Applied Evidence
Unhealthy drug use: How to screen, when to intervene
Recognizing and helping patients at risk for a substance use disorder doesn’t have to be time-consuming. Here’s how to make screening and...
Michael Raddock, MD
Rachel Martukovich, MA
Eric Berko, PhD
Christina Delos Reyes, MD
James J. Werner, PhD, MSSA
Department of Family Medicine, MetroHealth Medical Center (Drs. Raddock and Berko); Department of Family and Community Medicine, Case Western Reserve University (Ms. Martukovich and Dr. Werner); Department of Psychiatry, University Hospitals Case Medical Center (Dr. Delos Reyes); Cleveland, Ohio
mraddock@metrohealth.org
The authors reported no potential conflict of interest relevant to this article.
For the estimated 80% of patients who are in the Precontemplation or Contemplation stages and are unsure about the relative importance of changing behaviors and/or lack confidence to make changes, these directive techniques can cause defensiveness, which can make both the patient and the FP uncomfortable. For such patients, approaches that build on the patient’s own motivations and stories, such as MI and NT, may be preferred.
3 techniques that overlap
The FRAMES protocol and TM are based on behavior change theories, and each mixes directive techniques with relationship building to facilitate health behavior change. There is overlap in concepts across the 5 As, FRAMES, and TM, and some evidence suggests these approaches can be adapted for use in primary care settings.14-16
The 5 As is a brief intervention in which the FP sets an agenda and provides advice at the outset. This technique has been shown to improve smoking cessation rates in pregnant women compared with physician recommendations alone.17 It may also help with weight loss for patients who are ready to change and are given support for their
efforts.18
Putting the 5 As into action
CASE › An FP who wants to use the 5 As technique to assist Mr. G might proceed as follows: Ask: “How often do you exercise and follow a diet?” Advise: “I recommend that you start exercising 30 minutes each day and start following a healthier diet. It is one of the most important things you can do for your health.” Assess: “Are you willing to start exercising and trying a diet in the next month?” Assist: “Here is a list of local recreation centers and some information about a healthy diet.” Arrange: “I’d like to have one of the nurses call you in a week to see how things are going and have you return in a month for a follow-up appointment.”
The 6 components of the FRAMES protocol overlap with the 5 As.14 FRAMES utilizes relationship-building by explicitly reinforcing patient autonomy, offering a menu of choices, and acknowledging patient strengths.14
Putting the FRAMES protocol into action
CASE › Using the FRAMES protocol for Mr. G might consist of the following: Feedback: “Your eating habits and lack of exercise have contributed to your weight, high glucose and cholesterol levels, and shortness of breath.” Responsibility: “The decision to lose weight is a choice only you can make.” Advice: “I recommend that you start regularly exercising and eating healthily.” Menu: “Here are some options that many people find helpful when they try to lose weight.” Empathy: “It is challenging to change the way we eat and exercise.” Self-efficacy: “You have been able to overcome a lot of difficult things in your life already and it seems very important to you to make these changes.”
TM begins with the FP linking a patient concern, such as shortness of breath, to a physician concern, such as obesity.15 The FP then provides advice, assesses readiness, and responds based on the patient’s stage of change.16
Putting TM into action
CASE › Using the TM approach to help Mr. G might work as follows: Link a patient concern with specific behavioral change: “I think that your shortness of breath is caused by your weight.” Recommend change, offer support, and ask for commitment: “I recommend that you lose 15 pounds. I’m confident that you can do this, and am here to help you. Are you ready to talk about some specific ways you can do this?” Respond based on the patient’s readiness to change: “All right, let’s talk about healthy food choices and exercise.” (This statement would be appropriate if Mr. G was in the Preparation or Action stage of change.)
Solution-focused brief therapy
In solution-focused brief therapy, the FP helps the patient explore solutions and/or exceptions to problems that have worked for the patient in the past.SFBT highlights a patient’s previous successes and strengths, as opposed to exploring problems and past failures.19,20 The FP fosters behavior change by using strategic questions to develop an intervention with the patient.21 SFBT involves encouraging patients to find exceptions to current problems and increasing the occurrence of current beneficial behaviors.19 This approach begins with the patient identifying a problem for which he or she would like help. The FP helps the patient explore solutions and/or exceptions to this problem that have worked for the patient previously (or solutions/exceptions that the patient can imagine). The FP does not offer suggestions to solve the patient’s problem. Instead, the patient and FP collaboratively identify and support the patient’s strengths, and they develop a behavioral task to try based on these patient-derived solutions.22
Recognizing and helping patients at risk for a substance use disorder doesn’t have to be time-consuming. Here’s how to make screening and...
The USPSTF advises high-intensity counseling for those who are overweight or obese and have hypertension, hyperlipidemia, or other CVD risk...