How can you be sure that the message you need to deliver, in the little time you have with your patient, is going to make an impact? Clinical psychologist Sonya Tsancheva shares her tips for preparing patients to make self-sufficient, long-lasting changes to their behaviour.

Motivational interviewing is a counselling technique. It is collaborative and conversational and when it is executed well, it fosters autonomy in people to engage in changing their behaviour in a sustainable way; evidence from research and practice show that when people are autonomously motivated to change behaviours, they are more likely to succeed in doing so and maintain the results overtime.

Here are six key skills taken from this technique that will help to fuel productive conversations about weight and weight loss.

1. SHARING THE AGENDA

Often patients arrive to appointments with their clinician with more than one concern they would like help with. Taking the time at the beginning of the appointment to find out about all concerns a patient wishes to discuss will be invaluable in a number of ways:

• The patient will feel they are listened to, whilst you will be experienced as willing to help.

• It can help you identify connections between the concerns and thus improve diagnosis and treatment.

• It will allow you the opportunity to put what you consider important as an agenda item.

Sharing the agenda communicates the willingness to work collaboratively with your patient. If there are too many items to discuss for the limited time of the consultation, negotiating and prioritising the agenda items is very important. This will help to keep the consultation on track and focused on topics that the patient feels are most pressing.

Share the agenda by using an open question:

“We have about 15 minutes today, how would it be best to spend them?”

Once the patient’s concerns are established, it is your chance to add to the agenda. If you are concerned about their weight, you might say: “I have a concern to add to our conversation today. Would that be OK? I would like to talk about a trend I noticed about your weight.”. Then, with the agenda set, you could ask: “Where shall we start?”

2. RAISE THE ISSUE

When you reach your point on the agenda – the issue of weight – it might be tempting to rush in with advice or professional opinions about the importance of weight loss. This is rarely helpful with behaviour change and in fact is likely to result in friction between you and your patient and reduce engagement. Resist the urge and, instead, ask an open question that encourages the patient to share their thoughts and feelings.

“How do you feel about your weight?” “What do you understand about how your weight affects your health condition?”

Give them enough time to respond. Reflective listening and summaries at this stage are useful as it will help you identify vital information about the patient’s knowledge, attitudes and beliefs about their weight and their previous experience of weight loss.

3. READINESS TO CHANGE AND WORKING WITH THE AMBIVALENCE

The transtheoretical model for behaviour change suggests that when thinking about changing a behaviour, an individual can occupy or move between different stages of change. Each of these stages is characterised with a particular state of “readiness” that would guide you about the approach you need to take to help your patient achieve the desired behaviour.

For example, a patient who indicates that for them losing weight is not important or a concern could be characterised as being in the “precontemplation” stage of readiness to change. They might be at this stage because they have little knowledge about the health risks of obesity, in which case some simple information might be enough to convince them to consider weight loss.

A patient who expresses they are aware losing weight will help them regulate their blood sugar better but have found all of their previous attempts have got them nowhere is a patient in the contemplating stage of readiness to change. People at this stage are usually aware they need to make a change to their lifestyle but are not sure if it is really worth it or whether they would be able to do it. Patients in this stage are likely to use sentences that report both positive and negative attitudes and feelings about making changes. Holding both the positive and the negative about making change is what we call ambivalence.

Ambivalence is a natural process of behavioural change and healthcare professionals can learn to notice when it is present and work with it. Failing to work with ambivalence effectively and instead interpreting it as a sign that a patient in not willing or not ready to change their behaviour will most likely result in friction and frustration felt by both the healthcare professional and the patient. It will be counterproductive to behavioural change.

When you identify ambivalence, you can respond in the following way:

“You have some good knowledge about how losing weight will be beneficial for your health, but you feel unsure about achieving this, because you have found it difficult in the past.”

This is an example of reflective listening that identifies the patient’s ambivalent feelings. The positive actions the patients has taken in the past can be affirmed by asking an open, evocative question about the patient’s previous experience to build up their self-efficacy:

“It sounds as though you have managed to lose weight in the past. Tell me, what did you find worked for you before?”

4. BUILDING ON WHAT YOU HEAR

To build on what the patient is telling you, use the ASK – TELL – ASK framework; it helps with engagement, it communicates you are willing to work collaboratively with your patient and shows you wish to help by giving factual information to base decision making on.

ASK: For permission to share information or ask what they would like to know about obesity.

“Would it be ok if I tell you a bit about how being overweight can affect the health of your heart?” or “If you would like, I can share with you some things that others have found helpful, when trying to introduce more physical activity in their daily routine.”

TELL: Deliver information clearly in small chunks without using modal verbs such as “must”, “should” or “have to”. Be mindful of not making unsolicited suggestions about the patient should do, this

would discourage the empowering and collaborative tone the practitioner has set for the conversation.

“Some people find that planning their meals ahead helps them stick to healthier diet (and budget)” OR

“Some of my patients have told me that getting off one bus stop earlier and walking the rest of the way has helped them fit in more exercise in their day to day routine.

ASK: For feedback or check for understanding.

“What do you think of that?” or “How do you feel about what we just discussed?” or “Do you think any of these might be something you could do?”

This technique communicates that you are willing to help and offer expertise and work collaboratively with the patient, and that you are curious about their thoughts and experiences.

5. CULTIVATING ‘CHANGE TALK’

‘Change talk’ is different to ‘sustain talk’. While it is important to identify barriers and reasons for not changing (i.e. for ‘sustaining’) behaviour, dwelling on these can create friction and resistance.

‘Change talk’ favours making change. In the spirit of motivational interviewing, listen out for and cultivate change talk . Once you have identified something that will motivate the patient to change, you can move towards identifying a specific plan. You can move them from the contemplation stage to preparatory or even action stages of behavioural change.

Examples of ‘change talk’ include statements and sentences that convey intention “I will make changes”, desire to change “I want to change”, ability to change “I can change”, understanding the importance to change “I should change”, “It’s important to change.”

6. MAKE A PLAN

Once you and your patient have identified one important thing that will motivate them to lose weight, you can move towards working on identifying a specific plan. Again, maintaining an empathic stance here is important and using a collaborative approach with your patient to discuss SMART goals, or similar small steps they would like to work towards. Open question like such as “What has worked for you before?” might be enough to open up an explorative conversation about the options available to the patient.