CHAPTER 1. Introduction
Mrs. Burns has had heart problems in the past and gets very anxious when she gets breathless. Her doctor knows that her breathlessness now is mainly due to her inactivity. She rarely moves further than a trip to the kitchen to make a cup of tea (and she doesn’t even do that if someone is there to do it for her). She sleeps and has a bathroom on the ground floor, so rarely climbs stairs. All of her caregivers have explained the value of gentle exercise to strengthen her heart and lungs, but she will not accept any suggestions to go for short walks around the park or shops, or to join a seniors’ movement class. What her doctor sees as a behavioral problem, she sees as a medical problem that is out of her control.
Have you ever been delighted by a patient like Carlos Lopez?
Carlos developed back problems after an accident at work 5 years ago. Thorough investigations concluded that the best solution for him was exercise and pain management. Carlos was determined not to let his bad back rule his life, took all the advice given to him, built regular exercise into his daily routine and worked on cognitive strategies to manage his own response to the pain. He negotiated some changes in his job with his employers and is now back at work on a full-time basis, enjoying a full social and family life.
Have you ever felt discouraged trying to support someone like Sharon Barker?
Sharon wants to give up smoking. She is now on her fourth quit attempt. Her asthma nurse has offered all the support she can – referral to a support group, pharmaceuticals, nicotine replacement – but Sharon never lasts more than a few weeks before starting to sneak the odd one or two cigarettes, building to a complete relapse. She keeps trying and seems motivated, but nothing seems to work for her.
This book was written to make a difference in consultations with patients like these, based on our understanding of what works best. In recent decades, health practitioners have become more aware of how much patients can do to improve their own health, manage conditions such as asthma and diabetes, and reduce the risk of compromising their health in the future. Increasingly, conversations in consulting rooms have focused less on what can be done to or for the patient, and more on what patients can do for themselves.
Among the most frequently encountered changes in behavior which practitioners focus on are:
• eat less, eat different things, adjust timing of meals
• drink less alcohol, abstain altogether
• be more physically active, do particular exercises
• smoke fewer cigarettes, abstain altogether
• take a new medication, a different one, replace one with another, at a different time
• monitor levels of glucose in the blood, ingest more/less liquid
• reduce intake of a substance, abstain altogether.
Consultations about these changes occur in a wide range of patients who are, or who are thought to be:
• at risk of suffering from heart disease
• recovering from a heart attack
• diabetic
• overweight or obese
• pregnant
• at risk of contracting sexually transmitted diseases
• chronic pain sufferers
• problem drinkers
• substance misusers
• asthmatic.
The practitioners involved are usually:
• doctors
• nurses
• nutritionists
• dietitians
• physiotherapists
• health visitors
• health promotion practitioners
• psychologists and psychiatrists
• counselors
• pharmacists
• fitness instructors
• dentists and dental hygienists.
The settings in which patients are seen are thus widespread and may include:
Behavior change: the heart of the matter
Behavior change is something that only the patient can engage in, yet with every utterance, the practitioner has the power to make things better or worse, and influence the outcome. This book is designed to help practitioners to promote better and more satisfying outcomes.
The logic with which the patient can be viewed as responsible for the outcome of a behavior change consultation has a formidable ring to it; after all, it is not the practitioners who need to change their behavior, is it? One can quite easily rationalize the process thus: What you [the patient] put in is what you get out. This can take an aggressive form: I can’t help these people if they don’t want to help themselves…; or it can reflect a genuine desire not to impose one’s values and will on the patient.
I’ll help them if they want help, but if they don’t, that’s fine. … I respect the person more than I respect my right to tell them what to do (Primary care physician, aged 41).
Whatever our approach to behavior change, two things are fairly certain: the discussion about change with patients never goes away, and the outcome of the consultation is affected by our consulting behavior. There is a lot that can be done to make matters worse, or better. Behavior change, or the lack of it, is not just the patient’s problem.
Practitioner makes matters worse
Practitioner: Have you thought about losing some weight?
Patient: Yes, many times, but I can’t seem to manage. It’s my one comfort, my eggs in the morning, my fried chicken at lunch. I’m stuck in the house so much these days.
Practitioner: It would certainly help your blood pressure.
Patient: I know, but what do I do when I really want my eggs for breakfast? It’s a tradition in our family. [Sighs] I always get told to lose weight when I come to this clinic.
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