significant reduction in risk with an HR of 0.81 (95% CI, 0.69-0.94.) Morten et al concluded that there may be an opportune time early in the development of diabetes to apply MI techniques and that more studies should focus on timing as well as other factors.25
Considering outcome studies from a different point of view, a 2018 Canadian study by Keeley et al looked at training primary care clinicians in MI and the effect on disease outcomes. Findings included that providers trained in MI (a 20-hour training program of MI in year one and subsequent yearly four- to eight-hour trainings) who combined MI with standard care for depression reported statistically significant improved outcomes in depressed patients in primary care settings when compared to those providers providing only standard care.24
Conclusions from these researchers and others in the field emphasize the need for robust studies with high-quality methodology to help identify the population and disease states and stages most likely to benefit from MI. Additionally, identifying which providers benefit most from training and why, and isolating the most effective elements of MI are important research goals. It is helpful for providers considering using MI to note that none of the studies have identified potential or actual harm from this intervention.23-25
Despite the limitations of research involving MI and the many unanswered questions in the field, it is clear there are some areas in clinical practice where MI can be beneficial. According to Dr. Rollnick (one of the founders of MI), aspects of MI can be integrated into the clinical interview to “form a stronger relationship, address a tough topic, manage an angry/upset patient, or encourage the patient to make changes.” Gaining an understanding of the concepts behind MI and how to apply these efficiently in practice is a reasonable first step.26
What Is Motivational Interviewing?
MI can be understood best as an approach toward a patient interview, rather than an overall technique. The foundation of MI rests upon understanding that our role as a provider when discussing behavioral change is not directive — we are not able to “order” change. In fact, the responsibility for change and to summon the motivation for change lies within the patient.26,27
This concept does not delegate the provider to the sidelines. Rather, we take the role of a trusted partner or guide, developing empathy and assuring patient autonomy in decision-making while encouraging the patient to voice internal motivations and desire for change.
The OARS model developed by the founders of MI and outlined in the following paragraphs, gives some practical suggestions to assist with this process.25,26
O: Open-ended questions. These are questions that are not able to be answered with a single yes/no response. Try to avoid “why” questions, since these can promote defensiveness. For example, a provider may ask “What bothers you most about your situation?” rather than “Why does this bother you?” since the latter format may be taken as criticism. Keep in mind that the goal is not to find a solution for the patient, but to develop empathy and understanding so the patient feels comfortable discussing the health dilemma and contemplating potential solutions.27,28
A: Affirmations. Find the true internal strengths of the patient and acknowledge them. This differs fundamentally from praise and relies on the interviewer noting positive characteristics elicited by the interview. For example: “Coming here today must have been difficult after you had such a bad experience at your appointment two years ago.”27,28
R: Reflective listening. Listen carefully and voice back to the patient the concept, idea, or theme the patient is attempting to convey.27,28
S: Summarizing. Summarizing statements can be used midway and toward the conclusion of the interview and may take the form of, for example, “Here is what I am hearing so far … tell me if I am leaving out an important point or missed something you wanted me to understand.”27,28
Back to Alana:
“Why did I choose three and not one or two for my confidence level to exercise and lose weight?” Alana says. “I lost weight after our first child was born and I was in a lot better shape then. I used to love going to the gym with my friend. We did yoga and strength classes several times a week until I got pregnant again. I know what works for me, but it’s harder to get to the gym with two kids.” “OK,” says the provider, “you know you did this before and that gives you some confidence that you could do this again, but it sounds like your situation has changed — so even with the motivation to exercise you are not sure your old model could work? Is that what you are saying?”
In this spirit, and with this approach of MI in place, several processes help move along the conversation about change. These processes often occur in a back-and-forth manner, not in a linear fashion. All along, the provider is listening for “change talk,” where the patient is voicing arguments for positive change.26-28 These processes are:
- Engaging: Continue to interact with the patient in a respectful and collaborative manner. Develop an understanding of the patient as a person, not as a number or disease state. This connection becomes the foundation of the relationship.
- Focus: Agree on a focus for the appointment and help with refocus if necessary.
- Evoking: Evoke change talk from the patient by asking about motivations and both sides of the ambivalence.
