This post has been peer-reviewed by Dr Lynne Johnston (Registered Principal Clinical Psychologist, member of the Motivational Interviewing Network of Trainers (MINT), PhD in Exercise Science, Doctorate in Clinical Psychology). You can find out more about Lynne and her company ‘Halley Johnston Associates Limited’ here.

I’m sure most health care professionals (HCPs) have had those challenging consultations where the solution to your clients issues seems clear to you, yet the client really struggles to make the necessary changes or to sustain them in the long-term.

Most people have a good understanding of what they should do, but it’s the longer term compliance with change which is more challenging.

As promoting long-term behaviour change can be a complex skill which requires practice and experience, it would be unrealistic to try and encapsulate this within one blog post. Instead, this post will aim to summarise some of the mains do’s and dont’s for HCPs when it comes to supporting our clients to make and maintain long-term changes.

Many of the topics covered in this post are related to Motivational Interviewing (MI); you can find links at the bottom of this post for further information about this particular behaviour change approach.

Things to Avoid:

• Being prescriptive: Telling our clients what to do, how they should do it or continually emphasising the importance of changing a specific behaviour can cause a client to feel disheartened and patronised rather than empowered to make changes. A better approach is to explore our client’s individual motivational factors and barriers, and to help them to decide what changes (if any) they would like to make and why.
• Assuming that clients don’t care or don’t know how to change: This is an unhelpful belief to have and can lead to parent and child type interactions, with the HCP in the role of the parent explaining why and how the client should change, which can be counterproductive and cause resistance to change. A mutually respectful adult to adult collaborative interaction is much more beneficial (as explained further in the ‘expert trap’ below).
• The ‘premature focus trap’: This occurs when your consultation starts to focus too quickly on an issue which isn’t actually the client’s main focus or concern. This can occur as a result of projecting our own ideas of what a client’s priority should be, rather than properly exploring the client’s own motivations. For example, prematurely focusing on encouraging the client to increase their exercise levels, when they are actually much more concerned about starting to have healthy meals at home so they can set a good example for their children. Trying to encourage change in the first place may be a premature focus trap in itself if a client isn’t ready, or doesn’t want to make any changes at that time.
• The ‘question/answer trap’: This is when the HCP asks numerous questions and the client answers these and waits for the next question. A better approach is to empower the client to do most of the talking in the consultation in order to explore their key motivations for change.  
• The ‘expert trap’: Communicating in a way that emphasises that you are the expert in the room can make a client feel disempowered and disengaged.

It is important to acknowledge that the client knows themselves better than anyone else does, so really they are ‘the expert in themselves’. This can shift the responsibility back to the patient in an empowering way.

• The ‘labelling trap’: This involves imposing a label on a client, such as telling them that they are obese or an addict (etc.). This can cause the client to feel judged or stigmatised, which may affect their self-esteem and their willingness to engage in the consultation.   
• The ‘confrontation/denial trap’: this can occur when a HCP argues for the importance of change and the client feels the need to defend themselves and explain the reasons stopping them from making that specific change.
• The ‘blaming trap’: Clients or family members may try to blame somebody else for their problem, or a HCP might try to get the client to accept the blame for ending up in a specific situation. Both of these unhelpful situations should be avoided.
• The ‘righting reflex’: This is the urge to provide the solution to the client’s problem, or to tell them why it is important to make a certain change, rather than facilitating them to discover their own solutions and motivations (which may be different to yours).
• Spoon-feeding: Sometimes it can seem easier or helpful for us to go out of our way to organise things for our clients, but it is more empowering (and sustainable in the long-run) to teach patients skills which they can apply to their own lives. An example of this type of spoon-feeding could be: writing shopping lists or detailed meal plans for a patient, rather than working with them and teaching them how to do this for themselves; just like the “you can give a man to fish…” proverb.
• Putting ourselves under too much pressure: Just as we would advise our clients, it is important for HCPs not to be too harsh with ourselves, and to be realistic. For example, don’t feel like a failure if a client decides that now is not the right time to change.  Although it is a good idea to reflect and learn from less successful consultations, it can be counterproductive to dwell on these too much. Even when it feels like a client has not changed anything observable, we may have actually planted a seed which could have a positive impact at a later stage (i.e. ‘the trickle down effect’).

It can be important to remind ourselves from time to time that we don’t have a magic wand!

Things to Do:

• Empathise: Genuinely empathising with clients is a key part of building a good rapport and establishing a supportive environment for consultations.
• Explore your clients motivations: Discovering what is important to your client and what drives them to make changes is a vital step in encouraging positive habits.

When somebody has a realisation for themselves, or presents their own arguments for making a change, they are much more likely to make that change.

