Behavior change – lessons from the health sector for all leaders

Creating the conditions for, and facilitating, behavior change is a core competency of great leaders and managers. It is also perceived to be one of the most difficult things to achieve and requires approaches and skill that, although may be intuitive to some, the majority find challenging and perplexing. However, research and experience have shown us that there are some clear frameworks and simple skills that can be taught to give leaders and managers huge assistance in more elegantly and successfully influencing behavior change. The health sector provides us with a useful example and model for this.

Health practitioners have had to develop ways to help people change long-standing behaviors that pose significant health risks. These behaviors include smoking, poor eating habits, heavy drinking, drug dependence, managing diabetes and the like. It was through the examination of research on what it is that actually causes people to change their behavior that leads to the development in medical circles of the technique referred to as Motivational Interviewing (MI). Research around behavior change shows that motivation is a dynamic state that can be influenced, and that it fluctuates in response to a practitioner’s style. Importantly, an authoritative or paternalistic therapeutic style may in fact deter change by increasing resistance.

Motivational Interviewing has emerged in the last 20 years, arising from the work of Prochaska and Di Clemente, Stages of Change model and the work of Miller and Rollnick (2002). It is an effective counselling method that involves enhancing a patient’s motivation to change by means of four guiding principles, represented by the acronym RULE:

  • Resist the righting reflex; (ie the tendency for health professionals to advise patients about the right path to good health)
  • Understand the patient’s own motivations;
  • Listen with empathy; and
  • Empower the patient.

Changing behavior

There has long been an assumption that if we provide people with compelling information about the health consequences of some behaviors people will change. In reality we know this to be a fallacy. Information, no matter how compelling, regarding the harm to health of behavior such as smoking, or excessive alcohol consumption will not on its own bring about change in behavior.

From the theory and practice of behavior change it has been found that interventions that tap into people’s motivation, allow them to identify the personal benefits of any change, and allow them to shape what change they want are more successful. If this takes place in a supportive environment it is more likely to lead to sustained behavior change.

Motivational Interviewing (MI)

MI enhances motivation through the resolution of ambivalence, especially the ambivalence created when simultaneously wanting to change and not change because the conflict between the immediacy of the reward versus the longer-term adverse consequences of the behavior.

Three critical components of motivation are,

  • Willingness (the importance of change for the patient)
  • Ability (confidence to change)
  • Readiness (whether the change is an immediate priority)

Motivational interviewing is built on the principles of

  • Collaborative partnership between practitioner and patient
  • Evoking the patient’s own motivation for change, linking this to the personal benefits they identify from bring about change
  • Honoring the patients autonomy, i.e. it is their choice to change

The methodology has 2 key phases,

  1. Building motivation to change
  1. Strengthening motivation to change

Step 1 is done in the context of building rapport and the relationship. The guiding principles for building motivation to change in the one-on-one interview are as follows (from Kate Hall et al 2012),

  • Ask open-ended questions so that the patient does most of the talking and provides the practitioner with the opportunity to learn more about the patient’s values and goals
  • Make affirmations in the form of complements, or statements of appreciation and understanding. These help build rapport, validate and support the patient through change
  • Use reflection by re-phrasing to capture the implicit meaning in a patient’s statements to encourage continual exploration by the patient of their motivations, and deepen their commitment to change
  • Use summarizing to demonstrate listening, connect ideas, clarify and check understanding and contrasts difference in the patient’s present situation and goal.

Strengthening motivation for change, involves setting goals and negotiating a ‘change plan of action’.

In this phase the patient’s intention to change is elicited. This is done through a series of carefully constructed questions that cover the disadvantages of the status quo, the advantages of change, optimism for change and an explicit statement of intention to change.

Questions such as,

If you think of a scale from zero to 10 of how important it is to loose weight (or other behavior). On this scale zero is not important and 10 is extremely important. What would you be on this scale? Why are you at … and not zero? What would it take for you to go from … to (a higher number)?

A similar line of questioning can be used for confidence around change.

Strengthening the motivation to change is under-pinned by the therapist

  • Expressing empathy
  • Developing discrepancy
  • Rolling with resistance
  • Supporting self-sufficiency

Recent analysis (Kate Hall et al, 2012) has shown that MI has equivalent or better results than other treatments such as cognitive behavior therapy (CBT) or pharmacotherapy, and superior to placebo and non-treatment for decreasing alcohol and drug dependence.

Application of the principles of MI to leadership and management

Whilst leaders and managers are not trying to break an addiction, they often need to help members of their team change habits of a lifetime that have usually served them well in some way or other.

Tapping into their motivation and using it to bring about change in behavior can improve individual performance and have flow on benefits for teams.

The same principles apply as used in MI in the health sector. Seek to understand the person’s motivation for change, help them see the difference between where they are and where / how they would like to be, help them develop an optimism for change and a plan to bring it about. All this needs to be done by the leader developing rapport and nurturing a collaborative relationship with the team member, listening empathetically, drawing out the motivations through carefully crafted questions, helping them to see that change is possible, and supporting them to make the changes.

Jill Tideman

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