The mystery of change (-ing others): article in the Irish Psychologist
How may I help you– change you?*
“Change is the Law of Life. And those who look only to the past or present are certain to miss the future.” – John F. Kennedy
Trying to help somebody to change their bad habits is an admirable act of kindness. It shows our compassion and care for the less fortunate. The best is when it comes from the person’s own initiative. Motivated helpers are assumed to be good helpers. Some of us help others pro bono, while others do it as part of their job description. But what if the professional helper doesn’t want to help? How do you help the helper with change in others?
Encouraging professional helpers to address excessive drinking is a complex problem. It’s so complex and resistant to change, that their unwillingness to adopt these new practices can be viewed as a bad habit. Many experts called for complex strategies to persuade their clinician colleagues to address alcohol. But complex strategies did not help.
Professors Anderson, Laurant, Kaner, Wensing and Grol reviewed available scientific evidence and claimed it was possible to increase the engagement of doctors in screening and advice-giving for excessive drinking. They saw a potential in programs which were specifically focussed on alcohol and that were multi-component. Later, some of the original team tested this theory by doing a clinical trial, which is a type of study considered as a golden-standard by many experts. Their Swedish experiment “failed to show an effect and proved difficult to implement”. Are the Swedish too stubborn to embrace change? Let’s not be harsh by accepting this cultural stereotype as a plausible explanation for their negative findings, before we look at more perplexing findings from other countries.
When scientists ask doctors and other professional helpers about what’s so difficult in talking alcohol with their patients, they give the same reasons all over the world. The World Health Organisation (WHO) commissioned a multi-state study, at the beginning of the millennium, which documented all of these reasons – the myths about alcohol care. The myths were lack of time, inadequate training, a view that alcohol is not a matter that needs to be addressed by medical doctors, conviction that doctors’ advice won’t work and fear of talking about such sensitive issue. It seems that the next twist in the story of change brings us to helpers’ beliefs.
Recent research at the University of Michigan, cardiovascular centre demonstrated how doctors’ confidence in their ability to advise patients on diet and exercise correspond with their own personal health and fitness levels. Could this apply to alcohol too? Would it help if we use some evidence-based strategy to boost their confidence or ambivalence about drinking behaviours?
Motivational enhancement therapy (MET) is an evidence-based treatment which targets person’s ambivalence about unwanted behaviours including their attitudes and beliefs. A team supervised by Professors Hettema and Sorensen used this Swiss-army knife of addiction counselling to help doctors-to-be to resolve their ambivalence around managing alcohol and drug problems. They’ve put a group of nine medical residents through a brief MET therapy before they learned more about alcohol consulting and advice-giving. Five weeks later, their consulting and advice-giving went up, but due to the small numbers, the researchers called for caution with interpretation of their results.
Resident education was combined with a team-based approach to systems change in the Richmond clinic – a busy family practice in the south-east Portland, Oregon. Dr Muench led his team to change the way they deal with drinking issues – from receptionists, through medical assistants to physicians.
Dr Muench is a slim, middle-aged physician with a passion for teaching young doctors and helping patients from difficult backgrounds. Explaining their approach to practice change, he points out, ‘we’ve strengthened our practice systems, but the system leaks at three points. They are at the front desk, in the consultation room and in the teaching modules.’ In making these comments, Dr Muench argues that while their project led to many improvements, there are things that can be improved. Ultimately, Muench conveys a positive message about systems change being possible, although not without some obstacles. In the Richmond team-based approach, the receptionists should give patients alcohol check-ups while they wait for the consultation, but they often forget because the PC fails to remind them of this. When the receptionist doesn’t forget to hand out the form, and the patient brings it to a medical assistant, she frequently forgets to complete the full assessment. It is no surprise then that the next ‘cog in the machine’ – the doctors – ‘forget’ to discuss alcohol with patients.
What science tells us about implementing change is reassuringly similar to the traditional knowledge of common folk. If you can’t change others, change yourself. “We must become the change we want to see”, said Gandhi. Richmond truly became the change they wanted to see in others. And yet, the project’s 75% yardstick of engaging patients into alcohol discussions wasn’t met. Why was Richmond below targets? Embracing change in healthcare requires system changes and education on several levels – multi-level changes.
*This is a shortened version of my article published in the Irish Psychologist, Volume 40, Issue 2/3. Dennis McCarty, PhD gave me feedback on drafts of this blog post.
Citation for the full version of this article: