Tư vấn thay đổi thói quen
Là dạng trị lieu để bệnh nhân thay đổi thái độ hoặc hành vi không tốt cho sức khỏe
Gồm những bước chung là thảo luận về thói quen/hành vi không tốt của bệnh nhân, tác hại của nó, rồi gợi cho bệnh nhân thấy tương lai của hành vi, và lý do cần phải sửa đổi.
Chiến thuật: cần chọn một cách phù hợp cho chủ đ62, thầy thuốc và bệnh nhận Tránh tranh luận hoặc cãi vã, hay chất vấn, nếu không bệnh nhân sẽ tìm mọi cách để phản kháng, không chịu thay đổi. Việc thay đổi một thói quen hoặc hành vi đã kéo dài nhiều năm, cần phải lâu dài, dựa trên mối quan hệ hiệu quả giữa thày thuốc- bệnh nhân, chìa khóa là lắng nghe không áp đặt luận xét



  • Definition: A form of therapy that seeks to change behavior(s); general approach includes discussion of pt’s awareness of behavior  pattern  & its effects,  soliciting  pt’s  perspective  on  behavior  &  reasons  for change
  • Strategy: Different techniques available; important to find a strategy that is a good fit for the topic, the provider, & the individual; avoid arguments & confrontation, which can↑pt defensiveness & resistance to change; changing most of these behaviors are long-term goals & benefit from a therapeutic relationship; nonjudgmental listening key
  • Efficacy: Most counseling shows  a  “dose–response” relationship;↑success at changing behavior w/ recurrent discussions; providers can effect change despite their time limitations, but should also consider referral to others trained in this approach as local resources & situation  allow  (e.g.,  social  workers,  chemical dependency specialists, therapists)

Selected Approaches (AFP 2009;79:277)

  • Motivational interviewing: Pt-centered technique proven helpful in↓substance, EtOH abuse; can help develop therapeutic relationship & set individual goals (Cochrane Data System Rev 2011;5:CD008063)

Agenda: “Can we talk about exercise today?”

Exploration: “Are you interested in exercising?” (desire); “Can you walk for 30 mins daily?” (ability); “How would exercising help you?” (pt’s need)

Educating: “Exercise prevents so many diseases & will make you feel better”

Listening: “What do you think about that?”

Strategizing: “What would work best for you? Walking w/ friend? Joining a gym?”

  • FRAMES (Prim Care 2007;34:551): Provides framework for provider to discuss impact of behavior & offer recommendations for change Feedback: “Our labs show EtOH consumption is damaging your liver.”

Responsibility: “Only you can decide it’s time to stop drinking.”

Advice: “I strongly recommend you stop drinking.”

Menu: “There are many strategies to help people stop drinking, such as …”

Empathy: “Staying sober can be a real challenge, but I am here to help.”

Self-efficacy: “You seem determined to make this important change in your life.”

  • Transtheoretical: Behavioral changes occur in stages; model allows provider to assess pt readiness for change

Precontemplation: Advise pt of health consequences & ask what he/she thinks; “Being overweight is linked to heart disease & diabetes. I think it might be helpful for your health to lose wt. What do you think? Have you tried to lose weight before? What would signal to you that it’s time to lose weight?”

Contemplation: “What are the pros/cons of weight loss?”

Preparation: “Do you think you could start making those changes next week?”

Action: Praise/support pt efforts

  • 5 As: See “Tobacco Use”
  • 5 Rs: Designed for smoking cessation, but may be useful in other circumstances

Relevance: Why changing behavior is personally relevant (e.g., children’s health)

Risks: Negative consequences of behavior (e.g., shortness of breath, cancer)

Rewards: Potential benefits of changing behavior (e.g., improved health, saving money)

Roadblocks: Barriers to changing behavior (e.g., fear of wt gain, withdrawal sx)

