Responding to Nonadherence

Psychological Techniques for Increasing Adherence with Self-Care Recommendations

Why Don’t Patients Follow Recommendations?

Nonadherence is a common and frustrating problem. Why don’t people follow professional advice that would help them?!? Research on the process of behavior change explains this puzzle and suggests techniques for increasing adherence.

Why Do People Change Their Behavior?

Think about the changes you have—or have not—made in your own behaviors. Examples may be flossing, exercising, eating wisely, parenting, driving, etc. In general, we change when we believe: “Change will achieve something that is more important to me than my other priorities or options at this time” and “I can do it.”

People follow advice to change when changing becomes important to them -- when they are motivated and see changing as having high priority -- and when they believe change is possible for them. For patients to change what they are doing, they (not you) must see the changes as important and possible.

How Do People Change?

Successful long-term change seems to involve working through five stages:

1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance

People in the Precontemplation stage may be unaware that change is even needed (“What problem?”) or may deny the importance of change (“So what?”). In the Contemplation stage, they are dissatisfied or concerned, but ambivalent (“Maybe I should, but ….”). In Preparation, they believe change is both important and possible and are actively preparing to change in the coming weeks or months (“I will …”). In Action, they actually change (“I am ….”). In Maintenance, they continue the changed behavior indefinitely (“I am continuing to …”).

Understanding and Reducing Nonadherence

Nonadherence occurs at the Precontemplation, Contemplation, and Preparation stages. Reduce nonadherence by identifying your patient’s current stage of change and adapting your response.

Two questions can identify a patient’s stage of change:

1. Importance: “On a scale of 0 to 10 (where 0 is not at all important and 10 is extremely important), how important is it to you to [insert the self-care behavior/change] right now?”
2. Confidence: “On a scale of 0 to 10 (where 0 is not at all confident and 10 is extremely confident), how confident are you that – if you decided to – you could make this change?”

Scores of 0-3 suggest the person is in Precontemplation, scores of 4-7 suggest Contemplation, and scores of 7-10 suggest the person may be ready to change (in Preparation, Action, or Maintenance).

Increase importance or confidence by asking, “What makes you choose a [current number] rather than a [2-3 points lower number]?” Get your patient to talk about how change might be important and possible. An optional follow-up question is,“What would it take for you to move from a [current number] to a [1-2 points higher]?”

Summarize back to them their own reasons/words/values. Ask permission before giving information/advice (“Would you be interested in hearing ….?”).

Different Approaches at Different Steps

Pushing for change before someone is ready makes most people feel pressured or not heard. They then become rebellious/resentful, passive, or avoidant. Responding based on their current stage is more effective in fostering change.

In Precontemplation

Ask questions about what they dislike about the status quo and their reasons to change. Repeat their reasons for changing. Ask permission before giving information/advice. Then ask, “What do you make of that?” Acknowledge their right to decide when and whether to change but express confidence in their ability to change when they are ready.

In Contemplation

Ask questions that elicit benefits of change AND questions that help them see change as possible. Have them imagine successfully changing. Ask questions like, “What would you do first? Then what?” Continue to express confidence in their ability to change when they are ready and to ask permission before offering advice/information.

In Preparation

Ask what they need in order to change, then give it to them or help them figure out how to get it. Encourage them to publicly commit to changing by telling others about their plans.

In Action

Treat, teach, and trouble-shoot. Ask them to tell you what they have learned, have accomplished, and are doing that works.

In Maintenance

Ask how they will make self-care a routine part of daily life and how they will reward or encourage themselves. How they will track behaviors or results, prevent or quickly resolve relapses, and overcome foreseeable problems?

When Patients Relapse

Be respectful and curious. Express caring and concern. Re-assess their current stage of change and respond accordingly. Always offer hope and encouragement because no one knows what the future may bring.

Dr McMahon is the author of Overcoming the Emotional Challenges of Lymphedema, coauthor of Living Well With Lymphedema and Lymphedema Caregiver’s Guide, co-editor of Voices of Lymphedema, and is writing a book on increasing adherence.

“Responding to Nonadherence: Psychological Techniques for Increasing Adherence with Self-Care Recommendations” appeared in Lymph Link, National Lymphedema Network newsletter, 25(1): 8-10, January-March 2013. www.lymphnet.org