TABLE 9-2 Reasons Change Is Difficult

To help someone with the process of change, these issues must be addressed. Listening and empathic responding (discussed in Chapter 4) are very important here. People’s fears and concerns must be taken seriously and responded to in a respectful way. The fear or anxiety needs to be honored (“So, you are concerned that you may not have all of the resources that you need to make the necessary changes”), not disparaged. Attempting to minimize the fear (“Oh come on, it’s not so bad”) is not an effective way to gain trust. Comparing the person with others (“Other patients haven’t had difficulties with this”) is also not very effective.

Anger, blaming, and scapegoating. It is not unusual for people to become angry or defensive when faced with change, particularly if they do not feel they have been involved in the process or the decisions that have been made that will affect them directly. Therefore, when helping employees or patients deal with change, participation and feedback are essential.

As discussed in Chapter 6, anger is an emotion that is often used to mask another emotion such as fear, anxiety, or frustration. Rather than admitting that they feel afraid as a result of change, people often convert that to anger because anger feels more powerful and less “weak.” What sometimes follows this angry response is blaming, scapegoating, or some form of discounting. People begin to blame someone or something, calling the change silly or unnecessary and explaining why they can’t make the change or why it won’t work. They may discount the importance of the change so that they don’t have to do anything. After all, if the change is not important, then why should they invest in it?

The key is to understand that these kinds of responses indicate that people feel threatened and anxious about the change. Perceived threats need to be explored and understood rather than minimized. Individuals need to be respectfully confronted with statements like “From what you have said, I assume that you don’t believe the change is necessary. Tell me why. I’d like your input,” or “Given the problem we’re having, what would you propose instead?” We can hold the person responsible for his or her statements and behavior without being punitive or shaming.

Going numb, or avoidance. One response to change is to avoid it altogether—to go numb and act as though nothing has changed: If I don’t think about it, it will go away. Even though most of us would agree that this is unhealthy, it is still one way that people cope when they feel threatened.

Going numb can also mean deciding to do nothing rather than change because enough other people have made this same decision—even though all involved know that this decision may be harmful to themselves or others. For example, some pharmacists do not counsel their patients, even though they know that by doing this (nothing) they place their patients at risk. They use the fact that other pharmacists shirk this responsibility as justification for their inaction. Time and lack of reimbursement are often used as excuses for this inaction. However, time and money are surely less important than a human life.

Excitement, joy, and relief. Some patients may actually experience these emotions when they are diagnosed with an illness. For example, the patient who finds out she has diabetes may experience relief at finally knowing why she has felt so bad for so long. Knowing that the illness is controllable, she experiences relief and a sense of being in charge of her life again. For many people, change can be exciting if it clearly represents something better for them, whether that be working conditions, technology, health, or some other part of life.

Positive reactions to change should be verbally recognized or supported. If a patient is doing a particularly good job of managing his or her illness, this should be acknowledged (“I like that you are refilling your medicine on time and regularly monitoring your blood pressure”) so that desired behaviors are repeated. It is unfortunate that too often we focus on things people do that we don’t like, rather than on all the things they do that we do like. We sometimes ask ourselves why we should praise people for doing what they’re supposed to be doing. The answer is quite simple. We want them to keep doing it. All of us like to be recognized for our accomplishments.

Frustration. This is a common response to change. For reasons similar to those described for anger, change can be very frustrating when people affected by the change are not involved in the process and have not been asked for feedback. Again, the reasons for the frustration need to be explored rather than minimized.

Depression, both existential and clinical. When people are faced with change, even if they can see its benefits, depression sometimes occurs. This is particularly true when people find out that they have an illness that they will have to treat for life. Many times, the chronic illness is a harsh reminder that they are not immortal or that they are growing older. The feeling that they will live forever has been quickly jerked away, and this is difficult to accept immediately. When patients begin to express this sense of loss, which is healthy, too many health care providers and others try to fix the problem rather than being emotionally available to the person with the illness. This fixing includes statements like “Cheer up. At least you know what it is” and “It’s not so bad. Millions of people have diabetes (or high blood pressure or asthma or whatever), and it’s treatable.” These statements minimize the importance of the patient’s feelings—how he or she is currently experiencing the illness. Simply listening to the patient and reflecting back your understanding of the patient’s perspective is far more powerful.