- Planning: Discuss concrete, measurable, and obtainable steps.26-28
Returning to Alana:
“Exactly — it is too hard to get to the gym with both kids,” Alana says. “They closed the childcare area during COVID, and never opened it as far as I know. You have a good point, though; I could look at a different model. I know I respond well to classes, and there are so many exercise classes online now. How much weight do you think I need to lose to make a difference in my blood pressure? I really don’t want to increase my lisinopril dose again! Or do you think working out alone would help?” Sensing that Alana is close to a commitment to change, the provider helps her refocus and suggests some measurable steps, saying, “It really is different for everyone. How do you feel about starting to monitor your blood pressure at home? That way, if you decide to start online classes, you can see if and when there is a difference in your blood pressure.”
In this example, the provider maintained the mindset that Alana is in charge of deciding to make changes in her lifestyle. Open-ended questions, reflecting, and summarizing helped engage Alana to feel understood. The provider noticed change talk and refocused on the acute problem (blood pressure control), allowing a step toward the development of a concrete plan.
Factors Influencing the Use of Motivational Interviewing
Consider Murti:
Murti is a 53-year-old married father of three, a business owner with chronic back pain. He is a newer patient, having transferred care from a departing provider about four months ago. At that time, he expressed enthusiastic ongoing commitment to his plan to increase exercise and cut back on medication for pain. Today, he presents more than 10 minutes late in a day when your clinic is packed with back-to-back appointments. “Sorry about being late,” he says when you enter the examination room. “My car is in the shop, I’m in the midst of a chaotic divorce, and I’m struggling to keep my business afloat. I had to take the bus, and they just cut the schedule. All I need is a refill and then I can be on my way.”
A recent Norwegian study looking at primary care providers trained in MI revealed that the first barrier to use of this approach is time limits. This may involve the pressures of a full waiting room and/or the need to focus on other aspects of the encounter, such as the physical exam or documentation of the required healthcare measures. On the other hand, some of the respondents in the study noted that an approach derived from the principles of MI often resulted in more efficient and less laborious appointments.29
This study and others point to the need to understand obstacles to applying MI in a busy clinical practice.29,30 However, even without confirmatory studies, it may be obvious that there are practical benefits of gaining a fuller understanding of your patient before embarking on any particular direction or approach.
Back to Murti:
The provider remembers that, four months ago, Murti had come into the practice in the midst of tapering off pain medications and starting an exercise program. Suspecting that motivation for this change may have shifted with the recent downturn in his life, the provider consciously decides to focus on engagement and says, “Good for you coming at all today with all of this going on. I appreciate the effort you made to get here.” Looking at Murti, the provider notes some tears starting to appear and registers that Murti may be feeling understood.
Reestablishing a connection may be the most important aspect of this encounter. From there, the provider has many options for direction; without a connection, this encounter has the potential to be unsatisfying for both the patient and the provider.
The provider says, “I hear you say you want to make sure to get the medication refill today. With everything going on, how has keeping up with exercise and cutting back on the pills been going?” “I was afraid you would ask that,” replies Murti. “I guess I stopped caring about all of that when I found out my wife was cheating on me. I haven’t increased medication, though, just stopped cutting back. I still need them and still hate how they make it hard to think.” “Any thoughts about getting back to exercise?” asks the provider. “Well,” says Murti, “I did feel better when I was walking every day. And my kids keep bugging me to get out more. Maybe I will start again — how about you give me a few less pills on this refill and I will use that as incentive to get back on track?”
In this example, the initial engagement and a nonjudgmental stance from the provider leads to a more open discussion, with Murti taking the lead in decision-making. Notably, the initial engagement also resulted in a time-efficient interaction.
