Using personal experience of behaviour change to inform how we motivate and inspire others

Encouraging positive behaviour change is not something that should exclusively be aimed at people with substance misuse problems or indeed any problem that we might regard as being hugely significant.  Notions of positive change can be applied to all aspects of our lives and not necessarily in response to traumatic or devastating circumstances; such as being admitted to hospital because your alcohol use led to a diagnosis of pancreatitis or because your injecting drug use caused septicaemia.

These 2 examples may be obvious examples of moments when people may reconsider their behaviour and decide to make some changes, but at some point in our lives we will all have a behaviour or set of behaviours that for a given period of time (it might be a day or it might be 10 years) we were happy with and which later on we decided to change for one reason or another.

Think for a moment about a behaviour you have that you would like to change... 

...we all have them; for some us this will be dramatic and highly significant, something that the majority would agree is necessary to change, whilst for some of us the behaviour may be something that would seem to be relatively inconsequential to others.  It's significance to other people matters little; the only thing that does really matter is its importance to you.

For how long have you had this particular behaviour...

...is it something you've done for years or is it something that you only started doing recently?  Time can be a significant factor in us deciding to change or conversely a major part of our rationale for carrying on ("why should I change now, I've done it for years and its not really causing me a problem?") .

Now think about WHY you would like to change this particular behaviour...

...is it because it is damaging / having no positive benefits to your physical or emotional health, is it because its costing you money that would be better spent elsewhere, is it harming your relationship with friends and family, is it negatively affecting the way you feel about yourself?

Its highly likely that your reasons for wanting to change this behaviour will be associated with at least one of the above scenarios to a greater or lesser degree.  Its effects may be subtle or dramatic, life-threatening or relatively innocuous.  Again the significance to others is not relevant, defining your reasons for change is the most important thing.

After considering the above, you may realise that you feel really strongly about making changes; you may regard it as being one of the most important things you've done in your life - it might just be that important.  On the other hand, you may continue to feel ambivalence towards changing things.

Assuming its important to you now think about the challenges you will face when you start to make changes...

There may be few or many, they may be easy to overcome or seem like impossibly high hurdles.  This will depend upon the nature of the changes you want to make, to some extent how long you've done the behaviour for, whether you have support to make changes and crucially whether you believe that you can make them.

Belief is key; the easier path is probably to carry on with the behaviour, unchanged.  The alternative path represents a test, a greater challenge.  It is the one where we start to make changes and these may initially cause a feeling of discomfort.  Having the faith to continue at this point is vital and this faith will come from the personal reasons we gave ourselves for wanting to change in the first place. 

The point of this is that for all of us, the decision to change a particular behaviour is a deeply personal one; it can obviously be positively (or negatively) influenced to some extent by the opinion or actions of others (your family, a health professional and so on), but we will only sincerely regard it as a necessary change when we decide to that it is important enough; when the benefits of changing outweigh those we can think of for continuing.

We may have done the behaviour for many years and never regarded it as a problem (others may have told us it was but we didn't hear or believe them), we may have tried to change it on many occasions but struggled to overcome the challenges or struggled to maintain it.

Whether such decisions are about reducing your alcohol use, not injecting drugs, stopping smoking, eating a healthier diet, doing more exercise, being a better listener....the list is endless.  Whatever the change is, realising that it is personal, that it is going to take time, energy and perseverance are all extremely important factors.

If we use this knowledge of the challenges we have faced when changing our own behaviours to inform the way we encourage and motivate others to make positive behaviour changes, our interventions / advice are more likely to be effective.  

The decision to change may be a deeply personal one but we should never under-estimate the influence, both positive and negative, that we can have on this.

Cycle of Change - Prochaska and DiClemente

Lifestyle-related problems - should we pay for the treatment of them?

The cost of so-called lifestyle related problems on both the NHS and society as a whole is increasingly being scrutinised; figures such as 10% of the NHS budget have been quoted previously and today, savings of £400m are claimed to be possible by making such individuals pay at least in part for the cost of their treatment:

Make people pay for lifestyle related problems

The article in question makes pointed reference to those with Type 2 diabetes, suggesting that they should pay for their prescriptions.  This is one example of a huge range of health problems that can at least in part be caused by a person's lifestyle choices.

There is no doubt that as the number of people in society grows and as the population of older people requiring some form of care increases, the NHS as it appears now will have to change; possibly out of all recognition to the service that we are privileged to have today.

