Lecturing on the basics of Behavior Change Theory

I have had the great pleasure of lecturing to staff and students at medical universities in Southeast Asia including Chiang Mai University Faculty of Nursing and Hanoi Medical University & Hospital Department of Preventive Medicine and Public Health. Sometimes I am alongside Nutrition and Exercise experts as a workshop and sometimes solo as a more in-depth skill-building experience. Either way, I am helping to improve recognition of the terms “Integrated Healthcare”, “Integrated Behavioral Health”, and “Behavioral Health Consultant.”

When I lecture to students I always point out that we are all functioning in a Behavioral Health Consultant role in our ever-day lives. We all know one person, usually a family member, who we would like to help change some behavior. Behavior change theory can work for many different facets of healthcare and will work just as well in your every-day relationships.

What is Integrated Behavioral Health?

Integrated Behavioral Health is a new model of healthcare service delivery at the primary care level. Behavioral Health is a new field that is different and functions apart from the Mental Health field. A Behavioral Health Consultant is a new type of professional tasked with bridging the gap between physical health and mental health by helping patients to change their health behaviors. Science and research show that mental health and physical health are all linked and that when health behaviors improve physical health outcomes improve. As an exercise behavioralist (or behavioral change theorist) and researcher, I am happy to speak on this topic. I am introducing the new model of integrated healthcare where behavioral and physical health providers work as a team together. Physical health providers what to know, “How do I get my patients to do what I tell them to do?”. Behavioral health providers can help answer that question.

How does it work?

Any type of sustanable systems change comes from both the top and the bottom of any structure, healthcare and behavioral change included. I have spent the last 10 years of my career in the bottom; direct care, one-on-one with my patients. This is like the trenches of behavioral warfare. In direct patient care we are trying to change behaviors one person at a time,  but with the understanding that behavior change is very difficult for patients to do if the system they are in stays the same. For true success of this model, there must be a concurrent top-down approach in addition to the direct services Behavioral Health Consultants provide. Patients need a different healthcare structure that is cognizant of change theory to make healthy behavior change realistic and attainable (SMART goal Language alert!). That is why I take so much pride in lecturing to doctors and nurses about system structure changes that need to happen before a patient can produce sustainable behavior change (also because behavioral change theory is so interesting, it’s like a super power you can learn to cultivate!). Health care providers all have one thing in common- they want their patients to change health behaviors to be more healthy. However, before a patient can change, a provider must change! The most important change in the structure of healthcare must happen in the patient-provider relationship dynamic.

Currently in many health systems, the provider assumes an authoritarian role because that is what they are taught to do during their education. Providers assume most, if not all of the responsibility. This happens through the entire patient process, from the diagnosis to the outcome; providers feel responsible for all treatment give and all outcomes derived. But then, what is there left for the patient to assume? Where in this structure do we teach patients their role and their responsibility for their health outcomes? Where do we build success before we hold them accountable? The answer is that it does not happen. Health care providers are missing valuable opportunities to show show empathy, improve engagement and empower patient actions. All of this hinges on one little word: Collaboration.

Moving away from authoritarian relationships to the nuclear patient (or patient-centered) relationship frees up the system structure to become more collaborative. The provider can assume a consultative role and act in a more personalized way, collaborating with the patient on the best choices for them personally. This is a difficult balance to strike, but there is evidence based science in behavioral theory that supports this system of care. Behavior change tools like Motivational Interviewing (MI) and Trans-Theoretical Model (TTM) have been peer reviewed and validated to work in lifestyle change when used in a counseling setting. It is time to take those lessons learned into the primary care office.

Here are a few key assumptions to make when helping someone change:

  • Health Belief Model: Patients generally want to do the best thing for health
  • Health Literacy: Patients do not understand medical terms (even easy ones)
  • Pragmatism: Patients know more about their bodies than we do (I only know what has worked for the majority of the specific patients who where studied in that specific article I read- which is not usually inclusive of the patient I am currently talking with- “I don’t know what will work for you, but research says that this is a good choice, would you like to try it?”)
  • Personalized Medicine: Each patient is unique with their own social, cultural, economic and personal barriers
  • TTM Change Theory: Patients will not change if they are not ready (and talking to their stage of change will help)
  • MI Change Theory: Direct persuasion is not an effective method for resolving ambivalence, instead find common ground and “role with the resistance”

Prochaska, J.O., Norcross, J.C., & DiClemente. C.C., (2010). “Changing for Good” [Kindel]. New York: HarperCollins. Substance Abuse and Mental Health Service Administration (SAMSA), (2017). Screening, Brief Interventions, and Referral to Treatment (SBIRT). Retrieved from https://www.samhsa.gov/sbirt

Rollnick, S., Miller, W.R. & Butler, C.C., (2008). Motivational Interviewing in Healthcare: Helping Patients Change Behavior. New York, NY. The Gulford Press