Thursday, 1 August 2013

Behaviour change

Close up of pink thistle flower
National Botanic Garden of Wales, May 2013
I was definitely going to do some homework this evening. I brought home the folder of notes which I had been accumulating during the taught sessions of my Masters module, and brought the computer down to the dining table to make it easier to type (my bedroom doesn't have space for a chair as well as a bed, table and chest of drawers). I did the washing up, some laundry, had supper, spoke to Mr A, and then prepared to do some work.

The only thing missing was the actual case study - up to now I've been working on it at the hospital, and hadn't emailed myself a copy. Taking it back and forth on a memory stick is complicated due to NHS file security policies - they make it very difficult to take data out, so that we can't easily compromise patient confidentiality. So, no homework, and I'm blogging instead.

I didn't have a clinic today, so I went back to those carbohydrate reference tables again. It feels as though I have been working on this project forever, and in fact it has been an enormous amount of work. My colleagues came up with some suggestions and comments after I presented the first draft, and true to the adage, the last 20% has taken as much time and effort as the first 80%. It's nearly done now, and the time will soon come to compromise on perfection and go ahead with some flaws still present. For example, I would have to hold back for a few more months to get any decent carbohydrate figures for Christmas pudding.

I continue to have too few patients. I am starting to worry that unless I can fill my clinics, any extension to my contract will be at risk. Part of the problem seems to be that I keep discharging patients rather than offering them follow-up appointments. Having discussed a patient's lack of motivation to lose weight, for example, it serves no purpose to keep making them come to the hospital to have another discussion about how they haven't lost weight again. I may be repeating myself by saying that losing weight is one of the most difficult things in the world for most people to achieve, and you've got to want to do it to have any hope of succeeding.

There are a number of techniques that can be used in the complex world of behaviour change. Obviously active listening and open questioning are important to establish the topic to focus on - never assume that what's in the notes or the referrer's letter or even what you talked about last time will be what needs to be discussed this time. Circumstances change, things happen, and people move on. Last time the patient was 100% in favour of increasing the amount of exercise they wanted to do, this time they are worried about gallstones. Also important at this stage are empathy and taking care to withhold judgement.

Having established the topic, what does the patient want to do? What is the actual aim we are working towards? If it's a change towards 'healthy eating', how will we know when we have succeeded? What amount of weight loss in what period of time will bring about significant health benefit? It helps to describe the objective as fully as possible.

Then it's always worth exploring how realistic the aim is, often by questioning the importance it has to the patient, and their confidence in achieving it. At the most basic, you can use the Lickert scale, which is just a scale of 1 to 10. Anything less than 7 suggests ambivalence and is worth exploring further, and the whole thing can come apart when you really examine some of the practicalities of changing diet or lifestyle. Eating is really fundamental to who we are and how we fit into our families and wider society, and change isn't usually easy.

When it comes down to it, behaviour change is about breaking habits that aren't helpful, and developing and embedding more useful habits. Giving up smoking provides some obvious parallels - if someone always smokes with their afternoon cup of tea, then it will be important to discuss how to manage the feelings that will inevitably arise when having a cup of tea but denying oneself the cigarette. Replace 'cigarette' with 'biscuit' and there really is no difference. Setting a goal of cutting out biscuits while ignoring a lifetime of food-based habits is a recipe for failure.

We can ask questions about how a patient would feel if they achieved their objective, and what the first step will be towards that goal. What are the barriers that will interfere with success? How can they be anticipated, and overcome? Some of the barriers can be brought to light using an 'ambivalence grid', on which we record the positive and negative aspects of making a change, but also the positive and negative aspects of not making the change. It can be illuminating to examine how life would be worse if the patient lost weight (those of us who dislike shopping for clothes are well aware of one of the pitfalls). If the patient thinks that cutting out biscuits will lead to them taking up smoking again, then perhaps they should set a different goal.

These skills and techniques are among those used in Motivational Interviewing, Cognitive Behavioural Therapy, and addressing the Cycle of Change. The trouble is that I can't remember the theory or evidence base for any of these high-falutin' psychological theories, and I feel that for best practice I should know why I'm doing something as well as how best to do it. But for the moment I'm doing my best, and reflecting afterwards on whether I could have done things better, or differently, and that's how I hope to improve my practice. As well as doing my homework. Tomorrow.

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