Not all patients and not all clinical situations necessarily are appropriate for all of the techniques used in the MI approach. It is good to keep in mind that the intelligence level of patients may hinder participation in MI (if the patient has difficulty with abstract concepts or planning ahead) and cultural and socioeconomic factors likely play a role in the acceptability of the intervention.31
Some patients may need to discuss a particular social situation before addressing treatment issues. For example, patients may have few social supports, or may be living in an abusive situation or in an unsafe environment. Being sensitive to such psychosocial issues and open to understanding the effect on the patient without judgment is key to developing engagement, but change via MI may not be a reasonable goal (or may be more limited) in the face of overwhelming social stressors.28,30,31
Studies show that MI has the most association with behavioral change when an individual is ambivalent about change, but voices some degree of motivation. However, there are certainly occasions when patients will present with no desire to change an unhealthy behavior. This stance may be influenced by deep-seated cultural beliefs or other psychosocial factors. Without any motivation, MI is less likely to be helpful in eliciting change; preservation of the patient-provider relationship may be best accomplished by “agreeing to disagree.” In these cases, there are other reasonable approaches to patient care that borrow some techniques from MI but are more directive in approach and nature.31-33
The Five A’s
The Five A’s is a well-studied framework to use for counseling patients in a primary care setting. It especially is useful when a patient’s motivation to change is limited.
In 1989, the National Cancer Institute published a description of the “Four A’s” (ask, advise, assist, arrange) as guidelines to a structured approach for physicians when attempting to assist patients in stopping smoking. Over time, the Four A’s morphed into what is known now as the “Five A’s” with the addition of “agree” midway through the process. The Five A’s has been adopted as a strategy for several behavioral counseling scenarios in the healthcare sector.33-36
The U.S. Preventive Services Task Force, as well as national agencies worldwide, promote the Five A’s approach for behavioral counseling in primary care. There is evidence for use in assisting patients with smoking cessation, reducing alcohol use, and weight loss, and there is a growing body of case studies for use in other conditions.33-36
The Five A’s:
1. Ask/Assess. Although a benign concept in theory, asking about health-related behaviors can be complicated. Rarely are patients coming to primary care to discuss behavior; it is more likely the visit involves a disorder that can be at least partially addressed or prevented from advancing via behavioral change. Most patients are aware of the negative effect of behaviors, and many are sensitive to potential criticism. Borrowing from core MI concepts, the provider will get furthest by taking a nonjudgmental stance while trying to understand the patient view of the situation.34-36
Meet Chandra:
Thirty-three-year-old Chandra, a high-achieving third-year law student treated for headaches and anxiety and stable on a moderate dose of a selective serotonin reuptake inhibitor (SSRI), comes in for a recheck of her anxiety and for a refill. Chandra notes that she has had less headaches recently, but more anxiety (as noted on a screening tool) and wonders about an increase in her dose or even adding an as-needed medication. The clinician asks if she has any ideas about the increase in her anxiety — if perhaps Chandra has connected it to any events in her life. Chandra says, “Maybe — the end of school is intense, and the real world starts soon. I worry about moving and my new job and saying goodbye. I end up going out, staying up too late – sometimes most of the night — and probably drinking more than I should, and then I get anxious that I won’t get my work done. It’s a cycle.” “Do you have any worries about this cycle?” asks the clinician. “Not really,” says Chandra. “I always end up getting my work done, and I know after I graduate and start my new job, I will settle down. But until then, I think more medicine could help.”
The dilemma for the clinician is where to go with this. One option is to increase the SSRI and arrange a
follow-up, but this intervention may end up without a clear effect if the increase in anxiety symptoms is related to the factors Chandra identifies. Providing an as-needed medication may end up complicating the situation, especially if excessive alcohol and poor sleep are playing a role.
Another solution is to recommend specific techniques to try to achieve some mastery over the symptoms of anxiety, reduce drinking, and work on better sleep. However, Chandra is clear she is not necessarily looking at changing these behaviors (drinking and staying up late), despite connecting them to the increase in her anxiety. Looking back at the stages of change model, Chandra appears to be in the precontemplation stage.
Recognizing this, the provider decides first to assess the degree of alcohol use. Luckily, the office follows the recommendation of the National Institute of Alcohol and Alcoholism (NIAA) and routinely asks patients to complete a brief self-administered alcohol use screening tool (such as the Alcohol Use Disorders 10, or AUDIT-10) when a patient responds with a non-zero answer on a pre-screen question: “How many times in the past year have you had more than four drinks in one day (men) or more than three drinks in one day (woman or patients older than 65 years of age)?”37,38
Chandra scores at the top level of the “low-risk consumption” category on the screen.
