This interview is the fourth in a series of brief chats between CFAH president and founder, Jessie Gruman and experts - our CFAH William Ziff Fellows - who have devoted their careers to understanding and encouraging people's engagement in their health and health care.
David S. Sobel believes that there is good evidence that 'small success (in behavior change) may lead to lasting health improvement.
Gruman: Are there specific insights you have come across recently that you think would be useful for those working to support people's increased engagement in their health and health care?
Sobel: There is an accumulation of evidence that behavior change may not be very difficult if you apply what is known about behavior change. In the book Switch there is an example if you set as your goal a clean room, you have an early experience of failure. But if you put a 5-minute timer on, i.e., you clean your room for 5 minutes, you are more likely to have a success experience. In his book, 59 Seconds: Think a Little, Change a Lot, Richard Wiseman is challenged to provide the evidence on what people can do to leverage evidence-based behavioral techniques to change rapidly (a worthwhile read!).
Small success may lead to lasting change. But the experience of success/efficacy appears to have direct health promoting effects independent of the benefits of any particular behavior that is changed. Success change boosts mood, confidence, optimism and these are associated with better health outcomes, as well as a happier, more satisfying life!
Gruman: Can you be more specific about what this might mean
Sobel: My young son used to think life was about continuous improvement in all domains. As human beings we thrive on sensing improvement and mastery. However, whether as a result of age, accidents, or illness we begin to experience a decline in one or more domains of life.
One of the things people learn in the Chronic Disease Self-Management program is how to identify one small area where something can change, for the better. In addition, there is mounting evidence that adhering to medications (even if it is a placebo!) improves health outcomes. In other words, our beliefs or daily affirmation of doing something to improve our health (whether taking a medication, a vitamin or even a placebo) increases our sense of control over future health'and in fact, seems to shape our future health independent of the pharmacological effect of the medication.
Gruman: How do we help people have those confidence-building success experiences?
Sobel: One way is to shrink the change or help them identify some small baby steps that set people up for success. The other is to clear the path and make the change easier, often through changing the environment or providing 'hot triggers' to cue the behavior.
We too often set up others and ourselves for failure experiences with unattainable goals, resolutions, and expectations. Someone recently conducted a survey of diabetes educators what are all the things diabetic patients need to do? The survey found that it would take a person two hours a day to accomplish them all. Clinically we have to help patients prioritize what is likely to have the biggest impact on their health, engage them in prioritizing how this fits with all the other complexities and demands in their lives, and finally, teach them the skills to set small goals and have success experiences. This is one of the fundamental self-management strategies used in the Chronic Disease Self-Management Program at Stanford.
Gruman: What are the implications of this line of thinking for clinicians?
Sobel: I lead a training program on collaborative communication on medication adherence for clinicians that included strategies like motivational interviewing and involving patients in generating solutions. I told the story of one of my patients'a woman who was having trouble remembering to take her pills. I said, 'It sounds like you want to take your meds and have a hard time remembering. What might work to help you remember? And then I paused. After a brief moment, she said, 'I'll put it on the Tide box. I do laundry every day and I have the Tide detergent box. I asked her how confident she was that this'll work and she said she was pretty sure it would.
The question I posed to the clinicians in the program was 'How long would it take you to come up with the Tide box? Patient-generated solutions are more likely to succeed. If a patient or person cannot come up with any ideas there is a possibility that they are depressed. So asking for patient-generated solutions is also a quick way to do a preliminary screening for depression!
Gruman: That really requires a different approach: the clinician takes time to problem-solve with her patient'
Sobel: Physicians often complain that people are not motivated for treatment but don't look for what they ARE motivated about and for. What really drives and animates a patient's life? We need to try to align the needed behavior change with peoples passions and aims.
I had been seeing a patient with diabetes for many years. I really enjoyed him but his HgA1c was above 10 and I tried everything to help him work on it' Nothing I said seemed to help him get it down.' One day I asked him, 'What do you really enjoy? After a brief pause, he replied I love to go trout fishing. In that brief 30 second exchange many things changed: 1) I did a brief screening for depression (if he can't identify anything pleasurable then it is a signal that I should more thoroughly screen him for depression) 2) I no longer saw him as an overweight, diabetic, hypertensive, but rather the image I now held was of him in a river trout fishing, 3) Our treatment from then on was aligned with his internal motivation and our shared goal was to keep him healthy enough to continue to enjoy fishing, 4) He sensed that I cared about him as a whole person, not just a collection of problems, diagnoses, and symptoms, 5) I got for a brief few seconds to leave my world of patient problems, symptoms, and suffering and enter a pleasurable world of trout fishing.
I am now experimenting informally with asking selected patients what they enjoy. This is bringing some of my previous focus on Healthy Pleasures into the exam room for the benefit of both the patient and myself!
More patient engagement inteviews with our Ziff fellows by Jessie Gruman