COMMUNICATION TECHNIQUES FOR FACILITATING CHANGE

To bring about behavioral change, healthcare professionals use a variety of communication techniques to support patients in making significant, health-promoting changes in their lives. Some specific techniques used for this purpose are described below.

Motivational Interviewing in the Healthcare Setting

All of the following supportive techniques help to bring about behavioral change and comprise what is called motivational interviewing (MI). Those who practice motivational interviewing:

  • Show nonjudgmental empathy. Nonjudgmental empathy is the ability to encourage patients to fully express themselves, allowing patients to dominate the discussion. The empathic listener is attentive to what is being said, does not judge, does not interrupt, is sensitive to the emotion being expressed, and attempts to see the world through the patient’s eyes.
  • Listen attentively and reflectively to patients to draw out rather than impose ideas. Attentive listening involves the use of positive body language such as facing the person and making frequent eye contact to be “seen” as actively listening. (It is also important to be sensitive to cultural differences in communication; for instance, in some cultures, direct eye contact may be offensive.) Reflective listening involves expressing back to the patient what has been heard using either the patient’s own words or rephrasing them.
  • Develop and examine the discrepancy between the individual’s goals and current behavior. This involves helping the person focus on how current behavior differs from desired behavior by describing what the person’s values are and how current behavior is in conflict with those values.
  • “Roll” with resistance by recognizing, acknowledging, and exploring the patient’s resistance rather than opposing it. Resistance is evident by such behaviors as rejecting an idea, disagreeing, excusing, minimizing, inattention, ignoring, or being defensive. The clinician avoids arguing for change and addresses the underlying concerns and fear of change.
  • Empower the patient to make change and give responsibility to the patient to be active, rather than being a passive recipient of healthcare. Empowerment is a process that involves collaborative interaction, education, counseling, coaching, as well as self-education.
  • Support self-efficacy. Self-efficacy is the patient’s belief that change is possible and that they have the ability to make change. The clinician focuses on eliciting and supporting optimism by recognizing past successes and highlighting skills and strengths.
    (Hartney, 2021; Ingersoll, 2022; Psych Central, 2021)
EMPATHIC COMMUNICATION

Empathetic communication is an important part of motivational interviewing. Some skills to facilitate communication include:

  • Practicing listening. Listen intently, and focus on the other person’s words and body language.
  • Identifying patients’ various communication styles. Adapt to communication in ways that patients feel most comfortable with.
  • Evaluating personal communication skills, their strengths, and their weaknesses.
  • Managing one’s own emotions. Be aware of one’s own emotions as well as the patient’s emotions. During difficult conversations it is important that patients have a chance to process what is being said.
  • Admitting mistakes. When communication mistakes are made, acknowledge them and work to improve how patient interactions occur.

(McLaren, 2020)

Motivational interviewing is a particular type of conversation about change in which the patient rather than the healthcare professional brings forth the arguments for change. MI is also a collaborative process, a partnership that respects the patient’s autonomy, empowers, and gives responsibility for change to the patient. It requires the provider to recognize each patient’s worth and potential.

Using empathy, the healthcare professional strives to understand the patient’s perspective while affirming strengths and efforts. Through collaboration, the patient and provider negotiate a plan to help make change happen. Developing a partnership for change involves the willingness of the healthcare professional to suspend the reflex to give expert advice and to ask questions that allow for the exploration of the patient’s motivations.

The basic communication style of motivational interviewing, referred to by the mnemonic OARS, involves:

  • Open questions
  • Affirmations
  • Reflective listening
  • Summary

(Homeless Hub, 2019; Haque & D’Souza, 2019)

ASKING OPEN QUESTIONS

Open questions invite the patient to elaborate and cannot be answered with a yes or no:

  • Open question: “What makes change hard for you?” (“I’m not sure, but …”)
  • Closed question: “Change is hard for you, isn’t it?” (“Yes, it is.”)
  • Open question: “Tell me how drinking fits into your life.” (“I like to relax after work with a few drinks and …”)
  • Closed question: “Do you think you drink too much?” (“No, not really.”)
    (Hartney, 2021; Ingersoll, 2022; Psych Central, 2021)

USING AFFIRMATIONS

Affirmations are statements that recognize the patient’s strengths. They assist in building rapport and help the patient see themself more positively:

  • “You are really taking this seriously.”
  • “You’ve been successful in changing your smoking behaviors in the past.”
  • “You showed a lot of courage in dealing with that problem.”
    (Homeless Hub, 2019)

REFLECTIVE LISTENING

Reflective listening is a crucial skill in which the listener paraphrases and restates both the feelings and the words of the speaker. It does not involve asking questions. Techniques of reflective listening include mirroring and paraphrasing.