A distinction needs to be made between existential depression and clinical depression. Existential means that the feeling moves the patient forward; it promotes existence. When we are faced with change, even if the change is positive, we must give up some part of how we used to be to become something new. This creates a sense of loss that can be experienced as depression. If you have ever been in a funk for a day or two and could not for the life of you explain why, chances are very good that some important change was taking place in your life. Clinical depression, on the other hand, is much more severe and prolonged. Clinical depression can result from major change in a person’s life. It needs to be taken seriously by health care providers and treated by a therapist, with drug therapy, or both.

Feeling out of control. When faced with change, particularly sudden or chaotic change, people often feel out of control. To feel more in control, they revert back to old, familiar behaviors, numb out, blame someone, discount the change, or make the change. To encourage the person to make the change, it is important to understand the reasons for feeling out of control and examine ways the person might feel more in control of what is happening.

Shame or guilt. People may feel ashamed or guilty when faced with change. If the change is threatening, like a chronic illness or a change in their job description, some people believe the change is a result of past “sinful” behavior. They believe that in some way they deserve the “punishment” being inflicted on them. This is regrettable. Because these thoughts are irrational, they cannot be dealt with by reasoning. Listening and empathy are important. Staying focused on the task at hand is also vital. For example, Mrs. Jones states, “I just know I got diabetes because I ate too many sweets as a kid.” The pharmacist responds, “Let’s see what we can do to get your diabetes under control so that you can live a long, healthy life,” rather than “Oh, Mrs. Jones, I’m sure that has nothing to do with this.”

Feeling alone in the world. Even when people realize that they need to change, it can feel very lonely. People may receive help with the change, but ultimately change is most often made at the individual level. This can be frightening. Our primary fear is being alone in the world. One of the most powerful things pharmacists can do to help patients make necessary changes is to be emotionally available and reflect back their understanding. If a problem can be understood, it can be solved. This provides hope. Hope provides energy for change.

SUMMARY OF EMOTIONAL RESPONSES

Change can be difficult. It is our emotional reaction that often determines whether a change will be embraced or avoided. Depending on their abilities, insights, beliefs, values, and perceptions, people respond differently to the same change. Each response needs to be honored and explored, even if a change must ultimately be made. We should not presume to know how the patient is responding to the required change, but instead should explore his or her feelings, empathize with these feelings, and help formulate the problem in a productive way that makes sense to the patient.

READINESS FOR CHANGE

In the first part of this chapter we discussed people’s emotional reactions to change and why they have these varied reactions. Now we will examine change from the perspective of a patient’s readiness to manage an illness, particularly a chronic illness. Managing an illness often requires changes in multiple behaviors. For example, patients with diabetes will need to use their medications correctly, exercise, change their diet, and monitor their blood glucose. They will not necessarily engage in each of these behaviors equally well, nor are they likely to engage in each of the behaviors with the same degree of motivation or commitment. This part of the chapter will examine a model of change and discuss how pharmacists and other health care providers can assist patients in managing their illnesses.

TRANSTHEORETICAL MODEL OF CHANGE

During the 1970s and 1980s, Prochaska and colleagues did an exhaustive examination of the literature on change.¹,² They looked at why and how people change in therapy, why they do not change, and why and how they change outside of therapy. They examined change across more than 200 different psychotherapies. The objective was to develop a comprehensive model that could be used to predict how ready an individual is for change and how to intervene to assist the individual in making the change.

