Many of the common contemporary health problems such as diabetes, heart disease, and cancer, are related to patients’ lifestyles and specific behaviors. To treat patient’s health issues, clinicians must encourage reduction or elimination of destructive behaviors (e.g., smoking and alcohol dependence), promotion of healthier behaviors (e.g., weight control, regular exercise, stress management, safer sex), and adherence to medical regimens intended to treat acute or chronic illness (e.g., taking medications, dietary restrictions, checking blood glucose). Clinicians are hardly alone in their influence on patients’ behavior. Patients’ social networks, their personal histories, genetics and life circumstances, as well as the media and broader societal forces also shape behavior. Not everyone’s vision of the good life involves careful attention to healthy behavior. Many patients prefer a medication or procedure over behavior change to ameliorate a problem. All this can leave clinicians unclear about how much they are supposed to be pressing for behavior change and what are the limits of their influence in the brief context of the patient encounter.

Fortunately, work done in the field of behavioral medicine in the past 30 years has great practical application for clinicians and patients alike. In this chapter, we will incorporate the contributions from the most researched approaches to behavior change: the Stages of Change Model, Motivational Interviewing, Self-Efficacy, Social Influence, Willpower, Goal Setting, Mindfulness, Self-Monitoring, and Contingency Management. The objective is to use this research as the basis for a practical approach to influencing patients that respects both the complexity of human behavior and the resources and limitations of the medical encounter.

The Stages of Change Model introduced the idea that people move through a succession of five relatively distinguishable stages in making changes in behavior (in addition to Relapse if they revert to old behaviors after an initial period of success). Quickly determining the patient’s stage of change with regard to specific behaviors allows the clinician to focus where further discussion or assistance would be most valuable. Many of the other behavior change models and strategies work well when integrated into this framework. The stages are outlined in Table 19-1.

The following descriptions and examples more fully illustrate each of the stages of behavior change:

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  Precontemplation: The patient gives little thought to the problem and how best to solve it (e.g., adolescent drinks heavily, but is apparently oblivious to consequences).

  
  
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  Contemplation: The patient thinks about the problem and the potential methods, costs, and benefits involved in trying to address it, but makes only inconsistent stabs at changed behavior (e.g., dietary changes that last only a few days before relapse).

  
  
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  Preparation: The patient now commits to a specific course of action and timetable (e.g., patient decides to join Weight Watchers this month with a girlfriend from work).

  
  
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  Action: A plan is being carried out on a regular basis with relatively clear goals and strategies being pursued (e.g., walking at least 30 minutes in the morning or evening 5 days a week).

  
  
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  Maintenance: Successful changers begin to incorporate Action stage behaviors into a “new normal” way of living. Ongoing effort continues, but now feels less like a temporary alteration of familiar and normal behaviors and more incorporated into a sustainable lifestyle and identity (e.g., alcoholic with 5 years of sobriety).

  
  
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  Relapse: There is a consistent return to problem behaviors and attitudes after an initial period of successful change.

Clinicians typically associate behavior change with the action stage, yet fewer than 20% of patients report readiness to take action on a health behavior change in the next 30 days (e.g., quit smoking or start a weight loss program). Clinicians can increase patients’ readiness to take action, as well as improving the action they eventually take, by encouraging them to contemplate, choose, and then commit themselves to a specific plan, carry through and modify the plan when needed, and incorporate new behavior into healthier lifestyles or recover from relapse and get going again. Moving from contemplation to maintenance in smoking cessation, for example, has been shown to take years on average. The goal of each clinician–patient conversation is to catalyze movement through the stages, and most of the patient’s work is done outside the visit, as they think about, plan, commit, and then carry out the new behaviors with the guidance and encouragement from their clinicians. The indented examples that follow illustrate ways in which the clinician can converse with the patient in various stages, beginning with precontemplation.

People typically start out in the Precontemplation stage. They already have the problem (e.g., drinking excessively, smoking, gaining weight, elevated blood sugar), but appear unaware or unconcerned about it. Awareness often builds in response to some “bad news” (e.g., physical symptoms, clothes that do not fit, restrictions on smoking, media focus on a health issue, a routine blood pressure check, or laboratory test). Any and all of these may prompt patients to start thinking more about the problem and weighing the pros and cons of trying to address it, moving them into the Contemplation stage. The clinician prompts this movement into contemplation by asking open-ended questions that require exploration and self-reflection by the patient or family in the office and later at home.

