Do This, Don’t Do That, Can’t You Read the Sign?

The problem with advice giving like this is that your patients are very often aware of what they should be doing -- the struggle is in implementing this advice consistently. They may leave your office full of motivation, adamant that this time will be different. But weeks, days or even hours later, they lose track and struggle to get back on target.  

The reason for this is a simple one -- knowledge about what they should be doing just isn’t enough. This is why there are so many people out there who don’t have full diabetes health. Individuals who continue to smoke despite the warnings. Those who maintain overweight despite education about the importance of healthy eating. 

Perhaps you’re reading this as a diabetes professional and thinking, "Well, they just need to get motivated – that’s the missing ingredient." But motivation isn’t the issue either. Everyone with diabetes has high levels of motivation. They are motivated to do all sorts of things in life. Watch TV after work. Eat a delicious meal in the company of loved ones. Sleep late on the weekend. Spend a day pursuing a favourite pastime or hobby.

Rather than simply being a balance between knowledge and motivation, there are a range of reasons why people struggle to implement the health advice they know they should be following. This is because health does not exist in isolation from the person. It is affected by a complex interaction of internal factors - emotions, thoughts, behaviours, memories and relationships with others. These internal factors can have an unseen yet extremely profound affect and interact with the patient’s ability to care for their health. There is an important but often neglected psychological aspect to living with diabetes. 

The US researchers Prochaska and DiClemente (1983) demonstrated that changing a health behaviour is not a single event, but a process during which the individual goes through a series of stages. These range from no interest at all in changing behaviour, to thinking about changing, making definite plans, taking action and also relapsing. The "Stages of Change" model they formulated is a striving to describe this process and is used to explain how people progress towards making different health decisions and taking action in their everyday lives.

They also demonstrated that the process of change does not operate in an identical way across individuals. No two people will make changes in exactly the same way, so all the support you offer to help your patient change needs to be tailored individually and specifically to their needs.

Although this approach may sound time consuming, working in this way takes no more time than your current consultation style, and rather than having discussions about change that can often feel conflictual, working in the way described below can be experienced as much more collaborative. This style of working is called "motivational interviewing." 

What is Motivational Interviewing?

Motivational interviewing (MI) a particular style of therapeutic intervention that works very well alongside the stages of change model. Your usual consultation with a person with diabetes is likely to be very different to a conversation based on the principles of MI. Rather than the clinician being positioned as the "expert," an MI style is one of collaboration and partnership, positioning the client with diabetes as an "expert by experience." Rather than dispensing advice, or encouraging your patient of the value of health behaviour change, the responsibility is on the patient to think about the emotions they have towards making a change.  

Although learning to apply these techniques in full requires suitable training, there are simple strategies that you can use in your routine practice to allow a more meaningful exploration of your patients' personal barriers to implementing health advice.

There are four guiding principles to MI which can be remembered using the acronym RULE: Resist, Understand, Listen and Empower (Rollnick, Miller & Butler, 2008)

As a health professional, you no doubt want to put things "right" in some way. This, after all is probably why you wanted to do the job you do in the first place. MI asks you to suspend this desire, a first step that can often be challenging to implement. The difficulty with trying to put things right when working with a patient who is struggling to make a health behaviour change is that they already know what they should be doing. By taking this position in relation to the client, you are inviting the patient to move into a "yes, but" frame of responding. "Yes, I know I should do more exercise, but...." Helping the patient to think about their ambivalence starts with implementing principle number two.

It is the patient's own reasons for change, not your reasons why they should change, that need to be engaged to enable their behaviour to be altered. Therefore the most important thing you can do is to be curious about the patient's own concerns, values and motivations about a possible change in their health behaviour. Asking, "What is your main reason for (stopping smoking/exercising more/making healthier food choices?)" can be the key to unlocking this motivation.

Behaviour change outcomes are better when patients take an active interest and role in their own health care decision. Therefore empowering the patient to explore how they can make a difference in their own health is key. You know that healthy eating, exercise or stopping smoking is important but it is your patient who knows best how they could successfully build this into their daily lives.

The next article in the series outlines exactly how you can implement the MI in your discussions about health change, including the exact questions to ask to put these principles into practice when encouraging your clients to achieve their goals.

Prochaska, J. & DiClemente, C. (1983). Stages and Processes of self-change of smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 3, 390-5. 

Rollnick, S., Miller, W. & Butler, C. (2008). Motivational Interviewing in Health Care. The Guilford Press: New York.

Jen has had Type 1 diabetes since she was 6 years old so understands first-hand the ongoing demands of managing a chronic health problem. Jen is a Clinical Psychologist with the British Psychological Society and holds a Doctorate degree in Clinical Psychology. She has gained a wealth of experience of working one to one with clients in tackling their psychological difficulties. Her style is one of warmth and humility and she is passionate about collaborating with people with diabetes who are motivated to free themselves from emotions and behaviours that are holding them back from achieving their best health and wellbeing. Jen is a regular speaker for the Diabetes Research and Wellness Foundation, Diabetes Research and Wellness Foundation on the subject of "Think, Live and Be Positive: The Psychology of Living with Diabetes." Jen works with private clients at her practice in Central London. She runs educational seminars and workshops for both people with diabetes and NHS healthcare professionals. She teaches on Psychology and Counselling programmes at The Open University.

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