2. The Process of Change Dr. Terry Hagan February 27, 2002 OST 505

3. What Are the Three Top Causes of Death in the U.S.? §#1: Heart Disease (34%) §#2: Cancer (24%) §#3: Cerebrovascular Disease (7%)

4. §What are the three leading “actual” causes of death in the U.S. according to Drs. McGinnis and Foege in their review article published in JAMA? (Vol. 270, No. 18, 1993) §Tobacco §Diet/activity patterns §Alcohol

5. What Percent of Patients’ Symptoms Are Not Clearly Organic in Nature? §Dr. Herbert Benson, M.D, from Harvard reports 75% of patients’ visits are related to mind/body and stress induced conditions. (Timeless Healing, 1997) §Drs. Mayou, bass, and Sharpe agree putting the number at about 80% (Treatment of Functional Somatic Symptoms, 1995)

6. §What is the common solution to these mind/body, stress induced, or self- inflicted symptoms? §A Change in behavior

7. A physician can help his or her patients change their self-defeating behaviors by: §Understanding how humans accomplish behavior change, and. §Supporting what works and avoiding what does not work.

8. §According to Social Learning Theory, what causes behaviors to increase or decrease? §Reinforcement §Punishment

9. Positive Reinforcement §Positive reinforcement - anything that is added (+) following a certain behavior that tends to increase that behavior

10. Negative Reinforcement §Negative reinforcement - anything that is taken away (-) following a certain behavior that tends to increase that behavior

11. Punishment §Something added or taken away following a behavior that tends to decrease the probability of that behavior.

12. Social Learning Theory §What is rewarding for one person is not necessarily rewarding for others. §Short term, certain rewards tend to be more attractive than long term, uncertain rewards.

13. What Works Best? §When people accomplish behavior change on their own they tend to use reinforcement rather than punishment.

14. Health Belief Model §Perceived Susceptibility §Perceived Severity §Perceived Benefits (“Pros” of changing) §Perceived Barriers (“Cons” of changing) §Perceived Self-Efficacy

15. Stages of Change Model §Individuals are at varying levels of motivation or readiness to change. §People at different points in the process of change will benefit from different stage matched interventions

16. Stages of Change Model §The basic premise is that behavior change is a process and not an event.

18. Precontemplation §Has not thought about changing before §Surprised that it is an issue §Wants to know why you think change is necessary §Sees some of the “pro’s” of changing

19. Contemplation §Is starting to consider some of the pros but is worried about the “con’s” of changing §Talks about the difficulties that would have to be confronted. §The power of the con’s must be dealt with and the perceived importance must be decreased in light of the pro’s of changing

20. Determination §Self-efficacy and the potential for help must be stressed - “you can do it and you don’t have to do it alone” §Sorting out best course of action §Referral is often appropriate here

21. Action §Patient begins a change strategy §Physician provides support and reinforcement where possible §Physician continues to support self-efficacy

22. Maintenance §Identify and use strategies to prevent relapse - anticipatory guidance §Review pro’s of changing at each visit §Provide reinforcement on an ongoing basis whenever possible

23. Relapse §Having a relapse is a normal part of the change process §Begin again at the contemplation stage and work with patient to reduce the power of the con’s §Encourage patient to continue program