02 Mar A New Way to Combat Chronicity
A prohibition was lifted on human dissection in 3rd century Greece, under one condition, that the anatomists not involve themselves with the corpse’s soul. Body and soul at the time were considered separate entities, thus, the medical model was born. The focus on the symptom or body part from a purely physical and biological aspect of disease is still in place and has served us well until the recent explosion in chronic illness. The toll that chronic illness places on our larger macro economy and our collective quality of life is enormous and eating into our national prosperity.
As we look for ways to bend the health care inflation curve, it is fair to say, by every quality and cost measure, that what we are doing in traditional health care is not working. The chronic illness tsunami is upon us, diabetes, stroke, and heart disease with deeply disturbing upticks among ethnic and racial groups. What is really making us sick is how we live our lives everyday- what we eat, how we care for our bodies, how we engage in nourishing relationships [with others, with our vocation]. No amount of pharmaceuticals or “patient education” will reverse the chronicity epidemic unless and until we get smarter about sparking motivation. So what is the back-story to motivation and how do we leverage the spark into healthy action?
A truth that is rarely said out loud is that most chronic illnesses are entirely reversible. Much of what we do in our delivery system is prescribe pharmaceuticals and information to patients, regardless of whether they have a knowledge deficit or are ready to receive information. We have a health care workforce that rarely tries to reverse diseases but rather jump directly to “managing” them.
Traditional health care providers have a narrow and limited skill set in helping people achieve sustained and dramatic lifestyle change. Pharmaceuticals and knowledge cannot be the only way—patients need guidance through a change process, including emancipatory self-knowledge to realize one’s own potential or latent ability, not a yielding to our laziest or weakest selves.
We assume that motivation is a fixed state and that some patients are inherently unmotivated to change. Nonadherence, non-compliance and addictive personality are highly negative terms that exemplify this assumption that all patients are ready to change and present to us in a highly motivated state. People need to desire change before anything can begin. Without that, providing information often leads to resistance.
Many practitioners are not trained nor do they practice the very basic evidence-based motivational interviewing techniques grounded in the Transtheoretical Change Model. Many do not know how to elicit intrinsic motivation, the jet-fuel for change, or to build up individual competency for change. We know that people enter a predictable, sequenced cycle of change and that interventions tailored to their state of readiness for change is a far more nuanced, effective approach. We will never promote behavior change in an environment in which patients feel judged, diminished and/or are given advice which seems impossible to carry out. We often confuse motivation with agreement to engage in health benefiting behaviors.
Uncovering, Igniting and Sustaining Motivation
More exciting are techniques available to us from the coaching world that are grounded in several principles that must be adopted by the larger health care workforce. It expunges “non-compliant” and “non-adherence” from the vocabulary and starts with the notion that all people have some desire to be healthy and that identifying and amplifying strengths rather than spending time on the weakness is the key towards lasting change. Coaching principles are grounded in the knowledge that motivation is a state of readiness or eagerness to change and that this state can be influenced when we remember that:
- People must be put in charge of their own change process and can solve their own problems.
- No one can make another do what s/he does not want to.
- When there is an atmosphere of equality and respect, people will grow.
- When people have what they need, they will engage in positive activity.
- Individual strengths are to be built up rather than placing focus on problems or weakness (e.g. If a person has been successful in the business realm, those strengths of persistence and “closing the deal” can be brought to the fore in the wellness and health arena)
- Success breads success. Small successes lead to larger and more sustained success. Never let a patient leave the office with a goal unless they have a 70% or higher self efficacy rating (chance they say they will do it).
- Radical acceptance and unconditional positive regard enables individuals to get unstuck, learn, and grow.
- Growth and change are necessarily imperfect, falls /slips are seen as buoyancy
- The capacity to change is enhanced by positivism, self efficacy and resilience.
Coaching techniques that are particularly applicable to chronic disease include appreciative inquiry. This technique necessitates that a conversation centers on what the patient truly wants in their life. This leads to patient-directed goals and can often set off a cascade of change – when we get patients to say out loud what they want in great detail, the patient comes up with their own goals. The coach is there to mine strengths and identify and overcome obstacles. So let’s stop telling people what to do, and start asking them what they want.
Dr. Eileen O’Grady is a Certified Nurse Practitioner and Wellness Coach; she lives just outside of Washington DC. where she tries very hard to live every day in balance. http://www.eileenogrady.net