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Facilitating Compliance: helping patients choose health

Submitted by on Monday, 10 July 2017

How to get people to changeIn the late 1970s, I approached my studies for an MSc in Health Sciences (Community Health Education) with an idealistic goal to create ways to promote wellness and prevent disease. Although life took me in a different direction, I’ve tried to stay caught up on healthcare, but now have merely a passing understanding of what’s going on. Lately I’ve had some opportunities to look more intimately into the healthcare profession/industry, and I’m both gladdened and saddened.

On the plus side, there’s a committed effort in this country to assist the under-served. Food services that offer nutrition to hospitals and training in healthy eating for patients; outpatient groups for treatment and prevention for diabetes, obesity, heart disease, cancer sufferers; school lunches and Pre-K programs. I hadn’t been aware of the extent, or creativity, of the outreach of caregiving professionals. (How could I have known this? News sources focus on the bad stuff.). Esther Dyson’s Wellville.net, for example, even lets us track the progress of 5 groups of caregivers around the US as they design and implement innovative projects to promote preventative health care. We’re on our way to understanding that prevention is preferable to relying on treatment.

The bad news is that some easily treatable or preventable conditions (diabetes, heart conditions, cancer, obesity) are not garnering the necessary buy-in from patients to make the needed healthy choices. With the best will in the world, providers – intent on designing outreach programs to encourage change and choice – are facing non-compliance: even with adequate funding, multi-faceted prevention services, and supervised support, patients are not adopting the necessary changes that have the capability of making a difference in their long term health. What’s going on?

The problem is that the methods we’re using to inspire healthful behavior aren’t facilitating compliance. But with a shift in thinking, buy-in is achievable. Let me begin with a brief discussion of change and how our ‘system’, our status quo, fights to remain stable regardless of its (in)effectiveness. Buy-in is a change management problem.

STATUS QUO

We’re intelligent. We know smoking and sugar are bad, that exercise and fresh veggies are good. Yet we continue to smoke and eat sweets. We know that telling, advising, or offering ‘relevant’ and ‘rational’ information is largely ineffective and invokes resistance. Yet we continue to tell, advise, and suggest, knowing even before we start that the odds of success are against us, and blaming the Other for non-compliance.

We all tend to continue our current behaviors, hoping we’ll get different results (Hello, Einstein.), finding things to blame, or new approaches using the same thinking. The problem is that any change is a systems problem that demands buy-in from the very rules that created the status quo. And buy-in is much more intricate than knowing there’s a problem, or offering good ideas and recommendations, or getting people to sign up for healthful activities.

Let’s look at the problem from a different lens. Let’s understand why people keep doing what they do, regardless of any evidence that points to a need for other options.Each person, each family (everyone, actually), is idiosyncratic but made congruent through an internal – often unconscious – system of rules and goals, beliefs and values, history and foundational norms. It’s our status quo; it represents who we are and the organizing principles that we wake up with every morning; it’s habitual, normalized, accepted, and replicated day after day – including what created the identified problem to begin with – with the problems baked in, and will do whatever it takes to remain its own unique brand of congruent.

Any proposed change challenges the status quo, offering a potentially disruptive outcome. When a problem shows up, diabetes for example, the patient has a dilemma: either continue their comfortable patterns and be assured of a continued problem, or dismantle the status quo and risk disruption with unknowable consequences. How does she get up every day if she needs to eat differently and must convince her family that the food they’ve been eating for generations isn’t healthy? How does she avoid desert when the family is celebrating? And the family’s favorite recipe is her cookies!

Change means the status quo has to reconfigure itself around new/different/unknown rules, beliefs, and outcomes to become something that can maintain itself with the ‘new’ as normalized. Because – and this is important to understand – until people

  • recognize that something is wrong/ineffective,
  • recognize that whatever they’ve been doing onconsciously has created (and will maintain) the problem,
  • know how to make congruent change that includes core values and systems norms,
  • know exactly the level of disruption that will occur to the status quo, and
  • make a belief shift that is acceptable to the rest of the system and enables new behaviours,

they will not change, regardless of its efficacy of the value of the solution. In other words, until or unless someone recognizes that change can be accomplished without permanent disruption to who they are and how they live, AND are willing/able to do the deeply internal work of designing new habits, beliefs, and goals, AND manage any fallout, people will not change regardless of their need or your solution. [Note: I’ve been teaching the same premise to sales folks and coaches for decades.]