Mirroring is repeating back key words or the last few words spoken while using the person’s tone of voice, pace of speaking, and body language:

  • Patient (sarcastically): “I really am angry with everyone telling me to eat right and get more exercise!”
  • Clinician: “You really seem angry to me!”

Paraphrasing is putting the patient’s message into your own words in an abbreviated form:

  • Patient: “I wish I could wake up in the morning and feel ready to face the day.”
  • Clinician: “You want to feel motivated to get up and do things.”

(Hartney, 2021; Ingersoll, 2022; Psych Central, 2021)

SUMMARIZING

Summarizing is a type of reflection in which the clinician recaps what has occurred in all or part of the interaction. Summaries communicate interest and understanding. They can also be used to shift attention and prepare the patient to move on.

  • Clinician: “It sounds like you’re concerned about how much alcohol you are drinking because it has caused difficulties at home, and your wife wants you to stop. But you also said how important it is to have a few drinks when you get home from work so you can relax. That sounds like a difficult choice.”

(Hartney, 2021; Ingersoll, 2022; Psych Central, 2021)

ROADBLOCKS TO COMMUNICATION

People often have the tendency to jump in and “help” others by offering advice or reassurance to make them feel better. These responses may have the opposite effect and become “roadblocks” that fail to support good communication. Roadblocks tend to interfere with the person’s ability to explore and express their own perception of the problem. They may include:

  1. Commanding, directing, ordering (“You have to …”)
  2. Threatening, warning (“If you don’t, then …”)
  3. Providing solutions, making suggestions, or giving advice (“Let me suggest …”)
  4. Using logic, lecturing, or arguing in order to persuade (“The facts are …”)
  5. Preaching, moralizing, using “should dos” (“You ought to …”)
  6. Judging, disagreeing, blaming, or criticizing (“Maybe you aren’t thinking clearly …”)
  7. Approving, praising, agreeing (“I couldn’t agree more …”)
  8. Ridiculing, labeling, shaming (“Men do tend to think that way …”)
  9. Sympathizing, consoling, or reassuring (“Look on the bright side …”)
  10. Probing with questions (“Why did you do that?”)
  11. Interpreting or analyzing (“What you’re doing is …”)
  12. Humoring, changing the subject, distracting, withdrawing (“Let’s talk instead about what’s going well …”)
    (Gordon, 2019)

Eliciting Change Talk

It is said that the more an individual talks about change, the more likely they are to change. Change talk consists of responses the clinician elicits from patients. Patients’ responses normally contain reasons for change that are important to them personally. Elements of change talk can be remembered using the mnemonic DARN-CAT.

DARN-CAT
Desire “I want to stop overeating.”
Ability “I know I can give up eating too many sugary foods.”
Reason “It’s important to change because my blood sugars have been too high.”
Need “I should really lose weight because of my high blood pressure and diabetes.”
Commitment “I will make changes to my diet for my own health!”
Activation “I am ready, prepared, and willing to change, starting now!”
Taking Steps “My first action step will be going to the bookstore today to buy a weight-reduction cookbook for persons with diabetes.”

The clinician elicits change talk by:

  • Asking evocative questions (what, when, where, how) and avoiding “why” questions
  • Exploring decisional balance (pros and cons of change)
  • Asking for elaboration or example (“Tell me more about …”)
  • Looking back to the time before the onset of the behavior (“How was it different/better?”)
  • Looking to what life would be like a few years from now (goals and values)
  • Asking about extremes (“What are the worst things that may happen if change does not occur, and what are the best things if it does?”)
  • Siding with the status quo (“Drinking is so important to you that you won’t stop no matter what it costs you.”)
    (Motivational Interviewing, n.d.)