2. Advise. Advising this patient may present some challenges. Chandra clearly sees a connection between some of her less healthy behaviors and the increase in anxiety, but rather than wanting to change the behaviors, she is looking to enhance the treatment of her anxiety symptoms.
An empathic, noncritical approach (as borrowed from MI) is most likely to allow the provider’s advice to be heard.34-36
When thinking about unhealthy alcohol use and discussing this with patients, it is useful for the primary care provider to keep guidelines regarding such use in mind. The NIAA defines at-risk drinking as more than 14 drinks/week or more than four drinks in any one day for men up to age 65 years. For women and individuals ages 65 years and older, these limits are reduced to seven drinks weekly or more than three drinks on any one day. Additionally, NIAA sends a clear message, “Drinking less is better for health than drinking more.”39
A standard drink is any beverage containing 0.6 fluid ounces of alcohol, including:39
- 12 fluid ounces of beer
- 8 fluid ounces to 9 fluid ounces of malt liquor
- 5 fluid ounces of table wine
- 1.5 fluid ounce shot of distilled spirits
Although Chandra’s drinking is not screening into a problematic category, she does endorse more than three drinks on occasion recently (an at-risk category) and, perhaps more significantly, she is noting an increase in anxiety, possibly associated with the drinking.
Back to Chandra:
Trying to avoid phrases such as “you should” that may promote defensiveness, the provider attempts an empathic, noncritical approach, focusing on facts and connecting behavior to unwanted outcomes. “From what you are telling me,” the provider states, “I understand you are feeling that increasing the anxiety medication will help interrupt the cycle you identified. You know yourself well. But as your doctor, I want to tell you that this most likely is not the best course, because drinking and poor sleep can throw off the response to medication at any dose. Is it OK if we look at the screen you completed, and we discuss what it might mean in terms of your health and anxiety?”
3. Agree. This next “A,” as with its predecessors, is more complicated under the surface than may be anticipated. Notably, this step was not included in the original Four A’s of the late 1980s. Since that time, there has been accumulating evidence on the importance of patient-provider collaboration regarding medical care in general.
Patient choice and autonomy particularly is important when considering behavior change in healthcare. Consider that patient values may not be readily evident to the provider, but, along with psychosocial factors, patient values affect decision-making and compliance.34-36
In the case of Chandra, this does not necessarily mean agreeing to an increase in medication or starting an as-needed agent; the provider is on firm ground advising Chandra that these interventions are not likely to bring meaningful relief from her anxiety symptoms. However, coming to a collaborative goal is more likely to save time and frustration in this appointment and reach a better outcome over time.
Chandra and the provider review the alcohol screen and guidelines from the NIAA. “OK,” says Chandra, “I am at low risk on the screen, but maybe at-risk recently with three to four drinks when I go out with my friends. And sometimes shots. But that doesn’t happen much; actually, I’m not worried about my drinking at all. I just don’t like how I feel during the day — I can’t stop thinking something is going to go wrong or I that I might forget to finish a task or assignment. Then out of the blue, I feel panicky. You think that will go away if I am drinking less?” “Those feelings sound very unsettling,” replies the provider, “and I can understand why you don’t want to feel that way. I think cutting back on drinking will help identify any contribution from the alcohol to these symptoms. Then we can go from there.” Chandra looks skeptical and replies, “I could try cutting back. Most of my friends are leaving town anyway. But how will I let you know if it works? You are not the easiest to get ahold of — first there’s the front desk, then a nurse, and the hold time is always frustrating!”
In this example, the provider and patient reach an explicit agreement that reducing anxiety symptoms is the goal. Chandra remains uncertain about the benefits of a behavioral change and seems concerned about reaching the provider should this plan not be effective.
4. Assist. This step may involve a range of interventions, including assistance from staff members, such as a nurse or health coach, referrals to outside providers, apps that help with monitoring or tracking behavior, and/or any other concrete method of helping the patient move toward a goal.
