Both as a Christian and as a GP, I am often inviting people to change their ways. 'Repent for the kingdom of God is near!' 'Give up smoking, it shortens your life!' Of course, I dress these statements in softer language, but the challenges remain. And my success rate?
'Motivation for change is an important predictor of outcome.' I was struck by this statement and a six-stage model which followed it, in a recently published book about psychotherapy in primary care [1] . The model resulted from research work done in America in connection with recovery from addictions [2] . In many ways the statement is obvious, but as I reflected on the model and my own work in general practice I realised that I paid little attention to the issue of motivation before giving advice. I wondered if the model would enable me to be more effective in helping people to change and would cost me less in terms of time and energy?
The model proposes that people fall into one of six categories in terms of personal change:
- Pre-contemplation: the person is not really interested in changing
- Contemplation: aware that current behaviour is harmful and change might benefit, but has not yet decided to do anything about it
- Determination: poised on the brink of change and ready for suggestions as to how to go about it
- Action: actively seeking help
- Maintenance: struggling to maintain the change. Years can pass before a person no longer feels the problem is lurking in the wings
- Relapse: most people have at least one relapse
As I pondered this model the Parable of the Sower [3] came into my mind. Jesus had, in some ways, a similar task to ours. He was challenging people to change course, yet not nagging and feeling unhealthily responsible for people in the way some of us in the caring professions do. On the contrary, Jesus shows a deep understanding of human nature and is very realistic about the effects of his preaching.
He compares preaching with sowing seed. Some seed fell on the path and the birds ate it! Perhaps this typifies the people who do not want to change? Then there is the seed that fell on the rocky ground and because it had no root it died very quickly. Perhaps this represents those who seem to want to change but they are not yet committed to it at a deep level and do not do anything of significance? The picture of the seed that grew and then became choked by the weeds shows us what a hard struggle 'maintenance' is. Reassuringly, some seed grew until it produced a crop. Change is possible and therefore, in hope, we go on sowing the seed.
How does this work out? Certainly once we've identified a path we can stop throwing seed on it! An exploratory question such as 'You have heard me describe the risks attached to smoking; have you any interest in giving up?' prompts the patient to reflect honestly on his or her attitude to the proposed change. Further gentle prodding at this stage may uncover the real attitudes of those too polite, embarrassed or guilty to admit that they really love smoking and do not want to stop. Some patients want our approval and like to give us the responsibility for their health. These answer the question with 'I should like to but . . !' At best, such patients are in the 'Contemplation' stage. Maybe we help them most by avoiding 'parental' nagging advice. Instead, we could remind them that some choices in life are very important and cannot be made on their behalf by someone else.
Jesus took that view. In the story of the rich young ruler [4], Mark reports that a young man said to Jesus 'Good teacher, what must I do to inherit eternal life?' The reply Jesus gave disappointed the young man and he turned away sadly, having decided it cost too much to respond to Jesus' call. Jesus respected that decision and made no attempt to change it, although the Gospel records that Jesus loved him. When patients ask us a similar question 'What must I do to live longer?' they may similarly turn away saying 'That is too hard'.
Finally, I just wonder how much change we can bring about without the help of the Spirit of God?