Why isn’t a rational argument, or an obvious problem, enough to inspire behavior change? Because we’re dealing with long-held patterns, habits, and normalized activities and beliefs that represent the status quo and identity of the person. And because we’re trying to push change from the outside – usually through information, advice, and activities – before the system has figured out how to change itself congruently.

THE INTRICACY OF BUY-IN

With the best will in the world, we’re trying to cause change in the wrong place, in the wrong way, at the wrong time. We try to offer new choices, new behaviors, before we have enabled internal, unconscious agreement to change. And here’s the interesting bit: behaviors will change themselves once the core beliefs have shifted (i.e. I must go to the gym because I’m a Healthy Person, as that’s one way I define Healthy. And I hate going. But I must because I’m a Healthy Person.). By focusing on behavior change before facilitating belief change, our approach is actually creating resistance because our status quo must, by the laws of Systems Congruence, maintain our status quo at all costs (literally).

Behaviors are merely the expression – the representation – of our beliefs. Think of it this way: behaviors express our beliefs much like the functionality of a software program is a result of the coding in the programming. To change the output of a software program, you don’t start by changing the functionality; you first change the coding which automatically changes the functionality.

It’s the same with any human change: failure ensues when we focus on changing the output of the program (in this case, behaviors) rather than focusing first on adapting the source. Like a dummy terminal, our behaviors only do what its programming allows them to do. Trying to explain why a different output, or behavior, is necessary is useless, even when our information is ‘rational’ or ‘right’.

Here’s what happens. When influencers believe that if they share, advise, gather, or promote the right information in the right way, using the right words and offering good rational reasons why change is necessary, Others will comply. But our patients

  • hear us through biased filters and cannot hear our message as meant;
  • feel pushed to act in ways they’re unaccustomed to or that go against their beliefs;
  • resist and reject when expected to act in ways currently outside their norm;
  • lose trust in us when we push them.

Our patients cannot even consider, understand, or recognize the validity of, our information appropriately. Everyone actually listens through biased filters that only allow us to hear what our brain determines it wants to hear to maintain our status quo; our brains filter in/out at will, leaving out concepts, words, meaning, and adding in concepts, words, meaning. We all do this unconsciously, leaving us to assume that what we hear is what’s been said. (Note: I just wrote a book about this – What? Did you really say what I think I heard? – and was quite surprised to learn how effectively our listening controls our status quo.) So my brain might tell me you said ABX when you actually meant ABC, and I believe my brain is accurate (and it didn’t tell me what it left out) and you’re the one who remembered it wrong. We’re offering data that can’t even be heard or absorbed appropriately.

So how can we effect compliance if offering information or diets or exercise programs, for example, isn’t effective?

PEOPLE CAN ONLY CHANGE THEMSELVES

Start by recognizing that people change themselves; change can’t come from the outside. Instead of seeking better and better ways to offer plans, rules, and advice (and getting rejected and ignored), we must help people make their own discoveries and systemic changes and design a path to their own change so they can remain congruent. The sad truth that all influencers must understand is that the need for Systems Congruence is of greater importance (unconsciously) to the system than the need for change, regardless of how necessary the change is. That’s how people end up refusing smoking cessation programs when they have lung cancer, or continuing to eat unhealthful foods with diabetes (or voting for candidates that go against our best interest).