Several investigations looking at implementation of the Five A’s have shown that there is a higher likelihood of behavioral change when all steps (all five A’s) are addressed, but that providers around the world tend to falter on the application of the “assist” and “arrange” steps. Reasons for this include provider uncertainty regarding these steps, such as not knowing what materials and community resources are available to assist a patient in making behavioral changes.40
This finding highlights the importance of being connected to the region and community. Another notable finding from these studies points to organizational support as a major factor (even more critical than training) in determining if a provider applies the Five A’s method during a visit. This may range from providing staff to help with implementation to documenting support to providing brochures or other material with information about services available to reinforce desired behavioral changes.40
For providers who do not have support materials readily available or want to supplement what is available, Change That Matters: Promoting Healthy Behaviors (https://changethatmatters.umn.edu) is a 10-module curriculum intended for use in primary care. The free, downloadable materials include patient informational brochures, templates for electronic medical record documentation, and after-visit summaries, as well as examples of clinician interviews for each of the behaviors targeted, such as reducing alcohol use, addressing chronic pain, improving sleep, improving eating habits, and increasing physical activity. Many of the examples use MI and many present a structure similar to the Five A’s.41
Back to Chandra:
The provider notes that Chandra seems concerned about ongoing follow-up, acknowledges that calling to the practice can be cumbersome, and mentions several alternate options, including use of the email associated with the practice’s electronic messaging system. Chandra states, “I will keep my drinking below the three drinks in one day maximum and email you regarding any change in my daytime anxiety. That should work — unless it gets worse, and I don’t think it will.”
5. Arrange. This last step reminds the provider that behavioral changes happen over time and follow-up appointments typically are necessary to assess the relative success of the intervention. This model can be equated with models for management of a patient being treated for any number of chronic diseases. For example, a patient starting with hypertension treatment may need several follow-up appointments to determine the efficacy of the intervention and typically will need adjustment of the intervention over time.34-36
Behavioral changes take time as well. Future appointments for Chandra may involve reassessing the severity of anxiety symptoms, revisiting drinking and sleep patterns, possible referral for brief counseling to manage the anxiety symptoms, and possibly an adjustment of medication.
Sharing these options with Chandra can serve to strengthen the provider-patient bond and emphasize a collaborative spirit. This connection often results in better patient compliance and buy-in to the plan.
There are a veritable “alphabet soup” of other programs suitable to counsel patients in primary care, but studies of efficacy are limited. It is noteworthy that elements of MI are central to most all of these behavioral counseling techniques, including engaging with the patient in a collaborative, nonjudgmental manner, finding a focus or goal, working toward understanding how the patient feels about changing behavior, and moving toward a plan with actionable steps.
Some examples of other, less well-studied approaches include FRAMES (feedback, responsibility, advice, menu options, empathy, and self-efficacy) and BATHE (background, affect, troubling, handling, and empathy).42,43
There are emerging studies from the field of behavioral economics regarding the usefulness of “nudging” — a technique relying on framing information to encourage individuals to change behavior — in healthcare.44 There are no definitive studies comparing outcomes depending on the type of counseling or technique used and there remain guidelines from bodies such as the NIAA advising that primary care clinicians should provide “brief behavioral counseling interventions” for patients with whom screening demonstrates risky behaviors. Guidelines such as these seem to leave the choice of the counseling intervention to the provider.35
Take-Home Messages
- Lifestyle modification increasingly is recognized as central to the treatment of and/or prevention of many noncommunicable chronic illnesses; a strategy or direction to apply in the office to understand and enhance a patient’s motivation to change can assist with the process of lifestyle modification.
- The stages of change conceptualize how human behavior changes and reflects an inherent ambivalence; understanding where a patient falls within this cycle helps the provider target an interview.
- MI involves an empathic approach to the patient interview, incorporating techniques that encourage patients to self-reflect and voice reasons for change, while recognizing underlying ambivalence.
- There is evidence of efficacy in some clinical areas, especially when addressing substance use and physical activity. More robust studies are needed for definitive guidelines.
- The Five A’s is an example of an approach that borrows elements from MI and can be used when there is limited or no motivation to change.
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Motivational interviewing is an evidence-based, empathic approach to the patient interview incorporating techniques that encourage patients to self-reflect and voice reasons for change, while recognizing underlying ambivalence. This article presents approaches recommended for use in a primary care office when the clinical interview indicates a need for behavioral change.
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