Depending on the specific problem, there may be validated screening questions that fit in nicely here, for example, CAGE or MAST (Michigan Alcohol Screening Test) screening for alcohol, brief screening inventories for depression such as the Patient Health Questionnaire (PHQ-9) or anxiety, or the SOAPP (Screener and Opioid Assessment for Patients with Pain). Providing normative data is a potent stimulant for further contemplation and helps patients in weighing the pros and cons of change.

Contemplators often make inconsistent efforts to change, lacking the planning and determination needed to sustain them. Unfortunately, they often come to the wrong conclusion about why change has not followed (e.g., “I guess I don’t have the willpower”). Over time they may either get stuck in ambivalence and procrastination, or move forward to become increasingly committed to a specific plan, goal, and timetable. To help, the clinician can encourage contemplators to come to a conclusion from their self-reflection.

Although making a commitment is essential, the plan must be put into action to produce the desired dividends. In the Action stage, people are “doing it” on a regular basis (e.g., walking a mile five times a week, closely following a diet plan, adhering to a medication regimen). To succeed they must keep their specific plan and intentions front and center and muster sufficient resolve and willpower to overcome moment-to-moment temptations to slip back into old behaviors. Recent research about willpower has brought some objectivity into what has in the past been either overvalued or dismissed as an artifact. Willpower can be thought of as the energy, focus, or commitment that fuels the capacity to make the previously determined choice in challenging situations. Willpower grows by mindfulness, clarity of intentions, anticipation, and preparation for challenges, as well as by modifying one’s environment when not in the throes of immediate temptation (cool situations) to avoid overtaxing one’s capacity for self-control in more tempting (hot) situations.

Contrast this kind of contemplation, anticipation, and commitment planning to the “New Years Eve Resolution” marked by good intentions, but lacking the underpinning for adherence in the face of even mild temptation. Such failure is often misattributed to “a lack of willpower,” when actually it was a failure of clear intention and plan clarification and preparation that left the person unprepared at the first hint of temptation.

The initial conversion of Preparation into Action is usually a time of high effort and little payoff. Think about the first week of exercising after a long layoff. Patients do best when they have anticipated this and have a ready response that can head off second thoughts (e.g., “Pain is the weakness leaving my body. My decision to exercise is already made, and I am not going to remake it every morning!”). On the other hand, it is common to discover that some intensification of effort or the addition of other behaviors to the mix must be made to the action plan if desired results are to be attained (e.g., walking a mile a day will lead to some improvement in fitness, but without reducing caloric intake it is unlikely to lead to significant weight loss). Self-monitoring research points to the importance of patients tracking the data carefully (about their actions and their results) and using that information in moments of choice and when reevaluating their action plan if desired results are slower in coming than expected.

Contingency management research has always highlighted the importance of having rewards lined up for the accomplishment of intermediate and larger milestones to motivate the initial and continued efforts at change. People may come up with these rewards naturally (e.g., “When I have lost 15 pounds I will buy myself some new outfits.”). It can also be helpful for the clinician to anticipate and encourage the patient to build rewards into their action efforts.

In the Maintenance stage patients try to incorporate their Action stage behaviors into a sustainable new lifestyle. Depending on the problem they are addressing, maintainers may be able to reduce some of the frequency and intensity of action stage effort (e.g., attending fewer Alcoholics Anonymous [AA] meetings, or allowing previously forbidden foods back into their diet in a controlled manner) and still hold onto improvements they have made. This is a challenging transition. Patients may have secretly been hoping that the intensive efforts of the Action stage would be time-limited, but many behavior and lifestyle changes must be maintained indefinitely if improvements are to be sustained. In the Maintenance stage, those behaviors tend to come more naturally if people increasingly identify with the new lifestyle and can remind themselves to enjoy the improvements their efforts have produced. It is also necessary for their immediate social network to adapt or be reconfigured to support the new behaviors and routines (e.g., Long-term sobriety depends on building associations with people and activities that do not encourage drug and alcohol use. Family members must learn to not inadvertently encourage overeating, and the changer must learn how to gracefully say “no” to well-meaning offers of unnecessary food.). Self-monitoring is very important as the path to relapse often begins with a series of slips that are not recognized and not recovered from swiftly (e.g., a cigarette or two after putting the kids to bed, giving oneself permission to exercise less as winter weather sets in and the outdoors is less inviting).