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Key Elements of Effective Counseling

a. Ultimately the behavior change needs to come from the patient

b. The patient must see a compelling need for change.

c. The patient must feel confident that they can/will do what is suggested and that the proposed change will help.

d. Be empathic and demonstrate it


General Approach

a. Understand the patient’s beliefs and motivations. You cannot create motivation, you can only identify and redirect existing motivations.

b. Always look to “put the ball in the patient’s court”.

c. Avoid the temptation to give advice.

d. When in doubt, reflect back what the patient has been saying.

e. Try to bring the conversation to specific measurable achievable goals.


Initiating the Conversation

a. Ask the person how if they are concerned about their weight/diet/level of physical activity/health.

b. Give them time to really answer

c. Consider having them draw a weight history


Behavioral Models

*Know these

1. Transtheoretical Model (Stages of Change)

2. Health Belief Model

3. Values Based Counseling

4. Motivational Interviewing

5. Cognitive Behavioral Therapy


Transtheoretical Model

a. Model of the time ordered steps leading to sustained behavior change.

b. Focuses on the decision making process of the individual.

c. Relies on self report.


Stages of Change
Your goal is to help the person to the next stage



Health Belief Model

*Know this

a. Posits that a person’s willingness to change relates to their perception of their vulnerability for illness and the possible effectiveness of treatment.

b. Behavior change occurs if a person:
i. Perceives themself as at risk for illness.
ii. Identifies the problem as serious.
iii. Convinced that treatment is effective and not overly ‘costly’.
iv. Exposed to a cue to take health action.
v. Have confidence that they can perform specific behaviors that will be helpful.


What is a Compelling Need for Change? Core Values

a. Case 1: What if he sees the risks of health problems associated with his weight but does not make time for working on losing weight?

b. Perhaps “health” is not is top priority and he is putting his diet below other more “important” priorities.

c. How do we talk to him about this?


Action Phase

a. Person sees a compelling need for change

b. They may have their own idea of what they want to do

c. I would encourage you to support them. Their motivation for change creates forward momentum.

d. Help them see future challenges.



a. Patient is sad, this makes you frustrated/hopeless/avoidant.

b. Review positive aspects of the history.

c. Acknowledge how common relapse is.

d. Open the door to reconsidering behavior change.


Motivational Interviewing

*Know this

a. Examination and resolution of ambivalence is its central purpose

b. Direct persuasion is not an effective method for resolving ambivalence.

c. Readiness to change/resistance provide feedback about the counselor’s demands.

d. Build a sense of self-efficacy


Motivational interviewing

How it works

a. The goal is to have the patient do most of the talking

b. A person needs to see a compelling need to change

c. Ask questions like: “on a scale of 1-10 how much do you think your diet is causing your health problems?”


Motivational interviewing
Getting people to change

a. Many people see the problem they just don’t feel confident/competent/capable to change

b. Ask questions like: “on a scale of 1-10 how confident are you that you can change your diet?”

c. What does it take to get behavior change?
i. Probably about a 7
ii. Small changes
iii. High likelihood of success that will build self-efficacy
iv. Concrete goals that are measurable: what, where, when, how?


Sample goals

a. Keeping a Diet Log

b. Getting a Pedometer and measuring steps

c. Eating Breakfast

d. Going to Weight Watchers

e. Switching to Diet Soda

f. Reducing fast food from 3x/wk to 1x/wk


Cognitive Behavioral Therapy

a. Focus is on actually changing unwanted behaviors not motivation.

b. Self monitoring: intake, emotions, thoughts, motivations.

c. Stimulus control: identify trigger events and deal with them.

d. Cognitive restructuring: change unhelpful thinking.


Set Goals

a. If you want things to change, you have to set some goals and then try to meet them.

b. The more specific the goal the better

c. Small achievable goals are better than big difficult goals.


Other factors to consider

Stress at home or work
Social support
Cognitive function, numeracy
Substance use



a. It is hard to get people to change their behavior and there is no one right approach.

b. The more “tricks” you have the more flexible your approach will be.

c. “Stages of change” is a good place to start

d. Focus on whether the person sees a compelling need for change and how this relates to their core values.

e. Understand what they have tried in the past, what has worked, what hasn’t and why.

f. Try to have them do most of the talking.

g. Try to have them come up with the approach, while keeping the goals small, measurable and ensuring that they have a high level of confidence that they can succeed.

h. Keep the tone positive for them and for you..


Summary of what to try with patient

a. Self monitoring appears to be key
i. Not just what they are eating, but what they are feeling

b. Consider having the person develop some skills before changing their diet.

c. Most people will benefit from some structure, this can come from a commercial program, a nutritionist or a diet book.


Behavioral Models

*know these

1. Transtheoretical Model: Helps you assess readiness, doesn’t tell you what to do

2. Health Belief Model: Helps you focus on reasons that the patient does not find a medical issue motivating

3. Values Based Counseling: Helps you understand why people aren’t prioritizing health behaviors

4. Motivational Interviewing: Counseling style to address ambivalence.

5. Cognitive Behavioral Therapy: Counseling approach that focuses on skills and specific behavioral goals