It is important that clinicians elicit more information than they provide, ask rather than tell, and listen rather than advise. In order to provide information to the patient, the clinician should first find out what the patient already knows, and then ask permission to add more.

  • “What do you know about how smoking affects your circulation?”
  • “I have some information about how to begin an exercise program. Would you be interested in hearing about it?
CASE

Change Talk

Janet is 62 years old, 5 feet 7 inches tall, and weighs 201 pounds. She has been diagnosed with type 2 diabetes and is taking metformin (Glucophage), 500 mg, twice a day. Today Janet is returning to the clinic for her three-month follow-up visit. Her A1C level from yesterday was 7.9%, and her log of blood sugar readings shows less than optimal control.

Clinician: “Hello, Janet. Nice to see you again. Tell me, how are things going with you?” (open question)

Janet: “Well, pretty good. I’m not very happy about my blood sugar readings, though.” (evoked elaboration)

Clinician: “You say your blood sugar readings are not where you want them.” (rephrasing)

Janet: “No, they’re not! And I’m really upset about that because I thought I was doing pretty well with everything.” (evoked elaboration)

Clinician: “You sound quite upset.” (mirroring)

Janet: “I am! I know it’s my fault. I’m having a real hard time sticking to this diet and trying to lose weight.” (evoked elaboration)

Clinician: “You’re blaming yourself for not sticking to the changes needed to keep your blood sugars under control.” (reflecting)

Janet: “That’s right. I have a hard time passing up desserts, and I love my wine with dinner.” (evoked elaboration)

Clinician: “Giving up desserts and wine is very hard for you.” (reflecting)

Janet: “Yes. I’m a foodie and a wino (laughs).” (asking for empathy)

Clinician: “I understand and can certainly relate to that!” (empathizing)

Janet: “You know, I just can’t understand why it’s so hard for me to lose weight. I’ve lost at least 500 pounds during my lifetime. But eventually I gain it all back.” (elaborating)

Clinician: “You’ve been successful at losing weight in the past.” (affirmation)

Janet: “Yes, I have, but eventually it gradually creeps back on.” (elaborating)

Clinician: “It sounds like you want to stick to your diet and lose weight, but you still want to enjoy the foods you like. That sounds like a dilemma to me.” (summarizing)

Janet: “It is. I know how important it is to manage my diabetes, and I really want to change things. I want to live long and healthy to see my grandchildren grow up. I know I can change but just can’t quite manage to.” (change talk)

Clinician: “Let’s see now, you’re telling me how important it is to be in good health in order to see your grandchildren grow up. At the same time, you’ve told me how eating the foods you like and drinking wine are important to you.” (developing and examining discrepancy)

Janet: “Both of those are true. But I really do want to be there for them, and I believe I really can make some changes.” (change talk)

Clinician: “You have strong motivations for wanting to change, and you believe you are capable of changing.” (supporting self-efficacy)

Janet: “Yes, yes. I do.” (change talk)

Clinician: “Well, Janet, tell me what you think you can do to make these changes.” (finding out what the patient already knows)

Janet: “Well, I know about the Atkins Diet, the South Beach diet, the Grapefruit Diet, and any other weight loss program you can name.” (elaborating)

Clinician: “That’s a lot of information you already have. Tell me, though, would you be interested in learning some other ways to accomplish your goals?” (asking permission to give information)

Janet: “I could be. What other suggestions do you have?” (collaborating)

Clinician: “Would you perhaps be interested in attending meetings with other people who have diabetes and are experiencing the same difficulties you are?” (collaborating)

Janet: “Well …, I don’t really think that would be good for me.” (resisting)

Clinician: “You think that you wouldn’t want to be in a group?” (rolling with resistance)

Janet: “Well, group ‘therapy’ always seems to me to be about being too weak to do something on your own.” (evoked elaboration)

Clinician: “You believe others in the group will think you’re too weak on your own.” (reflecting)

Janet: “Yeah. But … maybe I could give it a try.” (collaborating and negotiating)

Clinician: “Would you like me to arrange for you to attend our diabetes education classes?” (collaborating, negotiating a plan, empowering)

Janet: “Yeah. Okay. Why don’t we try that.” (collaborative response)