• Empower your client: Building self confidence is important so that clients feel optimistic and believe that they can make and sustain healthy changes^1-2. The process of empowering a client involves encouraging clients to take an active role in consultations, facilitating client-led self-discoveries and problem-solving, providing accurate and positive feedback, and highlighting previous times when the client has been successful (for more information about strategies to help clients to improve their self-efficacy see here).
• Use your Micro-Skills: In motivational interviewing specific micro-skills (i.e. OARS) are used to elicit arguments for change or ‘change talk’ and to respond to this in a way that further strengthens and consolidates change statements.  The OARS acronym stands for:
  • Open evocative questions (questions are posed in a way whereby the answers are change-focussed)
  • Affirmations (statements of genuine praise and encouragement)
  • Reflective listening (listening with interest to a client and reflecting the meaning and emotion behind their statement back to them) 
  • Summarising (longer reflections used to sum up the client’s thoughts and feelings)
• Collaborate: Rather than imposing goals and actions onto your client it is best to work as a team and empower them to decide: whether they want to make a change at all, whether now is the right time for them to make a change; and if so which changes they would like to focus on and how do they think they could implement these.
• Provide information thoughtfully: This involves using the ‘Ask-Provide-Ask’ approach.

1. Ask permission / seek prior understanding: Ask whether your client would like information on a specific topic, or gage what they already know about a specific issue or topic.

2. Provide information neutrally: explain the information in a non-judgemental way e.g. “many people find that regular exercise can help to improve their mood” rather than: “your bad mood is likely to be related to your lack of exercise”.  

3. Ask what they think: after you have provided the information ask the client what their opinion about this, for example: “so what is your take on that?”

• Be holistic: Treat your client as a whole person rather than just focusing on one aspect of their life; such as snacking habits or their weight. This can involve acknowledging that there are more things to focus on in life than just healthy eating and exercising, and also highlighting the positive choices that the client already makes. For example,  “regardless of your weight, you are doing lots of healthy things, like fitting fruit and vegetables into your busy schedule every day”.

It can also help to boost a client’s self-worth, and therefore promote readiness to change, by reminding them that our self-worth should not be defined by our weight.

• Discourage ‘dieting mentality’: Encouraging realistic long-term sustainable habits should be the aim rather than ‘dieting’ which suggests a short-term fix. Also, some studies have found that dieting and intentional weight loss can be independent predictors of future weight gain ^3-7.
• Remember to take care of ourselves: Working with clients to create sustainable habits can be extremely rewarding, but it can also feel demanding and tiring at times (for tips about maintaining a healthy mindset see here).

It is important to take our own advice and prioritise self-care so that we can show up to work everyday and support our clients to our best ability

For more information on behaviour change techniques and motivational interviewing see:

• http://www.motivationalinterviewing.org/
• Dr. William Miller, “Motivational Interviewing: Facilitating Change Across Boundaries”
• Johnston, L. H., Hilton, C. E., & Lane, C. (2017).  Motivational Interviewing and Mindfulness in Weight Management.  In J. Weaver (Ed) (pp. 193-214).  Practical Guide to Obesity Medicine. Philadelphia, Elsevier.
• Johnston, L. H., Hilton, C. E., & Lane, C. (In Press for 2017).  Psychological Management Before and After Bariatric Surgery.  In J. Weaver (Ed) (pp. 299-313).  Practical Guide to Obesity Medicine. Philadelphia, Elsevier.
• Rollnick et al. (2009) “Negotiating behaviour change in medical settings: the development of brief motivational interviewing”
• Miller et al. (2006) “Eight Stages in Learning Motivational Interviewing”
• Miller (2009) “Ten things that motivational interviewing is not”
• Miller & Rose (2009) “Toward a theory of motivational interviewing”
• “Motivational interviewing. Third edition: Helping People Change” by Miller & Rollnick (2012)
• “Motivational Interviewing in Health Care” by Miller, Rollnick & Butler (2009)
• “Building Motivational Interviewing Skills: A Practitioner Workbook (Applications of Motivational Interviewing)” by David Rosengren (2017)
• “Wellness, Not Weight: Health at Every Size and Motivational Interviewing” by Ellen Glovsky (2013)

For more information on creating long-term habits check out:

Creating Long-Term Habits: A Healthy Mindset 

Creating Long-Term Habits: 10 Tips for Healthy Eating

Creating Long-Term Habits: Goal Setting in 7 Steps

References:

1. Stretcher et al. (1986) “The Role of Self-Efficacy in Achieving Health Behavior Change”
2. “The Wiley Handbook of Positive Clinical Psychology – Chapter 7: Self Efficacy” Maddux & Kleiman (2016).
3. Field et al (2003) “Relation Between Dieting and Weight Change Among Preadolescents and Adolescents”
4. Neumark-Sztainer et al (2006) “Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: how do dieters fare five years later?”
5. http://www.intuitiveeating.org/category/reject-diet-mentality/
6. Bacon & Aphramore (2011) “Weight Science: Evaluating the Evidence for a Paradigm Shift”  
7. Pietiläinenm et al. (2011) “Does dieting make you fat? A twin study”
8. “Motivational interviewing. Third edition: Helping People Change” by Miller & Rollnick (2012)
9. https://phpa.health.maryland.gov/ohpetup/docs/MI_resource.pdf

Disclaimer: I am not a trained psychologist but have been lucky to have worked with and received training from some excellent clinical psychologists in relation to behaviour change. This post reflects my clinical and personal experience of promoting healthy habits, but as this is a very individual topic each point may not be relevant to every situation, clinical judgement is always crucial.