Coming out of school and my dietetic internship I was ready to transform lives and help people overcome their eating challenges. I was bright-eyed and optimistic that my patients would achieve all their dreams in just one or two visits with me. Therefore, that first meeting was a blitzkrieg of information, a verbal diarrhea if you will. Never once did I consider how the patient was taking it all in, just assuming they instantly knew what I was talking about and so it was ok for me to plow forward. It was time to stop talking when our appointment time was up, not when I could identify the glazed over look, a telltale sign the patient had mentally checked out of the conversation.
I expected them to come running back a month later to proudly report all the positive changes that were going on in their lives. In reality they would half-heartedly make an attempt to come in for a follow up or they would take the same-day-cancellation or no-show route. We'd never be in touch ever again. What went wrong?
Memories of learning about nutrition counseling as an undergrad and dietetic intern are hazy. The lesson usually involved ridiculous/embarrassing "role play" so I never paid attention to the point of the exercise. Such a waste of an opportunity to show baby dietitians how to be most effective on the job. :( Besides at the time I was more focused on knowing "book knowledge" and having an answer for everything, not so much
how to get to the desired outcome (controlled blood sugars, lowered blood pressure, begin exercising, losing some weight, etc).
With my brains, sparkling personality, and extremely good timing in the job market, three years ago after finishing grad school I landed an outpatient dietitian job. Having a supervisor and colleagues very cognizant of the complexities of behavior change has defined my career. I finally began to see the bigger picture: there's no need to pester/use scare tactics/drag them to do something, or a need to waste your breath talking about something you fully know they will not follow through with. You simply elicit what information they'd like in this moment and present them with a menu of options to meet that need.
First it takes some exploring how aware the patient is that there is a problem. Prochaska and others best described this in the
Transtheoretical Model (TTM). Depending on the patient's stage of change it's most effective to tailor your information to match their level of thinking and motivation. Someone in denial they have diabetes? Don't even think about giving the "carb talk" or show them how to use their glucometer. Touch on the objective data like labs with reference ranges and leave it at that. Even then some patients might deny their blood sugar is that bad but you've done what you could. Someone all fired up to throw away the junk in their house? Awesome game plan, so then what will you do when someone invites you to their house or you see treats in the break room at work?
Most patients fail to recognize that their eating and exercise choices are lifelong so relapse is also part of the change process. It does NOT mean the patient is stupid, lacks self-control or is a failure when old habits creep in again. I encourage my patients to reflect on the experience and learn from it.
STAGES-OF-CHANGE CHARACTERISTICS AND STRATEGIES
| STAGE | CHARACTERISTICS | STRATEGIES |
Precontemplation | The person is not even considering changing. They may be "in denial" about their health problem, or not consider it serious. They may have tried unsuccessfully to change so many times that they have given up. | Educate on risks versus benefits and positive outcomes related to change |
Contemplation | The person is ambivalent about changing. During this stage, the person weighs benefits versus costs or barriers (e.g., time, expense, bother, fear). | Identify barriers and misconceptions Address concerns Identify support systems |
Preparation | The person is prepared to experiment with small changes. | Develop realistic goals and timeline for change Provide positive reinforcement |
Action | The person takes definitive action to change behavior. | Provide positive reinforcement |
Maintenance and Relapse Prevention | The person strives to maintain the new behavior over the long term. | Provide encouragement and support |
(Source: Zimmerman et al., 2000; Tabor and Lopez, 2004)
So you have someone ready and motivated to make changes? Learn from my mistakes and don't overwhelm them with all the possible choices to make. One of the most respected techniques for promoting behavior change is
motivational interviewing. Research shows it to be effective in helping people overcome substance abuse/addiction, eating disorders, and manage chronic lifestyle-related diseases like diabetes. Patients who use their own personal motivations as the reason for making changes are more likely to stick to the plan than if they were told to do something by someone else. What do
they care if
you think they eat too much salt or fat? It clearly doesn't bother them (at least up front). Or maybe it does bother them but they haven't thought of a solution to beat that rut. If there is a hint of dissatisfaction somewhere in their choices, carefully chip away at that barrier. Training sessions from
Molly Kellogg and
Steven Malcolm Berg-Smith have helped me craft the right open-ended questions and forced me to be a better listener so I pick up on when a patient expresses something personal and motivating to them. Then I use that to get the ball rolling on trying out a new behavior. It all ties back to them and what's ultimately going to matter most in their lives. I get to be the supportive coach watching on the sidelines.