Maintaining a health service that is for the most part 'free at the point of delivery' is an ideal that we should surely strive to maintain but in order to achieve this, it is likely that many harsh and difficult decisions will have to be made; the cost of problems associated with a person's lifestyle may well be one of them.  However we must be careful in pursuing this path no matter whether it seems entirely correct to make those with 'self-inflicted' problems pay for their care....after all they did this to themselves right?

However there are a number of significant problems to this idea.

Firstly who decides which problems are lifestyle related?  If I choose to go rock-climbing and in spite of my best efforts, honed skills and high quality equipment fall and fracture a bone in my leg, is that 'lifestyle related'?  Should I pay for the cost of repairing my leg, the cost of prescribed medications I may require or the cost of after care such as physiotherapy?  If I choose to drink alcohol in excess of lower risk guidelines and develop pancreatitis, should I pay for this care?  If I choose to work in a job that is potentially hazardous (driving a petrol tanker, working on an oil rig for example) and then become ill should I pay? ... ... ....the list is endless.

Secondly who decides to what proportion someone's health problems are lifestyle related?  If I am a serious road runner and develop a problem with my knee, how could anyone prove beyond doubt that this was related to my chosen lifestyle?  If I use ecstasy at weekends and develop a cardiac arrhythmia, again how can you prove it is related to my substance use, particularly if I have a family history of arrhythmias?

Furthermore should other factors such as a person's circumstances be taken into account as part of such decision-making; should people who are victims of traumatic events in their lives (for example, those with post-traumatic stress disorder having served in the armed forces or survivors of sexual abuse) be given more leeway so to speak should they drink alcohol excessively?  If they develop 'lifestyle problems' should they pay less than someone deemed to have fewer mitigating circumstances?

It may well be that ultimately there is a case for charging for certain parts of a person's care.  And it may well be that lifestyle factors should be taken into consideration as part of this.  But this must be done with extreme care and certainly without prejudice or discrimination.  It is all too easy to blame someone's lifestyle on their subsequent needs, yet it is often extremely difficult / impossible to know the extent to which someone's lifestyle contributed to their problems.

Indeed, if raising the public's awareness of the financial cost of care provision is deemed to be important, would it make more sense to provide all patients who receive NHS care, with a theoretical bill of how much it cost?  Doing this in itself may encourage people to consider their lifestyle and how they choose to use the care provided by the NHS.

To my mind awareness raising in regard to this issue and articles such as the one that this blog links to, should provoke us to consider how best to change the implications that the scenario of escalating 'lifestyle related problems' has.  We know that delivery of interventions aimed at positive behaviour change can be extremely effective, yet how much of our resources are genuinely aimed at ensuring that this occurs?  How many nurses and doctors receive training on how to deliver effective interventions?  How many healthcare professionals clearly see this as a part of their role or have the time afforded to them to provide such interventions?

We should grasp every opportunity to promote positive behaviour change - it isn't the magic answer and it won't make this problem go away, but if more of our energies were focussed on providing this part of care as thoroughly and properly as possible, it would make a significant difference.

Maybe it would reduce the need for us to make as many difficult decisions about who should and should not pay for their care.

The brilliance of opportunistic interventions

For almost the last 8 years of my life, I've worked as a specialist nurse in the field of substance misuse (alcohol and other drugs).  However I've done this work in a relatively unusual setting (though one which is thankfully becoming less unusual as its potential is increasingly realised); that of the general hospital as opposed to in the community.

My work is extremely rewarding, I am passionate about the role and its effectiveness; so contrary to what a number of people may believe, the job - whilst undoubtedly challenging at times - is certainly not "depressing" or filled with a continual procession of people who "don't want to change" or who are "hopeless cases."  Sadly there are a small number of people who I see on a number of occasions but even then to regard people in the negative terms you often hear is at best unfair and at worst hopelessly inadequate; the way I see it is that people take differing lengths of time to place sufficient value on aspects of their lifestyle and as such take varying lengths of time to decide to make changes / make sufficient changes.

The main differences between my work and that of workers in community settings are firstly that the people I see have an active physical health problem that may or may not be related to their substance use; this health problem is so severe that hospitalisation is required.  Secondly and crucially they are not actively seeking support or advice at the time of their admission to hospital.  Indeed the first time they often become aware that support is available to them is when I arrive at their bed-side.

The majority of my interventions are therefore highly opportunistic; I am required to have a range of specialist skills in initial engagement in order to take advantage of what has rightly been coined "the teachable moment."  Over the years of doing this job I have come to realise that using this moment to its fullest potential can often be a crucial component of an individual's recovery; it can be the "light-bulb" moment when the person begins to truly see the negative consequences of their substance use and more importantly acknowledge that something needs to change.