Here are some ways you can enter a change conversation to enable buy-in and avoid resistance:

  1. Shift your goal. Your job is to help Another be all they can be. It’s not about you getting them to accept the change you believe necessary, but enabling them to design the change they need, in a way that concurs with their beliefs and values.
  2. Enter differently. Enter with a goal/outcome of facilitating change and buy-in, not to change behavior. They must change their own behavior. From within. Their own way.
  3. Examine the status quo. First help Others recognize and assemble all of the elements that created and maintain their status quo – not merely the ones involved with the problem as you perceive it, but the entire system that created and maintains it. Outsiders can’t recognize the full complement of givens within another’s status quo. Starting with a focus on what you perceive is the problem (or the Other recognizes as a problem but hasn’t consistently switched to the new behavior) inspires rejection.
  4. Traverse the brain’s steps to change. There are 13 steps to change that must be traversed for all change to occur. Unless all – all – of the elements have been included, recognize a need to change, and know precisely how to make the appropriate shifts so a stable systems results, they will resist.
  5. Behavior is an expression and not a unique act. We must recognize that exhibited behaviors are expressing beliefs. Change must occur at the belief level. Trying to push or inspire behavior change is at the wrong level and causes resistance.
  6. Everyone has their own answers. They may not be what you would prefer and might not make sense given the outcomes. Help them recognize how and when and if to change. But not using information as it can’t be understood.

Here are some examples of how I’ve added Change Facilitation to elements of health care in a way that promotes belief change first (Note: these below exemplify only a portion of what would need to be included on forms, in groups, etc.):

Intake forms: instead of merely gathering the data you think you need (which you’ve inadvertently biased), why not enlist patient buy-in at the earliest opportunity? It’s possible to add a few Facilitative Questions (I developed a form of question that enables unbiased systemic change. It uses no information gathering and has no bias. See examples below.) to your forms to start the patient off recognizing you, and including you, as a partner at the very beginning of your relationship and their route to healthful choices:

We are committed to helping you achieve the goals you want to achieve. What would you need to see from us to help you down your path to health? What could we do from our end that would best enable you to make whatever changes you might want to make?

Group prevention/treatment: instead of starting off by sharing new food or exercise plans, let’s add some change management skills to the goals of the group. By giving them direction around facilitating each other’s change issues, we can enable the group discuss potential fallout to any proposed change, determine what change would look like, and begin discussions on how to approach each aspect of risk together to recognize different paths to success. Then the whole group can  support each other’s different paths to success:

As we form this group, what would we all need to believe to incorporate everyone’s needs into our goals? If there are different goals and needs, how do we best support each other to ensure we each achieve our goals?

Doctor/patient communication: instead of a medical person offering ideas or information, make sure you achieve buy-in for change first. This encourages the trust/belief that the professional has the patient’s success in mind, rather than a dependence on the information (and viewpoint) they wish to espouse.

It seems you are suffering from diabetes. We’ve got nutritional programs, group support, book recommendations. But I’d first like to help you determine what health means for you. How will you know when it’s time to consider shifting some of your health choices to open up a possibility of treating your diabetes in a way that doesn’t diminish your lifestyle?

A healthy patient is the goal. Be willing to enable change and compliance, rather than attempt to manage it, influence it, or control it. I’ve got some articles on these topics if you wish further reading: Practical Decision Making; Questioning Questions; Trust – what is it an how to initiate it; Resistance to Guidance; Influencers vs Facilitators.

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Sharon Drew Morgen is a Change Facilitator, specializing in buy-in and change management. She is well known for her original thinking in sales (Buying Facilitation®) and listening (www.didihearyou.com). She currently designs scripts, programs, and materials, and coaches teams, for several industries to enable true buy-in and collaboration. Sharon Drew is the author of 9 books, including the NYTimes Business Bestseller Selling with Integrity, and the Amazon bestsellers Dirty Little Secrets – why buyers can’t buy and sellers can’t sell, and What? Did you really say what I think I heard. Sharon Drew has worked with dozens of global corporations as a consultant, trainer, coach, and speaker. She can be reached at sharondrew@sharondrewmorgen.com 512 771 1117

  • davidlocke

    Smoking was found to be embedded in a network six degrees deep.

    My mom used to tell us she loved us by cooking. She was a great cook. My diabetes left her with no way to tell me she loved me. She did not learn to omit carbos and fruit. I loved all of it, but I went on the South Beach phase one and stayed there. Not ideal, but it was what I did. She was in my second degree network. I’m an introvert, so I don’t have a deep network, so I could change what needed to be changed, except for mom.

    OT: If you mom is a great cook, realize that she won’t like nursing home food.

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