Repetition: Approach these issues on a regular basis


  • Providers often have responsibility for sharing potentially upsetting news; wide ranges in nature of pt–provider relationship & in emotional impact for pt (& provider)
  • When delivering upsetting findings, providers  can  often  have significant positive impact on encounter by preparing & supporting  the pt appropriately

SPIKES protocol (Adapted from Oncologist 2000;5:302)

S: SETTING: Private setting, tissues ready, pager/phone set to silent let pt decide who is present: sit down w/ pt, establish rapport (eye contact, touching pt on arm/shoulder); advise pt of time constraints & potential interruptions

P: PERCEPTION: Assess pt knowledge/expectations;”What is your understanding of your medical situation?” or “What is your understanding of what we’re going to talk about?”

I: INVITATION: Ask pt what info they wish to know$What info would you like to know about your situation?”

K: KNOWLEDGE: Warn about bad news. provide infolknowledge in lay terms, & pause periodically to allow pt to digest/process info:”I’m sorry to tell you that the cancer has spread” — PAUSE —”There are new lesions in the liver” — PAUSE —”This is likely why your skin has turned yellow & itchy”

E: EMPATHY: Recognize & respond to pt emotion, goals. & hopes: sometimes it is helpful to name the emotion pt is expressing. i.e..”You seem upset”

Respond to their cues; try moving closer to pt & offering an empathic gesture (e.g., offering tissue) while being silent until pt speaks

Align provider goals wl pc (“I wish…”) while acknowledging situation (“…but”),e.g.,”1 wish you didn’t need insulin, but the pills we prescribed aren’t enough anymore”

Offer empathy & honesty for pts w/ unrealistic expectations:”I wish Alzheimer’s disease was curable, but I’ve never seen it happen. Ill always be honest with you about your health.”

Invite pt response:1 imagine this is very upsetting” or “Could you tell me what you are

worried about?”: assess pt safety if indicated (See “Suicide Risk Assessment)

S: STRATEGY & SUMMARY: Discuss a options; offer reasonable hopes for situation; invite questions & arrange f/tr. consider specialist/social work/counselor referral


  • Epidemiology: >50% of mental health visits are to PCPs; supportive counseling may be therapeutic for pt mood & physical sx (Prim Care Clin Office Pract 2007;34:551)
  • Challenges: Providing supportive counseling in a busy primary care practice is challenging, esp if pts p/w numerous other medical problems; The BATHE technique may provide therapeutic counseling in a time-efficient manner (1–5 mins)

BATHE protocol (Stewart MR, Lieberman JA. The 15-Minute Hour, 2008)

B: BACKGROUND: Elicit stressors.”You seem upset: what’s going on in your life (or how is life treating you)?”

A:AFFECT: “How do you feel about kr’

T:TROUBLES: Identification of a specific part of a problem makes it manageable & provides something the provider may assist with:What troubles you the most about losing your job?”

H: HANDLING: Assess coping mechanisms:”How are you handling the divorce?”

E: EMPATHY:Validate pt emotions:”That sounds very difficult for you”; attempt to address main issue. e.g.:Would you like to talk to our social worker about housing resources?”

GRIEF (JAMA 2013;310:416)

  • Definition: Grief is bereavement, often after the death of a loved one, typically lasting 6–12 mos; Complicated grief: Yearning/preoccupation for deceased, preoccupation w/ circumstances at death, intense sorrow/anger/self-blame, and/or denial/avoidance that impairs function, causes significant distress, & does not improve w/ time
  • Risk factors: , pre-existing psych d/o (anxiety, depression), childhood trauma, nature of death, death of spouse, social support/resources available, EtOH/illicit use
  • Epidemiology: ∼7% of pts experience complicated grief
  • Diagnosis: Clinical; Inventory of Complicate Grief scoring system available (Psychiatry Res 1995;59:65); Ddx includes depression, anxiety, PTSD, all of which may be comorbid
  • Treatment: Bereavement support groups, mgmt of comorbid d/o, targeted psychotherapy
  • Patient information: JAMA 2005;293:2686