Taking advantage of moments when people are the most receptive to behaviour change messages is key to our success as substance misuse workers or indeed anyone engaged in the area of promoting behaviour / lifestyle change.  Using these moments to foster belief, optimism and hope in an individual is paramount.

Having someone who believes in you and the changes that you can make is a powerful thing.

Having said that these moments can be fleeting and therefore it is vital that they are recognised and valued as soon as they occur and regarded highly; they can represent a significant turning point in a person's life.

The evidence base for the effectiveness of such interventions is now so strong (around 30 years worth) that their value cannot be disputed.  In spite of this health professionals generally receive little or no training in delivering brief advice; as such they frequently fall back upon out-dated and inaccurate stereotypes; a version of the world where people don't change because they either don't want to or are incapable of it.  The greater esteem in which such interventions are held, the better for people who would benefit from them.

In almost 8 years I've seen on too many occasions to count (I estimate that I've now seen around 5000 individuals), the value of talking to people about their lifestyles at times when they've not necessarily requested such advice or support but who are receptive to such messages because of their situation.  This of course doesn't have to be due to physical ill health, this concept can readily be applied to any number of settings.

What is key is using the 'teachable moment' to its fullest potential and empowering people with the belief that they can make positive changes to their lives.

The impossible is possible...

We should never underestimate the value that exercise in its various forms can have on not just our physical fitness but also on how balanced or happy we feel as individuals.

All too often we fail to recognise how important engaging in exercise can be, beyond its most common 'use' - to lose weight and/or gain physical fitness.  And yet there is no doubt that exercise can help us to feel happier in ourselves and about our lives in general, it can help us to feel more relaxed and better able to cope with the various stresses that we face.  It can be a powerful regulator of the frustrations we feel, but perhaps most importantly it can help us to feel truly exhilarated and to experience emotions that would otherwise not be felt.

Experiencing sun-rise on a Summer's morning, walking through woodland in Autumn and seeing Nature getting ready for Winter, reaching the peak of a hill or mountain...

As Scott Jurek says in the attached video, "happiness is like stillness..." and "life is about believing that the impossible is possible."

Everyone is capable of change

I regularly receive comments whilst at work that I am "too optimistic" or hear expressions of surprise that I'm trying to motivate or influence behaviour change in an individual that "isn't interested" or who "will never change."

Its easy to find ourselves in a position where this is the prevailing attitude; we let stereotypes get in the way and lose sight of the individual in front of us.

Everyone is capable of change.  And not only this, everyone is capable of change all of the time.  For some this will be relatively straightforward, others will require encouragement from those they trust, aspire to or who they respect.

Without realising it we can so easily de-motivate individuals and reinforce their lack of belief in change.  Then when they do not make the progress we would expect of them, it reinforces our own beliefs in that person and their "lack of interest" to change.

I have copied the text below from a blog by Katie Slack (MI training today) because its sentiment is so true:

It comes down to the question, will we choose to be judgemental and take a harsh stance with our clients about their lack of progress towards change...Or will we stand with them - where they are in the moment - and have compassion for their struggles, while still gently challenging them with the question "What do you want to do now?"

If the people we are involved with hear our lack of belief in them, where do they draw inspiration from then?

People come to believe what they hear themselves saying

People come to believe what they hear themselves saying...every opportunity we have to influence positive behaviour change should have this sentiment in mind.

A person's belief is far more powerful than any truth or advice that we can impart.  Influencing behaviour change will always be more effective if a person genuinely believes that they can (begin) to make changes to their life. We have a responsibility to foster personal belief and invest time in ensuring that the messages we give reinforce this in the peron we are talking to.

In its simplest form this can be asking a few questions about a persons lifestyle and LISTENING to their answers. It may mean offering basic advice or providing information on how to access specialist support. Sometimes it can take the form of an extended intervention with an individual.

However the underlying message has to be of optimism and positivity. If patients/clients/individuals hear negative messages from the person providing advice this will in most cases simply reinforce the status quo and reduce the chance that behaviour change will occur.

The value of opportunism

There are so many opportunities to influence positive behaviour or lifestyle change. However in order to take advantage of them we need to be able to see that they exist, have the skills to maximise the opportunity and have the belief that our intervention can be effective.

After 8 years of working as a specialist nurse in this area, specifically in relation to substance misuse, I believe passionately in the value of interventions aimed at influencing people to make positive lifestyle changes. Indeed I could now list so many examples of this that it surprises me how resistant other practitioners can be when it comes to encouraging them to provide this support.

This blog will illustrate the power that these interventions can have as well as the many opportunities that are constantly available for applying them.