From this research, the transtheoretical model of change was developed. In summary, Prochaska and colleagues were able to identify 5 stages of readiness for change (Table 9-3) and 10 processes of change (Table 9-4) that individuals use to move from one stage of readiness to the next. In other words, change is not an either/or process.³,⁴ People often cycle through the five stages of change (or readiness) before the change is internalized and habituated. The first three stages are cognitive. That is, people think about the change and weigh the pros and cons of making the change. They also decide whether they have the skills and resources to make the necessary changes (self-efficacy). While in each stage of readiness, people use different internal processes (Table 9-4) to move to the next stage.

It is the health care provider’s task to assess the patient’s readiness to manage the target behaviors and then use stage-specific skills and strategies to stimulate the internal processes used to motivate change and help the patient move to the next stage of readiness. Notice that the task is not necessarily to move the patient directly to action. It is to help the patient move to the next stage.

For example, one internal process is consciousness-raising. It is the most-used process of change. Increasing the information available to the patient can help the patient make better choices. For patients with diabetes to successfully manage their illness, they must first know enough about the illness and how to control it. Therefore, their understanding of the illness and its treatment must be assessed and then appropriate information must be communicated. Although education does not predict adherence, it is vital that patients assimilate accurate information and understand its relevance to their situation so that they have a reasonable chance to succeed. Thus, education is an intervention that can stimulate the internal process, consciousness-raising, in the patient.

This model is very powerful, yet sometimes it presents difficulties for health care providers who have a strong need for control or believe that they manage the patient’s illness. In reality, we cannot control, motivate, or save the patient. Nor do health care providers manage an illness. Patients manage illnesses, or they don’t. What we can do is provide sufficient, understandable information in a caring, trusting context in which patients feel safe enough and free enough to discuss their successes and problems in managing their illnesses. In addition, we can use patient-centered skills and strategies to help patients move toward healthy behaviors. We need to really listen to the patient instead of presuming to know the patient’s situation, and to provide only information that directly relates to the patient’s concerns, problem, and worries.

TABLE 9-3 Stages of Change and Pharmacist Support

TABLE 9-4 Process of Change and Most Prominent Stages

Table 9-5 contrasts the biomedical (paternalistic) model of care with a socio-behavioral model of care. The biomedical model is one in which the health care provider is in control. In the socio-behavioral model, the patient and provider are partners who negotiate care. The biomedical model works well in controlled settings such as hospitals and nursing homes. However, it does not work well at all when the patient is ambulatory and can choose whether or not to follow a treatment regimen; this is where socio-behavioral models (such as the transtheoretical model) work best.

TABLE 9-5 Traditional versus Empowerment Model of Care

SOME IMPORTANT CONTRASTS

Before further discussion of the stages of change, let’s look at some important contrasts (Table 9-6). When people are faced with change, initially the change may seem foreign to them. This is especially true when they are told they have a chronic illness to manage. They may say, “It’s not happening to me” or “It’s not really that serious.” In other words, they don’t accept what is happening to them. Until the change or illness is internalized or integrated and becomes part of who the person is, the change is unlikely to take place. Empathy, understanding, and education assist in the process of internalization.

Ambivalence is a major reason people don’t change. If they don’t know what to do or how to do it, or do not believe they have the skills or resources to do what is necessary, change usually does not occur. And if they don’t believe that the pros of making the change outweigh the cons, they won’t change. Interventions that help people understand what is needed, the benefits that will result, and how to minimize or overcome real or perceived barriers are often useful. In addition, dissonance about not changing is a powerful promoter of change. If people believe that staying the same will create more problems than changing, change is more likely. Dissonance stimulates self-re-evaluation. In order to change, the patient must decide that he will like himself more as a result of the changes. More on creating dissonance later.

People are less likely to change if they feel coerced or feel their freedom is being impinged on. People are more likely to change when they believe the decision is theirs. Good decision-making is aided by accurate, nonjudgmental information, empathic understanding, and emphasis on the benefits of making the change.

TABLE 9-6 Important Contrasts

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