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Changing people's behaviour
  1. CARLO C DICLEMENTE
  1. Department of Psychology
  2. University of Maryland, Baltimore County
  3. 1000 Hilltop Circle
  4. Baltimore, MD 21250 USA
  5. diclemen{at}umbc.edu

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    Health behavior change: a guide for practitioners. Stephen Rollnick, Pip Mason, Christopher Butler. Edinburgh: Churchill Livingstone (Harcourt Brace), 1999. ISBN 0443 058504. 225 pages.

    “You cannot get people to change in five minutes.” “Doctors do not feel that they have the expertise or training to help people change behaviours.” “Getting diabetics (smokers, drinkers, heart patients . . .) to change their diets (smoking, drinking, exercise . . .) is difficult if not practically impossible.” These statements represent typical comments from third year medical students in a class on behaviour modification that I teach at the medical school. I have often encountered these negative views of health behaviour change among health practitioners. In response I contend as cogently as I can that medical professionals can be taught about the process of change and trained to help individual patients make positive movement toward change in a brief period of time. I now have help. This practitioner guide by Rollnick, Mason, and Butler does a wonderful job of making these points in an elegant, convincing, and motivationally enhancing manner. This small, easy to read volume is filled with practical insights and strategies that would be useful and valuable for both the busy health practitioner and the behaviour change specialist. Although it may take a little more than five minutes to do what they suggest, the authors discuss and more importantly demonstrate how quickly and efficiently to approach and engage a patient in a conversation about changing one or more health threatening behaviours. This is a book that can and should be read by health professionals at all levels of training. Anyone who interviews patients and talks with them about changing health behaviours can benefit from the insights and suggestions of these talented behaviour change negotiators.

    The book is ambitious in scope. The first part offers an overview and theoretical foundation of the proposed approach to negotiating health behaviour change in the consultation setting. Readers seeking an extensive conceptual analysis will be disappointed. However, the basics are all here for the rationale and the spirit behind the practice of this approach. The authors even provide a guide for how to use the book depending on the amount of time the reader is willing to devote to learning the behaviour change consultation tasks of establishing rapport, setting an agenda, and negotiating behaviour change. The second part of the book outlines these tasks and describes strategies for achieving these objectives within the spirit of this respectful, motivational approach that sees the client and practitioner as partners in promoting behaviour change. Finally, the third section describes common clinical problems and how to apply these strategies to single and multiple risk factors, from smoking behaviour to safe sex practices and cardiovascular rehabilitation to low mood and chronic pain. Also included in this final section are a discussion of training people in how to use this approach and a series of brief discussions highlighting some conceptual, clinical, and ethical issues raised by this approach. The scope of the book makes the approach or method described accessible to most practitioners, including those who have either minimal or extensive knowledge of motivational interviewing and behaviour change models.

    There are several very useful aspects of this guide to health behaviour change that deserve a more extensive discussion. In almost every chapter there are clear examples of what the authors are trying to get practitioners to do in order to develop rapport, to set agendas, and to negotiate change. The scripted dialogues between patient and provider throughout the book are one of the most useful aspects of the book. The authors provide many interesting examples both of what to do and of what not to do to prevent the patient from disengaging, and to foster meaningful dialogue about change. Many practitioners will see themselves in some of the “not so good” approaches. I could picture myself doing some of the not so good engagement strategies and that gave me a better sense of the style and content of this behaviour change method. The authors illustrate well the dangers of forcing a premature focus on active problem solving, not listening well, and giving prescriptions and advice unsolicited or in a condescending manner. Immediately following the not so good are brief, interactive vignettes that highlight one or more ways to meet the patient and address the issue of change more effectively. These vignettes are a wonderful teaching tool that engage the reader, and are a very effective method for giving the reader a real feel for what a behaviour change negotiation would look like from beginning to end.

    The second very useful contribution to the practitioner lies in the brief assessment tools that the authors use to facilitate the conversation and the change process. There has been some controversy about whether the stages of change represent distinct categories and how to assess them in day to day practice. The authors acknowledge the heuristic value of the stage model but find a unique way of getting clients to discuss where they are in the process of change. The assessment is elegant in its simplicity. The recommended procedure is simply to use a numbered line, a sort of ruler, that can be shown to the patient so that he or she can mark where they see themselves with respect to the dimension in question. The problem I have always had with these single ladder or ruler assessments is that they try to put too many dimensions into a single assessment. These authors have avoided this dilemma by suggesting that there are several dimensions that need to be evaluated. They ask about the importance of the proposed behaviour change to the patient, the confidence that the patient could accomplish the behaviour change, and finally the readiness of the patient to change the behaviour. By having patients place themselves on a scale from 1 to 10 on these three dimensions, the practitioner gets a view of how each patient evaluates this particular health behaviour change and their location in the process of change. This is a brilliant resolution to the assessment dilemma and offers the practitioner multiple avenues to begin a conversation with the patient about the needed behaviour change. I have already incorporated some of these suggested assessments in training practitioners for a brief motivational intervention in one of our research protocols at the University of Maryland. The trainees have found the exercises and the assessments to be very helpful. Imitation is in this case my highest form of praise.

    Helping people change is a thoughtful, practical guide for practitioners that deserves to be read by a whole host of health practitioners. Some may be able to adopt the entire method. Others may only be able to change their approach to giving advice to patients modestly. However, few will remain untouched by the rationale and the examples offered by these authors. They clearly have experience with a variety of problems and patients. It is as much their experience as their thoughts that makes this a very useful guide. I am recommending it to my colleagues and students interested in health behaviour change as required reading.

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