Behaviour-Change Conversations
“You tell someone to sleep 7+ hours and stop eating late. They nod. Six weeks later nothing has changed. Whose failure is it?”
The teaching
- Information is rarely the missing ingredient. Most people know what is "good for them". The consultation's job is to help them connect it to their own reasons.
- Motivational interviewing (MI). A collaborative, goal-oriented style that strengthens a person's own motivation for change. Core skills: open questions, affirmations, reflections, summaries (OARS), and eliciting "change talk". Evidence: Rubak et al. (2005), a systematic review and meta-analysis of randomised trials in healthcare settings, found MI outperformed traditional advice-giving in a majority of studies; effect varies by outcome and practitioner.
- Stages of change (transtheoretical model): a useful vocabulary, a contested evidence base. A Cochrane review of stage-based interventions for smoking cessation (41 trials, more than 33,000 participants) found no proven added benefit over non-stage-based approaches. Teach the stages as a way to listen, not as a way to sort people.
- Shared decision-making (SDM). The person and the clinician combine what the evidence says with what matters to this individual: their values, circumstances and preferences. This is the natural fit for private, individualised care, where time allows genuine exploration of options.
- Agreeing small, specific, owned goals. Link back to Module 3's Prioritise and Personalise steps: one change the person chose, how they will know, when you will check (Measure).
- Relapse is data, not failure. Return to the conversation, don't repeat the advice.
Translation box
Practitioner | Coach |
|---|---|
Weave MI into clinical decision-making: risks, tests and treatment options | MI is native territory; the skill is the product |
SDM includes medical options and uncertainty | SDM is about the plan and its trade-offs; medication/diagnostic decisions go to the clinician |
Myth vs Reality
Motivational interviewing means never giving advice.
MI asks permission before advising and tailors advice to what the person has said. It is not advice-free.
Dr Haq’s 30 Seconds
A short personal take from your course director
Recording to come — 20–40 seconds in Dr Haq’s own words.
A note on the evidence
MI evidence is moderate and heterogeneous. Stages-of-change evidence for specific interventions is weak. SDM is guideline-endorsed; its effect on long-term outcomes varies by setting. Do not overclaim any of these.
Patient Journey — Checkpoint 15
Richard says: "I know I should sleep more. I just can't." Write two reflections and one open question that would move the conversation toward his own reason (hint: his father, Checkpoint 3).
How would you apply the lesson to this conversation?
Mini case
Sam (from earlier in the course) agrees to a plan, then returns having done none of it. Role-play the first three minutes: what do you say, and what do you leave unsaid?
Reflect before you move on
Which of your recommendations do you give because you want the person to do them, rather than because they have asked for them?
Video · scripted role-play · reflection prompts.
References
- Pendleton D, Schofield T, Tate P, Havelock P. The Consultation: An Approach to Learning and Teaching. Oxford University Press, 1984. (Seven tasks incl. ICE in task 1; via GPnotebook.)
- Neighbour R. The Inner Consultation. MTP Press, 1987. (Five checkpoints; via GPnotebook.)
- Kurtz SM, Silverman JD. The Calgary-Cambridge Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. Med Educ 1996;30:83–89. (Task list and two-thread structure.)
- Rogers CR. On Becoming a Person. 1961. Core conditions summarised in StatPearls, NBK589708.
- Rubak S, Sandbæk A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract 2005;55:305–312. (via NCBI DARE NBK71656.)
- Cahill K, Lancaster T, Green N. Stage-based interventions for smoking cessation. Cochrane Database Syst Rev. 2010;(11):CD004492. https://www.cochrane.org/evidence/CD004492_are-stage-based-interventions-more-effective-non-stage-based-ones-helping-smokers-quit
- Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ 2003;327:741–744.
- West M. Compassionate leadership: attending, understanding, empathising, helping (via FMLM materials).
- Elwyn G et al. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017;359:j4891. https://www.bmj.com/content/359/bmj.j4891
- Rubak et al. Full review: https://bjgp.org/content/55/513/305
- Gigerenzer & Edwards: https://www.bmj.com/content/327/7417/741
Consultation resources
- ICE & Consultation Prompt Card · PDF
- Explaining a Number · PDF
- Behaviour-Change Conversation Guide · PDF
- Referral & Scope Pathway Template · PDF
- Module 4 Self-Audit Worksheet · PDF
Key Points
- Pick one structure and use it deliberately for a week.
- Ask ICE in every first appointment.
- Give every number a meaning and a next step; use natural frequencies.
- Reflect before you advise.
- Name your scope and your referral route in one sentence.